“The Nurse Will See You Now” (but you won’t know it’s a nurse!) – Internecine Warfare in Anesthesia

 

Introductory note on language: In the US, an anesthesiologist is a physician, an M.D. with 4 or more years specialty training in the field after completion of medical school; with rare exceptions, all are board certified by rigorous examination by the American Board of Anesthesiology. An anesthetist is a nurse, a C.R.N.A. (certified registered nurse anesthetist). New graduates have a BSN (bachelor of science nursing and a MSN (master of science nursing); a total of six years of schooling plus one year working in ICU,  for a total of 7 years. A significant number still practicing have neither degree, but are ‘grandfathered’ under the less rigorous former standard. Not so in the United Kingdom, where ‘anaesthetist’ generically  describes whoever is administering ‘anaesthesia.’ Until recently, as far as I know, anesthesia was administered only by physicians in the UK, but the “anesthesia care team” (more below, and likely the best) model has been introduced and is growing in prevalence in order to extend physician manpower.

Undergoing anesthesia today is nearly 100 times safer than it was 50 years ago. Why is that? Because anesthesiologists – physician scientists – developed devices and procedures designed to improve safety. As an anesthesiologist, I frequently say to patients, “I understand that you did not come here today to see me. The best evidence that I have performed at the highest level will be your forgetting all about me when you leave the hospital.” The combination of improved safety and the veracity of this statement makes for a perverse consequence: in the mind of the general public, anesthesiologists lack any constituency; nobody says – compared to surgeons, say – “that is my anesthesiologist.” Our services are self-limited, impersonal, interchangeable. We only seem to exist when things don’t go perfectly, when we are called into account. We are one of the few professions still held rigorously accountable. These facts of life have important practical and political consequences in America, as will become clear below.

Only about 20% of anesthetics are administered by physicians alone, one-on-one with a patient. The vast majority are provided in the “anesthesia care team” mode, where one physician medically directs the activities of up to four nurse anesthetists CRNA’s simultaneously. Medical direction means the physician evaluates each patient pre-op in order to determine if the patient is fit to undergo anesthesia in the first place, and if so, prescribes the anesthesia plan (general or regional, as well as many other decisions as to techniques of ventilation, medications, gas mixtures, monitors, vascular access, etc., etc.). Suffice it to say that the combinations and permutations are complex, varied and consequential. These decisions, taken before the anesthetic per se has begun, are highly determinative of outcome.

After prescribing the anesthetic and explaining it to the patient, the physician then obtains proof of informed consent in the form of a signature on a witnessed legal document. The physician then personally performs or directs the CRNA in performance of a nerve block, spinal, or epidural, or directs and assists at induction of general anesthesia. In long cases, we visit intermittently, while performing all these same duties with other patients under our care simultaneously. In the event established parameters of vital signs are exceeded or if the surgery deviates from usual, the CRNA calls the physician to intervene. We are called to be present for emergence, render all necessary care in recovery room and discharge patients from there when ready. We take care of all complications and answer for them, even if caused by others. CRNA’s have no experience answering for complications.

Now, the great radical egalitarian tsunami of American culture (see Bork, Slouching Towards Gomorrah) has not finished crashing on shore and crushing all structures before it. It is, however, a bizarre and incoherent egalitarianism. While one must be licensed by the state in order to clip another’s cuticles, today CRNA’s are on the brink of being allowed to administer anesthesia independently, “in competition” with and as “equals” of anesthesiologists. Pending legislation requires that all licensed institutions like hospitals and surgery centers not discriminate in any way between them. This is the American ideal now carried to its absurd, illogical extreme: discrimination is not only prohibited due to race, creed, sex, etc., etc., but also is forbidden on the basis of training, competence or demonstrated and time-tested ability! All this, in a country where “safety” can reliably trump any other value in furthering state intrusion into the lives of everyone. Incoherent.

Since all that matters in modern America are perceptions, do you imagine for a moment that any state or federal legislature would dare to elevate nurses to equality with surgeons? Can you imagine arriving at the hospital only to learn at the last moment that a nurse will perform your surgery, not a physician? This is what I mean by having a “constituency.” Now, this in no way is intended to denigrate the skills of nurses generally or CRNA’s in particular; they perform excellent and valuable services. It is merely to assert unequivocally that there are significant differences in skill sets as well as depth of knowledge, training and ability between the two groups. l aver, also unequivocally, that differences in ability between the two groups result in part from the far more rigorous selection process in admission to medical school (at least that has been the case until identity group and “victim” status came to trump merit in most all endeavors) compared to nursing school.

