“When we ended, it was not because I’d stopped caring, but because we were unwilling to shift what we wanted or could offer one another.”

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METs >4

“I used to be a heroin addict, ex-alcoholic too,” he said to me, as his piercing blue eyes looked into mine awaiting judgment and scrutiny. As his nurse anesthetist (student) it took me hundreds of patients later to maintain a neutral response, unscathed by his words but exuding understanding and genuine care instead. After all, I would have to take on his body for the next forty minutes or so. Not only did I have to know what heroin’s effect on the body was and alcohol’s chronic use on his liver, translating into a chronic vitamin deficiency but really how was I going to keep him breathing and safe for the next few minutes keeping his stories in the back of my head?

 

Dear future me

As I sit here in a Starbucks (after a 10ish hour shift at my 2nd clinical rotation) I can’t help to think about how time is either on your side or not. And for me, I just want to fast forward, become a CRNA, so I can work on endless side projects I have always envisioned. One that sticks out, in particular, is creating a senior center for the Asian community in my neighborhood. Particularly South Asian.

You see, my father was diagnosed with bipolar disorder last summer (coinciding perfectly with the stress of starting summer classes of what I did not anticipate to be the hardest months of my life after) and has been progressing into roller-coaster results. Hospitalized a handful of times of syncope episodes, and medication noncompliance which resulted in being admitted to an inpatient unit. That was not pretty. To watch your father, once an influential surgeon in Bangladesh, Japan, and Vienna regress to childish behavior and being locked up behind the bars of a psychiatric center. Was he always bipolar? Was he just manic all of those times that he had a freak episode in Bangladesh, and people attributed it to him a surgeon?

He’s a lot better now. Besides the fact that he constructed a metallic shiny gate surrounding the perimeter of my house without my mother’s consent I think he is doing quite well. The only other problem is- he is incredibly bored. Amidst his mental disorder, there is just NOTHING to do in my neighborhood besides go to the mosque and pray five times a day. There is no social life. There are no friend circles. Just as we were children, our elderly need to be similarly stimulated or we are faced with a noticeable decline in the activity of daily living. Surrounding retired neighbors are also similarly just as bored as I find them loitering in my backyard, entertaining my dads nonsense bicker.

My point is senior centers need to be a thing. Not just for those who are disabled but for everyone who is getting old. Those are retired and may or may not have grandchildren or means to a hobby. I would love to start this. Back in nursing school for our community nursing clinical rotation we facilitated a “eat better and move more” program for the senior citizen of East Harlem. I would love to mirror this, to have a schedule every day for weight training, walking groups, field trips, educational sessions about nutrition. They seemed to really love it as if they finally had a purpose again. Bangla translators and Bengali young professionals who want to give out pro-bono advice and teaching need apply! 🙂

 

 

Cultural Autobiography

My name is Jasmin Zaman and I am a 26-year-old going on to be a 27-year-old female (T-minus 5 days) of Filipino and Bangladeshi origins. My background is a blend of culture and beliefs: I was born Catholic, having been baptized as a child as a result of my mother’s Catholic background. However, she later converted to Islam while my older brother and I were still young; hence we did too. Growing up, I learned both Tagalog and English as my native tongue, and when my family moved to Bangladesh, I learned to speak Bangla as well. In the United States, I would go on to take Spanish in school for several years and adopt a fourth language.  I consider myself part of a middle-income family; my parents are still married and living together. Consequently, the idea of a family unit is one that is very important to me. Growing up in an immigrant-Asian household the value of education was a top priority and the expectation is that the family raises the children until they are married, then, the children have the responsibility of returning the favor and have to take care of their elderly parents in return.

Culture and values have been exposed to me both in school and from my interactions with the world. From living in a third world country where everyone spoke the same language and practiced the same religion to a melting pot of people who coexist albeit their culture and beliefs is beyond fascinating to me. Hailing from a fairly religious family background, I grew up heterosexual while misconstruing homosexuality, as the idea of being something “different” was shunned upon. I was also made to believe that “white” is powerful. Often times, Filipinos will be found bleaching their skins to be more light-skinned. Actors in tv shows were all light-skinned and this seemed to be omnipresent in the Asian world. Even in Bangladesh, I learned that many of the women used products called “fair and lovely” to also try to brighten their brown skins.

I never understood the value of being a white person until I came to the United States. Let alone, a white man. I would later find out that with all of the political undercurrents, with Donald Trump as the president, racism towards minorities is still omnipresent. White males would take on more powerful roles in most industries while minorities and females were subjugated to more submissive ones with little room for growth. It is to no surprise that Filipino women, just like my mother, are found to be nurses with their caring and nurturing manners. My mother encouraged me tenfold to consider nursing as a profession because as a woman it would teach me not only to understand how my body functions, but to be able to take care of others, and most importantly how to raise children. So, I only continue to be part of the minority – a Brown, Muslim, woman.

