I read yesterday that January 2019 is being celebrated as “CRNA Month.” CRNA is an abbreviation for certified registered nurse anesthetist. They’re registered nurses with additional training and experience in providing anesthesia care.
From my experience as a Houston, Texas medical malpractice attorney, I think that many anesthesia providers do little to educate people about what CRNAs are and the critical role that CRNAs have in their care. I think that CRNA Month is an ideal time to delve into these issues.
Texas law requires physicians to obtain informed consent before starting treatment or a surgical procedure. Informed consent involves the doctor going over with the patient the risks and benefits of the procedure or treatment, alternatives, and doing nothing. According to Texas Medical Board rules, obtaining informed consent is a duty that can’t be delegated by the physician.
There’s one exception to the rule and it involves mid-level providers, like CRNAs, nurse practitioners, and physician’s assistants. To the extent they’re allowed to practice independently, or under the supervision of a doctor, mid-level providers can obtain informed consent from patients.
When patients are going to have a surgery requiring anesthesia, there will be a separate informed consent for the procedure itself and another informed consent for the anesthesia services.
The anesthesia consent is where things often get, to put it very politely, interesting. Let me explain why.
In Texas, CRNAs don’t practice independently, but rather under the medical supervision or medical direction of a medical doctor. I’ll go into that more later. What I find dubious about informed consent for anesthesia services is that it is almost always done by a physician anesthesiologist.
The part that’s almost always left out is that’s about the last time the anesthesia doctor will be substantially involved in the patient care. After informed consent is complete, it’s a bait and switch, a passing of the baton from the doctor to a CRNA, who will manage essentially all of the remainder of the patient’s anesthesia care.
Medical direction and supervision
Medical compensation and salary studies always show that anesthesiologists are among the top earners of all medical specialties. As you might have guessed by now, CRNAs are much cheaper to hire. That’s why Medicare and private health insurance companies have come up with different payment rates for anesthesia services, depending on how involved the physician anesthesiologist is in a case.
These payment rates encourage anesthesia groups to use more CRNAs and become less reliant on costly anesthesiologist physicians. Here’s how they work.
For medical direction, the anesthesiologist manages, or directs, up to four CRNAs handling four different procedures at once.
For medical supervision, the anesthesiologist manages, or supervises, over five CRNAs handling five more different procedures at once.
For both medically directed and supervised systems, the anesthesiologist is supposed to be “immediately available” if there’s a complication. Plus, the anesthesiologist is required to be in the operating room during the most dangerous parts of the anesthesia services, including induction (putting the patient under general anesthesia) and emergence (bringing the patient out of general anesthesia).
From my experience, I think that most CRNAs handle most routine cases well. The difference between CRNAs and anesthesiologists emerges, though, when there’s a complication or problem during surgery—things like the patient stops breathing (respiratory insufficiency or distress) or heart problems. Anesthesiologist have more extensive training to handle these medical emergencies, and that’s why operating room personnel (including CRNAs) rush to get them into the operating room (OR) when there’s a problem.
Questions you should ask
If you or a loved one is having a surgical procedure, be ready for the anesthesia informed consent conversation. Let me share what happened when I was in the OR with a family member a few years ago at Houston Methodist Willowbrook Hospital.
A registered nurse came into the patient room in the OR with some paperwork to sign off on. One of the “fine print” boxes that required patient initials and agreement said that some anesthesia care may be provided by a CRNA. The nurse was friendly but offered no explanation for anything. When we stated that we would not be agreeing to that, she was quick to take back the paperwork and said that she’d have a doctor come in to discuss it.
A few minutes later, a friendly and impressive anesthesiologist came into the patient room. I asked point blank if she or another anesthesiologist would be personally present in the OR with my relative throughout the procedure. She smiled and said, “No, CRNAs handle that at this hospital.”
I asked the anesthesiologist if she could find a physician anesthesiologist to handle my relative’s case from start to finish. She gave an approving, understanding smile and said she’d see what she could do. This was around 3:30 p.m. on a weekday, and a few minutes later she returned and said that she was the only anesthesiologist on duty in the OR for the whole hospital. We were relieved to hear her say, though, that she would personally handle my relative’s procedure, and everything turned out fine.
By the way, if I understood her correctly that she was the only anesthesiologist on duty, I wonder what would’ve happened if there was a complication in one of the ORs that the CRNAs were handling.
When talking with the anesthesia provider about how your procedure will be staffed, don’t be shy—it’s your life on the line! Besides, if the CRNA lobbying groups are correct that CRNAs are just as competent as anesthesiologists and have the same types of results, then no one should be shy about answering these questions.
(1) Will a physician anesthesiologist be in the OR the entire time?
(2) If not, will the anesthesiologist be in the OR, at the patient bedside, during induction and emergence?
(3) Is the case being staffed under medical direction or medical supervision?
(4) How many other simultaneous surgeries will the anesthesiologist be staffing, along with yours?
(5) When did the CRNA finish CRNA school?
(6) How long has the CRNA been practicing in ORs as a CRNA?
(7) How long has the CRNA been practicing as a CRNA for this type of procedure?
Why it matters
If a patient’s general anesthesia is being managed by a CRNA who is inexperienced in handling emergencies, there can be serious consequences.
If the patient has heart or breathing complications during surgery, the providers at the bedsides have only a few minutes to set this right before the brain is permanently damaged by a lack of oxygen. Beyond that, I’ve represented multiple families in wrongful death medical malpractice cases where a sluggish, panicked CRNA response, and even a short delay in getting the anesthesiologist back to the OR led to patient death.
We are here to help
If you or someone you care for has been seriously injured because of anesthesia errors and mistakes, the experienced anesthesia medical malpractice attorneys at Painter Law Firm, in Houston, Texas, are here to help.
Click here to send us a confidential email via our “Contact Us” form or call us at 281-580-8800.
All consultations are free and, because we only represent clients on a contingency fee, you will owe us nothing unless we win your case. We handle cases in the Houston area and all over Texas. We are currently working on medical malpractice lawsuits in Houston, The Woodlands, Sugar Land, Conroe, Dallas, Austin, San Antonio, Corpus Christi, Bryan/College Station, and Waco.
Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.