While there are surely overlaps in ability as to outliers in the two groups, when it comes to native intelligence and innate ability, this difference is undoubtedly expressed as a probability function: however unfashionable it is to say so, physicians are most likely to be superior to nurses as measured by intelligence, innate ability or any other objective performance criterion. This is as would be expected, given that the activities engaged in by physicians are far more complex with significantly higher stakes as to outcome. The public, by and large, understands this and this understanding explains why regulators will never substitute nurses for surgeons or reduce the training requirements of commercial airline pilots (unless it is done in the dead of night for correct progressive reasons and thus with media connivance via silence).

While I in no way attempt to diminish the role played by CRNA’s individually, their professional organizations defame anesthesiologists as a matter of course. This group is bold in self- promotion and belittling anesthesiologists, notwithstanding these facts:

  • CRNA’s have never had to answer for bad outcomes. That responsibility until now has fallen to the physician anesthesiologist or the surgeon, even if it was caused by the negligence of the nurse anesthetist (respondeat superior).
  • Their relentless argument to legislators that they are the equivalent of physician anesthesiologists requires one to believe that I have wasted 7 years of my life (I have 7 more years education and training than they do;many of my colleagues have 8 more years via subspecialty fellowship). Either that is true or we have risk management backwards (the three pillars of improved quality in any risky endeavor are training, training and training). The only logical alternative is that nurse anesthetists are so superior as a group, a priori, that they can learn everything that I did in seven fewer years!
  • Regularly, this group of nurses, whose members immediately demand (there have been lawsuits won by them and Medicare/Medicaid already pays them the same) the same pay as physician anesthesiologists, defame me and my colleagues by saying that physicians are only resisting their independent practice to protect our own income. One would think such blatant unprofessional, actually slanderous conduct would give legislators and regulators pause as to motives of the nurses…but no – this is modern America, where envy is a (if not the) major force behind all politics.
  • Let’s say I am working in an OR where CRNA’s are my “competitors.” What happens when one of their patients gets in trouble. Who do you suppose the surgeons and OR staff are going to seek out to rescue the patient, to fix the problem? Another CRNA?? If 60 years of work in OR’s is any guide (40 of them as an anesthesiologist), I can say with some assurance they will be looking for me to assume responsibility (and liability) for a patient in extremis whose problem I might well have prevented in the first place by virtue of my superior training.
  • Perhaps most telling of all – in a culture where “choice” has been elevated to sacramental status when it comes to certain issues, the poor aforementioned patient in extremis, above, will never have been offered the choice of who administers his/her (for simplicity’s sake, in an attempt to include all possible patients, I refer only to birth sex, since considerations of gender have nil effect under anesthesia) anesthetic. Others – hospital administrators most likely, will decide who provides anesthesia in a given institution. The patient’s “choice” will be to sign or not the pro-forma “informed” consent form handed them as a matter of routine immediately before the procedure (virtually no one ever reads these documents). The patient will definitively NOT be offered a choice between an anesthesiologist and a CRNA. This despite scores of appellate decisions in state and federal jurisdictions, which wax eloquent, poetically extolling the virtues, indeed the absolute necessity of fully-informed consent prior to medical procedures. Do you think a reasonable person just might think this includes knowledge of the qualifications of the individuals who will literally be holding his/her life in their hands.

All of which leads to my only possible response to this lunacy. I will never work for one minute in an OR where CRNA’s are my ”competitors;” I am perfectly happy working with them in the teammode, asI have done for 40 years. To “compete” would place me in both an intolerable ethical dilemma and at unreasonable legal jeopardy. Were I to work under these conditions, it would be generally expected that – after the hospital, CRNA, and patient (unknowingly) have excluded me from the patient’s care a priori –  were I present in the OR, I would be expected to ”help out” with emergencies which will inevitably arise for the CRNA’s patients. No thanks. What am I supposed to do, for instance, if I am giving a patient anesthesia, by myself (i.e. not medically-directing a CRNA) who did ask for my services? Leave my patient? Sorry, I can’t abandon a patient who did ask for my services. Alternatively, if I am on a break or between cases, it is fundamentally unfair to expect me to take on this responsibility and this liability – a fortiori if I could have prevented it in the first place. Yet, as anyone who has ever worked in an OR knows, that is precisely what everyone will expect of me. If those are the rules of engagement, don’t expect to see me on that battlefield. I will never work in that irrational and astoundingly unfair system. 