I consider myself a product of the NYC public school system. I immigrated here from Bangladesh when I was eight years old. I grew up in the Bronx, went to high school in Brooklyn, and lived in Manhattan for a few years when I attended nursing school. Currently, I live with my parents in the Bronx. My first job was a teacher’s assistant in the specialized high school admission test (SHSAT) program, to help students of the public-school system get admission to a competitive, elite specialized high schools in NYC – such as Stuyvesant, Bronx Science, and Brooklyn Tech. My first job as a nurse was at the Mount Sinai Hospital, providing care to a plethora of patients from the underserved populations of Spanish Harlem and Harlem to the wealthy Upper East-Siders. I am grateful to have grown up in New York City, where all walks of life have learned to thrive with one another – or so I thought.

Living in the Bronx, news of shootings, stabbings, and gang violence is common. However, the recent news of the death of an innocent boy named Junior left me in shambles: a 15-year old approached by five young men armed in machete and kitchen knives would drag him out of the neighborhood deli and take turns ramming their knives into him. How was nobody able to help this boy? Why did Junior have to walk to the hospital and bleed out to death as people stared at him walk by? Have we, as a society, become desensitized to all that makes us human? I have to admit that with the presence of crime in my borough often as a result Black or Hispanic assailant, has left me cautious and undeniably afraid whenever I walk past one. However, being a girl with ethnically ambiguous looks walking in the streets of the Bronx often calls for unwarranted attention and getting cat-called by a group of ANY men is a norm. To say the least, these experiences have allowed me to remain hypervigilant of my surroundings and maintain a sense of “street smarts.”

On a more positive note, I love to travel and explore the world. Some of my favorite places typically include sun and beaches like Greece and sunny California. I love to learn from my experiences, not only during a pursuit of fun but while helping others in need. I was part of a three- week Habitat for Humanity mission to help build houses for those who lost their homes in riverbanks of Pasig City, Philippines after a devastating storm in 2011.  It was a humbling experience to help these people who genuinely seemed so happy with having so little in their lives. Travelling has allowed me to keep an open mind and embrace differences people may have. My interactions with so many walks of life have defined me as the person I am today.

What was the most important moment of my life? I would say starting this CRNA journey. I think this was a pivotal point as this is when all of my worlds would collide – nursing, love for others, and the idea of helping people abroad with my medical knowledge. It is actually a dream come true. As a nurse anesthetist, I am excited to use my experiences to understand patients on a cultural and personal level, in order to tailor their care appropriately. As someone who loves to be in control of every situation, I am excited to be their vigilant guardian angel.

Nurse Anesthetist- Surgeon Collaboration: To address the Anesthesia Provider Shortage

 

In 1936, Dr. George W. Crile, one of the greatest surgeons of all time, said regarding nurse anesthetists: “I think this is one of the most beneficent movement we have seen in the whole field of operative surgery (Bankert, 2013, p. 39).” Anesthesia care in the United States dates back to the 1800s and the turn of the twentieth century. To meet the needs of patients, American surgeons trained and recruited nurses during the Civil War (Koch, 2015). A shortage of anesthesia providers, combined with the reluctance of physicians to accept lower pay and a subordinate role, led nurses to take on the role. Surgeries were made possible by the introduction of certain techniques and a collaborative effort of the nurse anesthetist-surgeon relationships. The purpose of this paper is to highlight three nurse anesthetist-surgeon collaborations to purport their use in the anesthesia shortage in low and middle-income countries like Uganda and Kenya.  The insight of each collaboration reflects a potential road to success for future collaborations and contributions to anesthesiology innovation and techniques.

Surgeon-Nurse Anesthetist Collaborations

Alice McGaw and Charles Mayo

Alice McGaw and Charles Mayo mastered the open-drop technique of anesthesia when they administered ether and chloroform by dropping it through a cloth instead of pouring, making the induction of anesthesia less barbaric. Medical providers came from all over the world to watch the nurse anesthetist techniques that were being performed at the Mayo Clinic. “Notes on the Administration of Anesthetic in America, with Special Reference to the Practice at the Mayo Clinic” was presented to the Section of Anesthetic of the Royal Society of Medicine in 1912 (Bankert, 2013, p. 35). This highlighted the significant impact of the nurse anesthetist role in the changing world of surgery.

