3 answers
Mari
Student
1
Question
Updated
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What is the most ethically challenging decision you face when balancing adequate anesthesia with patient safety, especially in settings where resources are limited?
I recently went on a medical trip to Nigeria, and witnessed many procedures that could have more adequately supported the patient if there was better access to anesthetic care. As someone who is curious and passionate about a future in the medical field, aiming to work as a Certified Registered Nurse Anesthetist (CRNA). My goal is to understand this question from a human perspective or from a personal experience. Rather than a general or textbook answer.
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3 answers
Brett Schlifstein
Anesthesiologist
42
Answers
Pittsboro, North Carolina
Updated
Brett’s Answer
Hi Mari,
You pose an interesting question. CRNAs practice in a variety of locations, and in several different models. Laws vary from state to state, and policies vary from hospital to hospital, but CRNAs are required to have a supervising physician. This physician may or may not be an anesthesiologist. I very much doubt that a CRNA supervised by a non-anesthesiologist who runs into a problem (usually an airway issue), would be able to count on that physician for rescue. So I think that a potential ethical issue for you in the future is whether you feel comfortable in the practice model.
So my advice to you is to thoroughly investigate the policies of the facility where you are considering practicing, and the model of anesthesia practice. Ask yourself what kind of help you can expect when you run into an emergency (and when you practice long enough, you will certainly encounter them), and if you are comfortable with that emergency help. Would you allow one of your loved ones to be cared for in that situation? If the answer is no, then you need to look elsewhere.
You may also feel pressure from employers/supervising physicians to do things that are clearly wrong, can hurt patients, and possibly even be illegal. There was a hepatitis outbreak that was traced to an endoscopy center in Las Vegas. Upon investigation, the owners of the center (the gastroenterologists) who employed and supervised CRNAs instructed them not to waste syringes of unused sedatives, and to use the same syringe on subsequent patients. Patients were harmed, licenses were lost, and people went to jail, all in an effort to boost profits for the owners of the facility.
Hope that answers your question, and good luck!
Brett Schlifstein, M.D.
Anesthesia Director
ECU Health Roanoke Chowan Hospital
You pose an interesting question. CRNAs practice in a variety of locations, and in several different models. Laws vary from state to state, and policies vary from hospital to hospital, but CRNAs are required to have a supervising physician. This physician may or may not be an anesthesiologist. I very much doubt that a CRNA supervised by a non-anesthesiologist who runs into a problem (usually an airway issue), would be able to count on that physician for rescue. So I think that a potential ethical issue for you in the future is whether you feel comfortable in the practice model.
So my advice to you is to thoroughly investigate the policies of the facility where you are considering practicing, and the model of anesthesia practice. Ask yourself what kind of help you can expect when you run into an emergency (and when you practice long enough, you will certainly encounter them), and if you are comfortable with that emergency help. Would you allow one of your loved ones to be cared for in that situation? If the answer is no, then you need to look elsewhere.
You may also feel pressure from employers/supervising physicians to do things that are clearly wrong, can hurt patients, and possibly even be illegal. There was a hepatitis outbreak that was traced to an endoscopy center in Las Vegas. Upon investigation, the owners of the center (the gastroenterologists) who employed and supervised CRNAs instructed them not to waste syringes of unused sedatives, and to use the same syringe on subsequent patients. Patients were harmed, licenses were lost, and people went to jail, all in an effort to boost profits for the owners of the facility.
Hope that answers your question, and good luck!
Brett Schlifstein, M.D.
Anesthesia Director
ECU Health Roanoke Chowan Hospital
James Hanson
Pediatric Intensive Care Physician; Consultant
160
Answers
Oakland, California
Updated
James’s Answer
Fortunately, if you learn excellent anesthetic technique and patient assessment, the risk of providing "adequate" anesthesia is reasonably safe (although always caries risk). Be certain to explain to each patient the risks and benefits of anesthesia, including the possibility of some recall of sensation/hearing that was unpleasant - then try to titrate the anesthetic to minimize harm while achieving good anesthesia.
Many patients want to feel nothing, but it is much safer to provide procedural sedation, rather than general anesthesia for many procedures. Don't be afraid to counsel them accordingly.
Refuse to perform unsafe anesthesia when the patient has medical or anatomical reasons that make anesthesia too risky. Only fully trained anesthesiologists then might agree to anesthetize them with clear warnings about the risks and how they might mitigate those risks.
Many patients want to feel nothing, but it is much safer to provide procedural sedation, rather than general anesthesia for many procedures. Don't be afraid to counsel them accordingly.
Refuse to perform unsafe anesthesia when the patient has medical or anatomical reasons that make anesthesia too risky. Only fully trained anesthesiologists then might agree to anesthetize them with clear warnings about the risks and how they might mitigate those risks.
Martin Schoen
APRN
387
Answers
Ocala, Florida
Updated
Martin’s Answer
When the patient and surgeon are both comfortable and relaxed to adequately perform the procedure. I have had pts that state they were inadequately under and heard or felt the surgical procedure. The surgeon must confidently feel you know enough not to over-sedate, but be relaxed so they can manipulate the structures, especially skeletal, that need intervention.
I appreciate you taking the time to answer this.
Mari