Which leaves only the question: qui bono? Little or no money will be saved overall; it will be redistributed. The same amount of money is paid per anesthetic regardless of who administers it or how. In the care team mode, that amount is split between the physician and the nurse. By directing multiple cases and doubling or tripling his/her liability exposure and workload (and becoming involved often-tendentious OR management, scheduling etc. to boot), a physician may make a small increment in income compared to simply doing his/her own cases, hands-on, one at a time. My own preference would be to do that; it is a much less stressful undertaking compared to directing 2 or 3 CRNA’s simultaneously. So, little or no cost saving will result, notwithstanding the nurses’ hortatory remonstrations. Hospital administrators may be seduced at the outset by such arguments, until actual experience administers a dose of reality in the form of notably increased liability costs.

Thus, the CRNAs’ income will increase. Physicians involvement in anesthesia will be either diluted to down to (theoretically) “supervising” care (i.e., not be involved in all cases; merely put out fires and sign on the line that says M.D. = malpractice defendant) or excluded entirely from patient care. Those hospitals which employ any anesthesiologists will likely have one and one only. That sorry individual will administer only ink to paper or pixels to flat screens in the form of “policies and procedures” so when the hordes regulators blow through sporadically, the hospital will look good structurally (kind of like how the Constitution’s structural safeguards of individual have (not) worked). As this is directly analogous, think teachers’ registers in public schools. There, numbers and checkmarks are found in every row and column, neatly written as required. Totals appear at the bottom of each column; well-regulated, orderly, even color-coded. Looks great on paper. The only problem is that the majority of students can’t read, write, do arithmetic or think critically. As with progressive public schools, so with future anesthesia (If Republicans were in charge of city schools, the “media” would make this state of affairs a national scandal, non-stop).

As you read, regulators and legislators – poseurs, really when it comes to safety – are undoing the far safer existing system of anesthesia which has been hard won over the past few generations through physician leadership and research. To the detriment of patients, this is being undone in secret, with none of the zealous “investigative reporting” reserved nowadays for deployment only against Republicans or conservatives and their policies – and truth, in that regard, is optional in reporting. This fight, as I understand it, is about progressive compulsive deconstruction of systems in which merit and/or authority rightly reign. The only part I can’t understand is the role played by those who purport to be lobbying for anesthesiologist associations. All they want is money to offer legislators. I have asked them why they don’t go around the legislators and appeal directly to the public. It is not a hard case to make to the public. I haven’t received an answer to my question. And unlike over many years in the past, they haven’t received my money. They most recently reported they can’t get any legislators to side with us. So, it seems, the battle is lost.

In my numerous letters to legislators over the years (the nurses have been waging this war for 20 years or so), I suggest they have the courage of their convictions. If they believe safety will not diminish, I ask, why not create a mandatory registry of anesthesia complications and record whether or not a physician directed the anesthetic? I have never received even an acknowledgement of my letter, much less an answer to my question. Airline crashes, you see, are newsworthy since many deaths occur simultaneously. Anesthesia mortality, by comparison, is sporadic. The way our “media” works, that is not newsworthy, precisely because those deaths are sporadic – occurring one at a time – even though the total number likely exceeds those from average annual airliner crashes by a factor of two or more. This, of course, is another progressive tactic I will entitle “fake non-news.” If the “media” don’t report it, it didn’t happen. If they did report the facts responsibly, legislators would never dream of gutting the medical specialty of anesthesiology.

Next time you have anesthesia for surgery, inform yourself as to who is taking care of you. Nobody else will. You are on your own. The ever “safety-minded” state is not really in the business of protecting you when you are at your most vulnerable; it is counting on your not ever knowing the risk to which you are being exposed. And, as with those who never receive the benefit of a drug which never came to market because of regulatory roadblocks, there is no constituency among those who die in preventable anesthesia mishaps. Other than sporadic, highly-local and unpublicized negligence lawsuits, these are silent victims when it comes to determining government policy.

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Author: civil westman

Driven to achieve outward and visible things, I became a pilot, a doctor and a lawyer. Eventually, I noticed the world had still not beat a path to my door with raves. Now, as a septuagenarian I still work anesthesia part-time, fly my flight simulator to keep my brain sparking and try to elude that nagging, intrusive reminder that my clock is running out. Before it does, I am trying, earnestly, to find a theory of everything - to have even a brief "God's-eye" view of it all before the "peace which passeth all understanding."

21 thoughts on ““The Nurse Will See You Now” (but you won’t know it’s a nurse!) – Internecine Warfare in Anesthesia”

  1. Thank you for this post.

    Besides objective things like age, weight, and various vital signs, do you gather a feel by looking or talking to the patient?