Hodgins and Crile

Agatha Hodgins was celebrated for the nitrous oxide technique she performed with surgeon Dr. George Crile. Dr. Crile acknowledged “the administering of an anesthetic is not only an art but a gift. In my mind, it ranks close to the work of the operating surgeon… Miss Hodgins made an outstanding anesthetist for she had to a marked degree both the intelligence and the gift” (Bankert, 2013, p. 41). Crile and Hodgins also succeeded in starting the Lakeside Hospital of Anesthesia where the nurse anesthetist service and training flourished. Hodgins later went on to become the founder of the American Association of Nurse Anesthetist (AANA).

Graham and Lamb

Finally, Dr. Evarts A. Graham was considered the father of modern-day chest surgery, working alongside his nurse anesthetist, Helen Lamb.  Lamb introduced and taught the practice of endotracheal intubation. This duo worked together to come up with an anesthetic plan for the first pneumonectomy in the US. Koch (2015) mentioned that Helen Lamb understood the concept of positive pressure ventilation well before her time, as she compressed the breathing bag continuously throughout the 165-minute operation. Lamb proved that aside from her innovative ideas, she was also built to be a leader when she served as president of the American Association of Nurse Anesthetists and chaired its powerful Education Committee (Koch, 2015).

Anesthesia Shortage in Low and Middle-Income Countries

Dubowitz et al. (2009) mentioned that sub-Saharan African countries are suffering from a lack of anesthesia providers. In Uganda, there are approximately 14 physician–anesthesiologists for a population of more than 30 million people. Neighboring country Kenya has a total population of 32 million people, yet there are only 13 out of 120 anesthesiologists who work in public hospitals. In comparison, in the US the ratio is an estimated 1 anesthetic provider per 4,000 population. Uganda and Kenya have programs in place utilizing “nurse anesthetists” in an attempt to address the anesthesia shortage in these countries.  Similar successful programs have been implemented in Malawi and Mozambique, Nepal, and Iran (Dubowitz et al., 2009).

Professional Role

In the future, the United States and the AANA should employ humanitarian efforts to alleviate the anesthesia shortage in the developing world. Alongside other US-trained nurse anesthetists, I hope to partake in the start of many nurse anesthetist schools. This will increase utilization of the anesthesia provider to close the growing gap between the number of providers and surgical need. By doing so, we can encourage leadership roles in the nurse anesthetist profession.

Conclusion

In the United States, the birth of nurse anesthesia came from a dire shortage of anesthesia providers in the surgical arena. Anesthetists have pioneered the field of anesthesia with arrays of techniques and devices to enhance patient experience during surgery. Good rapport, training, and teamwork are reflected in the aforementioned nurse anesthetist-surgeon collaborations. In these examples, it is evident that nurse anesthetists are competent in providing safe anesthetic care and are respected by fellow surgeons, in addition to trailblazing the profession by taking upon leadership roles in the national association (AANA). By understanding and learning the history of anesthesia practice and development, it is crucial to employ the nurse anesthetist- surgeon collaboration method to address the shortage of anesthesia providers around the world and to promote future leaders in the nurse anesthesia profession.

References

Bankert, M. (2013). Watchful care: a history of Americas nurse anesthetists. Park Ridge, IL:

American Association of Nurse Anesthetists.

Dubowitz, G., Detlefs, S., & Mcqueen, K. A. (2009). Global anesthesia workforce crisis: a

preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices. World Journal of Surgery,34(3), 438-444. doi:10.1007/s00268-009-0229-6.

Koch, B. E. (2015). Surgeon-Nurse Anesthetist collaboration advanced surgery between 1889

and 1950. Anesthesia & Analgesia,120(3), 653-662. doi:10.1213/ane.0000000000000618

 

 

The Swiss-cheese Model and the Healthcare System

Patient Safety Reflection on the Swiss Cheese Model: Checklists and Near Misses

According to Johns Hopkins, medical errors is the third leading cause of death in the United States right after cancer and heart disease. This statistic is alarming! In this reflection I will highlight Dr. Laura Ardizzone’s patient safety lecture on the Swiss Cheese model, the use of checklists and reporting “near misses” to fix potential future adverse events from occurring.

Multicausal Theory of Errors and Safety “Swiss Cheese” Model

Dr. Laura Ardizzone mentioned the Swiss Cheese Model during her patient safety presentation. She mentioned that this explained why medical errors occurred as there are often many holes in the systems or process. She goes on to explain that if one safety barrier fails, it has the potential to fall through other safety barriers and cause harm to the patient. Interestingly, there have been more research on this explaining that there can be 5 slices that can address these holes. The five slices are as follows: (1) training, (2) technology (3) checklists (4) the culturally expected scripted or standardized communication and (5) institutional policies and procedures (Stein & Heiss, 2015).

