Pain treatments at heart of dispute

Friday, March 9, 2012 | 12:01 a.m. CST

SPRINGFIELD — Retiree Alicia Ritchie's chronic back pain started up again right around Thanksgiving. It was so bad she sometimes had to use a walker to get out of bed.

Seeking relief, Ritchie went to Mercy's pain management facility where Ben Lampert inserted four 10-centimeter needles near the joints of her spine. He used the needles to burn away the nerves with radiofrequency waves and ease Ritchie's pain.

"I feel fine," Ritchie, 74, said after the procedure. "I don't have any pain now. There's no pain."

Procedures such as Ritchie's are at the center of a dispute between doctors and nurses over who should perform them. So far, the two sides have tussled before the state board that oversees doctors and the state Supreme Court. The conflict has now moved to the General Assembly, where physicians want the legislature to place restrictions on nurses performing some pain-relieving procedures.

"They want to practice chronic pain management, which I think is part of the practice of medicine," Lampert said.

Carol Kemna, executive director of the Missouri Association of Nurse Anesthetists, said bills that the Missouri legislature is considering could prohibit certified, registered nurse anesthetists from performing many procedures to treat or prevent acute pain, such as epidurals for women in labor or some nerve blocks after surgery.

"If this bill is passed, it would have catastrophic effects on the patients and the financial health of the rural facilities" Kemna said.

Missouri isn't the only state where this struggle is playing out. Similar battles have taken place in at least seven other states including Alabama, Iowa, Kentucky, Louisiana and Oklahoma.

The power struggle comes as proponents of health reform have urged that the role of advanced practice registered nurses be expanded to ease a doctor shortage that's expected to increase. Advanced practice registered nurses generally have post-graduate education.

"There's going to be a turf battle when it comes down to the bottom line because doctors make money off of advanced practice nurses," said Jill Kliethermes, the chief executive officer of the Missouri Nurses Association.

Sen. Bob Dixon, R-Springfield, has introduced another bill that would allow certified registered nurse anesthetists to provide anesthesia services without supervision. It also would expand the authority of advanced practice registered nurses.

"Timely access to quality health care is important to every Missouri family," Dixon said. "Taking advantage of every opportunity for health care providers to discuss improving access and service delivery is valuable."

David Barbe, the secretary of the American Medical Association and a family doctor from Mountain Grove, said the training of advanced practice nurses doesn't compare to that of doctors.

"The clinical training for a physician is approximately 10 times that for an advanced practice nurse," Barbe said. "It's hard for me to see that someone with a tenth of the training can do the same work. That doesn't seem to be good public policy."

The struggle over what role nurses should have in pain management has involved Glenn Kunkel, a doctor in Rolla, and Kevin Snyders, a certified registered nurse anesthetist who was supervised by Kunkel. In December, the state disciplinary board for doctors reprimanded Kunkel for allegedly not examining a patient identified as R.M.O. in state disciplinary documents who was treated by a certified nurse anesthetist in April 2007.

The patient underwent the same type of procedure that Lampert recently performed. A lawsuit filed by Ronni Michelle Oliver against Kunkel and Snyders complained that the procedure caused vocal cord paralysis. Online records show the case was dismissed in February at the request of the parties. Whether the parties arrived at a settlement is unclear.

Kunkel's reprimand also mentions another patient identified as D.G. in state disciplinary documents who received injections. A patient named Debra Garren, also sued Snyders and Kunkel. Her lawsuit, which is pending, said she lost the use of much of her upper right extremity after being treated by Snyders.

Snyders and Kunkel could not be reached for commentafter several phone calls.

The Missouri Nurses Association said that multiple studies have found that certified registered nurse anesthetists provide high-quality care with low litigation rates associated.

"There's lots of restrictions," said Shanna DeWater, an advanced practice registered nurse in Mount Vernon who is one of the authors of a paper issued by the nurses' association. "We're trying to get these decreased, so we can provide the care we're educated to do."

But Lampert, the doctor who treated Ritchie, said a line should be drawn somewhere about what care nurses should provide.

"Can they do heart surgery?" Lampert asked. "Replace a knee?"

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