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  2. CW, my husband and I talk about this all the time.  It’s happening in every  field of medicine. “Nurse-practitioner” is, or should be, an oxymoron.  Well—I could go on and on, but I won’t.  For some reason I can’t comprehend, doctors allowed this to happen to their profession.

    Do you think it will ever happen in law? People being represented in litigation by paralegals or advised by “legal information specialists”? Traditionally the legal profession has known how to keep a closed shop.  But, if people  are actually happy  to entrust their very lives to persons without an MD, just for the sake of showing how egalitarian they are ( like, y’know: “People  with mediocre intelligence deserve a chance to screw up my surgery, too!” ) well…I guess anything can happen.

    Everything— medicine, law, immigration— should be “merit based”. Okay? And as for those who came up short in the talent and intelligence lottery, let ‘em complain to their Creator.

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  3. 10 Cents:
    Thank you for this post.

    Besides objective things like age, weight, and various vital signs, do you gather a feel by looking or talking to the patient?

    Yes, but…

    I do get inklings – but suspect they are really nothing more than my own heightened fears, which only serve to make me even more cautious overall (if that is even possible). Objective factors weigh more heavily. Example: a patient who must use oxygen at home for activities of daily living, will have much lower risk with regional anesthesia (numb the region of the body being operated on with the patients breathing on their own) compared with general anesthesia (where they must be deeply enough asleep that I must breathe for them). Some operations, like most head/neck, abdominal and thoracic surgery, cannot be done with regional anesthesia. Having to breathe for patients opens the door to many more pulmonary complications, which can be very serious.

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  4. Hypatia:
    CW, my husband and I talk about this all the time.  It’s happening in every  field of medicine. “Nurse-practitioner” is, or should be, an oxymoron.  Well—I could go on and on, but I won’t.  For some reason I can’t comprehend, doctors allowed this to happen to their profession.

    Do you think it will ever happen in law? People being represented in litigation by paralegals or advised by “legal information specialists”? Traditionally the legal profession has known how to keep a closed shop.  But, if people  are actually happy  to entrust their very lives to persons without an MD, just for the sake of showing how egalitarian they are ( like, y’know: “People  with mediocre intelligence deserve a chance to screw up my surgery, too!” ) well…I guess anything can happen.

    Everything— medicine, law, immigration— should be “merit based”. Okay? And as for those who came up short in the talent and intelligence lottery, let ‘em complain to their Creator.

    I think doctors allow things to happen mainly because they are so busy doing the next thing which must get done. It is one thing to allow nurse practitioners more leeway when decision making is spread over years, months, weeks – as it is in primary care. In caring for hospitalized patients, it is over days, hours, minutes. Here, too there is room for physician extenders. But in anesthesia, decision making is over hours, minutes, seconds;not the place, IMHO, to remove physicians entirely.

    I suspect lawyers will effectively protect their turf, and courts will wax eloquent over the importance of doing so, as they do with informed consent as a general legal principle and no matter how they conveniently ignore those principles when they offend progressive goals.

    We live, regrettably, in a “meritless” age. Bork well explains the “radical egalitarianism” underlying this in Slouching Towards Gomorrah. If equality of outcome is not the result of normal social interactions, regulatory agencies, legislatures or courts will make it so by fiat and call it social justice. There will be no body count resulting from such decisions from their  progressive allies in “media.”

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  5. Oh and do not get me started on  “midwives”.  It’s almost too infuriating to write coherently about.  Parturition presents the greatest risk of death to an otherwise healthy adult organism.  A delay of minutes in a situation where the baby’s oxygen supply is involved can mean that individual is mentally compromised for life.  Oh but hey, mom: you wanna play Little House on the Prairie , at the cost of jeopardizing your life and the baby’s?  Go ahead!  As long as everything goes perfectly—and you better hope it does— maybe you won’t have cause to regret it.

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  6. I had an assistant/or MD once some 25 years ago, and woke on the operating table, screaming while the surgeon is yelling at him, “put her out” as he is laying across my body holding me down. I now question thoroughly who is going to be the anesthesiologist, if it isn’t a trained M.D. I refuse to go under the knife.

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  7. Right, because your anesthesiologist could very easily and very quickly kill you, or kill your brain, right CW?  It has to be perfectly and exquisitely calibrated.

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  8. Hypatia:
    Oh and do not get me started on  “midwives”.  It’s almost too infuriating to write coherently about.  Parturition presents the greatest risk of death to an otherwise healthy adult organism.  A delay of minutes in a situation where the baby’s oxygen supply is involved can mean that individual is mentally compromised for life.  Oh but hey, mom: you wanna play Little House on the Prairie , at the cost of jeopardizing your life and the baby’s?  Go ahead!  As long as everything goes perfectly—and you better hope it does— maybe you won’t have cause to regret it.

    This is an example of how society “pockets” all progress, takes it for granted and then actively suppresses the knowledge which gave rise to the progress in the first place. It is at work in my field as well. In the old days, before endotracheal tubes almost eliminated death from aspiration pneumonitis  (inhaling of gastric contents into the stomach) we were very careful to be as certain as possible enough time passed to allow stomach emptying in patients we made to fast, before anesthetizing, lest stomach contents be present. The mere presence was a sufficient risk to cause allowing 8 hours or more to pass before surgery. Now, in response to the “natural” movement, we are now supposed to allow 90 year-old patient whose fractured hips are to be repaired, to drink clear liquids up until 2 hours before surgery. This is despite the sure knowledge that they will have delayed stomach emptying due to 1. general debility, 2. pain and 3. opioid pain medication which further delays gastric emptying. This is justified, supposedly to prevent them from becoming dehydrated – notwithstanding the fact they all are receiving IV fluids in any case. It goes against the most fundamental and enduring (regardless of what these absurd guidelines say) principle of anesthesiology. “First do no harm” is out the window. Now it is “follow hospital guidelines” (no matter if they are stupid. I have sent a letter objecting to this practice to the hospital. What they don’t know is that, when I am testifying in my own defense at the certain lawsuit, I will be saying that the hospital guidelines caused this, not me. Talk about infuriating!

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  9. Hypatia:
    Right, because your anesthesiologist could very easily and very quickly kill you, or kill your brain, right CW?  It has to be perfectly and exquisitely calibrated.

    It is probably more forgiving than you imagine – provided one is trained, experienced, rigorously follows proper procedures, monitors patients continuously (using invasive monitors when dictated by their specific medical condition and type of surgery) and responds to changes sensibly. The conduct of most anesthetics is routine, smooth and unemotional. As pilots say, “hours of boredom separated by occasional seconds of terror.”

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  10. civil westman:

     

    In the old days, before endotracheal tubes almost eliminated death from aspiration pneumonitis  (inhaling of gastric contents into the stomach) we were very careful to be as certain as possible enough time passed to allow stomach emptying in patients we made to fast, before anesthetizing, lest stomach contents be present. The mere presence was a sufficient risk to cause allowing 8 hours or more to pass before surgery. Now, in response to the “natural” movement, we are now supposed to allow 90 year-old patient whose fractured hips are to be repaired, to drink clear liquids up until 2 hours before surgery. This is despite the sure knowledge that they will have delayed stomach emptying due to 1. general debility, 2. pain and 3. opioid pain medication which further delays gastric emptying. This is justified, supposedly to prevent them from becoming dehydrated – notwithstanding the fact they all are receiving IV fluids in any case. It goes against the most fundamental and enduring (regardless of what these absurd guidelines say) principle of anesthesiology. “First do no harm” is out the window. Now it is “follow hospital guidelines” (no matter if they are stupid. I have sent a letter objecting to this practice to the hospital. What they don’t know is that, when I am testifying in my own defense at the certain lawsuit, I will be saying that the hospital guidelines caused this, not me. Talk about infuriating!

    Preach! CW, I have been a preop nurse for over 20 years and this practice change has been one of my biggest complaints (along with the new “ERAS” fad). I’d love to know the stats on how many cases we postpone or flat out cancel because patients drank something other than clear liquid or decided they could eat cause we were letting them drink. It’s hard enough to get them to understand NPO after midnight without adding the “except clear liquids 2 hours before your surgery”.

    To your point in your OP, a good CRNA is a great asset to the team, but I would be very leery of any place that didn’t have direct supervision by an anesthesiologist.

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  11. Blondie:

    civil westman:

     

    In the old days, before endotracheal tubes almost eliminated death from aspiration pneumonitis  (inhaling of gastric contents into the stomach) we were very careful to be as certain as possible enough time passed to allow stomach emptying in patients we made to fast, before anesthetizing, lest stomach contents be present. The mere presence was a sufficient risk to cause allowing 8 hours or more to pass before surgery. Now, in response to the “natural” movement, we are now supposed to allow 90 year-old patient whose fractured hips are to be repaired, to drink clear liquids up until 2 hours before surgery. This is despite the sure knowledge that they will have delayed stomach emptying due to 1. general debility, 2. pain and 3. opioid pain medication which further delays gastric emptying. This is justified, supposedly to prevent them from becoming dehydrated – notwithstanding the fact they all are receiving IV fluids in any case. It goes against the most fundamental and enduring (regardless of what these absurd guidelines say) principle of anesthesiology. “First do no harm” is out the window. Now it is “follow hospital guidelines” (no matter if they are stupid. I have sent a letter objecting to this practice to the hospital. What they don’t know is that, when I am testifying in my own defense at the certain lawsuit, I will be saying that the hospital guidelines caused this, not me. Talk about infuriating!

    Preach! CW, I have been a preop nurse for over 20 years and this practice change has been one of my biggest complaints (along with the new “ERAS” fad). I’d love to know the stats on how many cases we postpone or flat out cancel because patients drank something other than clear liquid or decided they could eat cause we were letting them drink. It’s hard enough to get them to understand NPO after midnight without adding the “except clear liquids 2 hours before your surgery”.

    To your point in your OP, a good CRNA is a great asset to the team, but I would be very leery of any place that didn’t have direct supervision by an anesthesiologist.

    Why is clear liquid and lack of food important, Blondie or CW?

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  12. 10 Cents:

    Blondie:

    civil westman:

     

    In the old days, before endotracheal tubes almost eliminated death from aspiration pneumonitis  (inhaling of gastric contents into the stomach) we were very careful to be as certain as possible enough time passed to allow stomach emptying in patients we made to fast, before anesthetizing, lest stomach contents be present. The mere presence was a sufficient risk to cause allowing 8 hours or more to pass before surgery. Now, in response to the “natural” movement, we are now supposed to allow 90 year-old patient whose fractured hips are to be repaired, to drink clear liquids up until 2 hours before surgery. This is despite the sure knowledge that they will have delayed stomach emptying due to 1. general debility, 2. pain and 3. opioid pain medication which further delays gastric emptying. This is justified, supposedly to prevent them from becoming dehydrated – notwithstanding the fact they all are receiving IV fluids in any case. It goes against the most fundamental and enduring (regardless of what these absurd guidelines say) principle of anesthesiology. “First do no harm” is out the window. Now it is “follow hospital guidelines” (no matter if they are stupid. I have sent a letter objecting to this practice to the hospital. What they don’t know is that, when I am testifying in my own defense at the certain lawsuit, I will be saying that the hospital guidelines caused this, not me. Talk about infuriating!

    Preach! CW, I have been a preop nurse for over 20 years and this practice change has been one of my biggest complaints (along with the new “ERAS” fad). I’d love to know the stats on how many cases we postpone or flat out cancel because patients drank something other than clear liquid or decided they could eat cause we were letting them drink. It’s hard enough to get them to understand NPO after midnight without adding the “except clear liquids 2 hours before your surgery”.

    To your point in your OP, a good CRNA is a great asset to the team, but I would be very leery of any place that didn’t have direct supervision by an anesthesiologist.

    Why is clear liquid and lack of food important, Blondie or CW?

    Clear liquids leave the stomach quickly, in all but the most impaired patients. As well, they are (usually) less of a problem if inhaled into the lungs. Caveat: if the stomach is making a lot of acid for some reason, the clear liquids can be acidified, thus more dangerous. Since I am the one who must answer for these complications, you would think I ought to have the authority to make the decisions as to how to prepare patients for safe anesthetics. It is another example of hoe do-gooders’ “good ideas” being without consequences for them; the consequences are left for others to suffer and answer for.

    Inhaled food or acid is disastrous. Either causes a raging pneumonitis (inflammation) which inevitably leads to bacterial pneumonia – very damaging to lungs and oxygenation. Often lethally so.

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  13. civil westman:

    10 Cents:

    Blondie:

    civil westman:

     

    In the old days, before endotracheal tubes almost eliminated death from aspiration pneumonitis  (inhaling of gastric contents into the stomach) we were very careful to be as certain as possible enough time passed to allow stomach emptying in patients we made to fast, before anesthetizing, lest stomach contents be present. The mere presence was a sufficient risk to cause allowing 8 hours or more to pass before surgery. Now, in response to the “natural” movement, we are now supposed to allow 90 year-old patient whose fractured hips are to be repaired, to drink clear liquids up until 2 hours before surgery. This is despite the sure knowledge that they will have delayed stomach emptying due to 1. general debility, 2. pain and 3. opioid pain medication which further delays gastric emptying. This is justified, supposedly to prevent them from becoming dehydrated – notwithstanding the fact they all are receiving IV fluids in any case. It goes against the most fundamental and enduring (regardless of what these absurd guidelines say) principle of anesthesiology. “First do no harm” is out the window. Now it is “follow hospital guidelines” (no matter if they are stupid. I have sent a letter objecting to this practice to the hospital. What they don’t know is that, when I am testifying in my own defense at the certain lawsuit, I will be saying that the hospital guidelines caused this, not me. Talk about infuriating!

    Preach! CW, I have been a preop nurse for over 20 years and this practice change has been one of my biggest complaints (along with the new “ERAS” fad). I’d love to know the stats on how many cases we postpone or flat out cancel because patients drank something other than clear liquid or decided they could eat cause we were letting them drink. It’s hard enough to get them to understand NPO after midnight without adding the “except clear liquids 2 hours before your surgery”.

    To your point in your OP, a good CRNA is a great asset to the team, but I would be very leery of any place that didn’t have direct supervision by an anesthesiologist.

    Why is clear liquid and lack of food important, Blondie or CW?

    Clear liquids leave the stomach quickly, in all but the most impaired patients. As well, they are (usually) less of a problem if inhaled into the lungs. Caveat: if the stomach is making a lot of acid for some reason, the clear liquids can be acidified, thus more dangerous. Since I am the one who must answer for these complications, you would think I ought to have the authority to make the decisions as to how to prepare patients for safe anesthetics. It is another example of hoe do-gooders’ “good ideas” being without consequences for them; the consequences are left for others to suffer and answer for.

    You have skin (and other things) in the game, CW.

    Thank you for the answer. I didn’t realize that a little coloring would affect the in stomach time.

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  14. The first question I ask a patient is when they last had something to eat or drink. Had a guy one time tell me not since 10pm.  The anesthesiologist came in for his interview and the patient gave the same answer. The CRNA came in to take him back to surgery. As we always do, she asked the same question but this time the guy said he had a full breakfast. Now sometimes people joke around with you but now is serious time so she asked again with a stern tone in her voice. He said it was true, he’d had a full breakfast. It just so happened that the ‘ologist and I were standing nearby and heard this exchange. We both yanked open the curtain and asked him why he lied to us. He said after the third person asked the same question he figured it must be important. I didn’t give the ‘ologist time to talk before I started reading him the riot act about how he could die on the operating table from his stupidity. We were all so pissed he was canceled outright instead of delaying the case for later in the day.

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  15. Blondie:
    The first question I ask a patient is when they last had something to eat or drink. Had a guy one time tell me not since 10pm.  The anesthesiologist came in for his interview and the patient gave the same answer. The CRNA came in to take him back to surgery. As we always do, she asked the same question but this time the guy said he had a full breakfast. Now sometimes people joke around with you but now is serious time so she asked again with a stern tone in her voice. He said it was true, he’d had a full breakfast. It just so happened that the ‘ologist and I were standing nearby and heard this exchange. We both yanked open the curtain and asked him why he lied to us. He said after the third person asked the same question he figured it must be important. I didn’t give the ‘ologist time to talk before I started reading him the riot act about how he could die on the operating table from his stupidity. We were all so pissed he was canceled outright instead of delaying the case for later in the day.

    Why is it so dangerous? Is it because of stomach acid? Does this mean emergency surgery also very dangerous because there was no fasting prep?

    Does brushing your teeth affect things? Could that be counted as eating?

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  16. 10 Cents:

    civil westman:

    10 Cents:

    Blondie:

    civil westman:

     

    In the old days, before endotracheal tubes almost eliminated death from aspiration pneumonitis  (inhaling of gastric contents into the stomach) we were very careful to be as certain as possible enough time passed to allow stomach emptying in patients we made to fast, before anesthetizing, lest stomach contents be present. The mere presence was a sufficient risk to cause allowing 8 hours or more to pass before surgery. Now, in response to the “natural” movement, we are now supposed to allow 90 year-old patient whose fractured hips are to be repaired, to drink clear liquids up until 2 hours before surgery. This is despite the sure knowledge that they will have delayed stomach emptying due to 1. general debility, 2. pain and 3. opioid pain medication which further delays gastric emptying. This is justified, supposedly to prevent them from becoming dehydrated – notwithstanding the fact they all are receiving IV fluids in any case. It goes against the most fundamental and enduring (regardless of what these absurd guidelines say) principle of anesthesiology. “First do no harm” is out the window. Now it is “follow hospital guidelines” (no matter if they are stupid. I have sent a letter objecting to this practice to the hospital. What they don’t know is that, when I am testifying in my own defense at the certain lawsuit, I will be saying that the hospital guidelines caused this, not me. Talk about infuriating!

    Preach! CW, I have been a preop nurse for over 20 years and this practice change has been one of my biggest complaints (along with the new “ERAS” fad). I’d love to know the stats on how many cases we postpone or flat out cancel because patients drank something other than clear liquid or decided they could eat cause we were letting them drink. It’s hard enough to get them to understand NPO after midnight without adding the “except clear liquids 2 hours before your surgery”.

    To your point in your OP, a good CRNA is a great asset to the team, but I would be very leery of any place that didn’t have direct supervision by an anesthesiologist.

    Why is clear liquid and lack of food important, Blondie or CW?

    Clear liquids leave the stomach quickly, in all but the most impaired patients. As well, they are (usually) less of a problem if inhaled into the lungs. Caveat: if the stomach is making a lot of acid for some reason, the clear liquids can be acidified, thus more dangerous. Since I am the one who must answer for these complications, you would think I ought to have the authority to make the decisions as to how to prepare patients for safe anesthetics. It is another example of hoe do-gooders’ “good ideas” being without consequences for them; the consequences are left for others to suffer and answer for.

    You have skin (and other things) in the game, CW.

    Thank you for the answer. I didn’t realize that a little coloring would affect the in stomach time.

    Alas, it is not the coloring, but the particles. Clear liquids like water, apple juice, ginger ale or black coffee have no suspended particles. Compare this with milk, orange juice, or blenderized fruit drinks. You can’t see through them because of the fine particulate matter. Fine matter, yes, but big enough to block microscopic air passages in the lungs. When blocked, these become a nidus for infection, especially if also injured by exposure to stomach acid, which likely accompanied the particulate matter.

    Yes, emergency surgery does present a higher risk of aspiration pneumonitis. In those cases the need for surgery NOW exceeds the risk of aspiration; otherwise put, the risk of waiting exceeds the risk of aspiration (as if the patient is exsanguinating). Some operations are of lesser urgency and can wait. As I explained above, though, the risk can still be increased – even with fasting – if the patient is in pain or on opioid pain medicine. Both of these delay gastric emptying. Clear liquids are believed to leave the stomach more quickly than those with particulates; in any case, the risk of damage from their aspiration is less, as I said. BTW aspiration of particulate antacids (any of the liquid or chewable ones like Maalox, etc.) also results in serious lung injury. So, take Zantac or Pepcid (H-2 blockers) a couple hours pre-op with a sip of water, not Maalox! Proton pump inhibitors like Prilosec take a couple of days to start working, so a single dose is less effective than H-2 blockers.

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  17. In 2007 I had an MVD (micro vascular decompression) to lift an artery off the brain stem, which was rubbing against the #7 or facial nerve. (And also discovered the #8 Vestibular nerve was entangled) I wasn’t allowed to eat or drink 10 hours prior to surgery. I was given an IV but the surgery was started several hours later so actually went 12 hours with out eating or drinking. The anesthesiologist is so important for this surgery it takes a supper expert to do it. The touch and go for the anesthesia is so intrinsic, I had to read a book to really understand why. “Working in a Very Small Place” by Mark Shelton, the making of a neurosurgeon. I doubt if the neurosurgeon would have let a Nurse Practitioner do this. I was also positioned in what is called a “park bench” sitting in a bean bag chair with my head pinned, so couldn’t inadvertently move. The neurosurgeon wants you to wake up immediately when you are taken back to recovery, which I did, promptly fell back to sleep and had problems for the next 2 or 3 days staying awake. The recurring voices kept saying, “wake up Kay and breathe, wake up Kay and breathe.” I was in ICU for 3 days with this little problem.

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  18. Thank you, CW, for your beautiful explanation. I have always thought the clear liquid was not that important but now I understand the risks because of you and Blondie.  The logical connection to lung problems was not obvious to me.

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  19. 10 Cents:
    Thank you, CW, for your beautiful explanation. I have always thought the clear liquid was not that important but now I understand the risks because of you and Blondie.  The logical connection to lung problems was not obvious to me.

    And regards to your question of brushing your teeth, we appreciate when you do (CW can tell you better than I can about that). Just swish and spit like at the dentist. 😜

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  20. The natural result of “cost-cutting”.  I am a buyer by trade, and I hate cost-cutting.  You are taking your life in your hands deciding on the anesthesia medical specialty.  More power to you, CW, and thanks for this very informative post.

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