Checklist benefits

I thought that her advocacy for checklists was telling. I, too, often use checklists and I find it helps me with efficiency. Instead of remembering everything we have to do in our heads, a checklist ensures all tasks, menial or not, are completed. In our principles of anesthesia lab class last semester, while emulating the scenario of malignant hyperthermia, it was evident that anxiety was lessened and the chaos of a potentially fatal event was under control with the use of a checklist. When one person was designated as the leader of the team, assigned roles, and read everything off the list to ensure that every guideline was followed and not missed, the task of protecting our patient was done in a timely manner.

As a CRNA, I know that I will often be faced with a difficult situation especially in the case of securing and maintaining the airway. The setting when I cannot intubate, cannot ventilate is one that I am most afraid of. However, with the help of the difficult airway algorithm, like a checklist, where we ensure nothing is missed along with our training during school; I can address this in the clinical setting in an organized efficient manner.

Near Misses

Another topic Dr. Ardizzone mentioned were the cases of “near-misses” and the number of planned and unplanned events. The thought of an unplanned event with no safety mechanism in place is unsettling. This is partly due to the number of underreported events. In a 2018 study by Hamilton et. al, “Only 1 of 137 observed events was reported in the handwritten variance system.” The study shows that despite multiple reporting systems, many observed faults in processes were not reported. This is even more concerning to me as a future provider. I think we need to enforce “just culture” throughout the healthcare system of focusing mistakes on learning and not punishment. It should be everyone’s responsibility to report an observable near- miss error. Thus, we can prevent such future errors from happening.

Conclusion

I believe that understanding the holes in the systems can allow us to operate more efficiently. By employing the above-mentioned strategies of following the “slices” of the cheese, as well as promoting just culture after reporting “near misses” we can work together to provide safe, effective and high-quality patient care for our patients.

 

 

 

Reflection on Diversity: Historical Trauma and Cultural Humility

Dr. Vivian Taylor holds such an incredible title of being the associate dean of Diversity and Cultural Affairs here at the Columbia University School of Nursing. Her lecture was a powerful reminder to us, students, that education does not stop in our anesthesia textbooks, but in fact begins again within ourselves. The purpose of this paper is to reflect on her lecture as it reverberated with me when she spoke about historical trauma, her examples when explaining it, and cultural humility.

Historical Trauma

Tuskegee Study of Untreated Syphilis

Historical trauma has been defined as “anyone living in families at one time marked by severe levels of trauma, poverty, dislocation, war, etc., and who are still suffering as a result” (Cutler, n.d.). I have never heard of this concept until yesterday and when she spoke about the Tuskegee Study of Untreated Syphilis, I wanted nothing but to regurgitate the contents of my breakfast that morning. It is shameful to know American history consisted of inhumane medical experimentation on African Americans. Studies have shown that historical trauma, which leads to post traumatic stress disorder often go undiagnosed. Diagnosis and treatment could have prevented vulnerability in such populations suffering from PTSD. The lack of culturally competent providers and referrals for mental health service after such assaults has often lead to a cascade of negative events. This includes “weapon carrying, substance abuse, and further alienation from stabilizing institutions such as employment, education, and healthcare (Rich et.al, 2005).”

The Father of Obstetrics

Similarly, the father of obstetrics Dr. Marion Sims is known to have performed fistula repairs on African women without anesthesia. It is a horrendous to hear that the leader of great medical movement received his recognition after inflicting pain on parturient of color. Whoever had figured out how to perform and repair fistulas, I imagined, would have been a well-deserved hero. A hero who would have thought to treat his patients like human beings and not like caged animals. It is disturbing to me that the literature provides such conflicting tales of his successes and support his human experimentation and say that “evidence suggests that Sims’s original patients were willing participants in his surgical attempts to cure their affliction—a condition for which no other viable therapy existed at that time (Wall, 2006).”

Cultural Humility

Cultural humility was also something I was not familiar with and its three tenets of lifelong learning, the ability to recognize power imbalance, and institutional accountability is something we must all learn to incorporate into our professional lives and our personal ones as well. In our melting pot of a society this is something we must all learn as healthcare providers – perhaps in a simulation setting, like we did in the classroom. It is not just enough to be culturally competent but to engage in lifelong learning about the changing diverse groups of people around us.

Conclusion

I am beyond grateful for attending Dr. Taylor’s lecture on diversity. It is evident that the United States has a dark history of conducting research on African Americans. It is our due diligence as healthcare providers, with knowledge of historical trauma and cultural humility, to set personal biases aside as well as understand the implications of history and adapt to the changing faces of healthcare today.

References

 

Cutler, M. (n.d.). Multigenerational trauma: Behavior patterns in cultures [PowerPoint slides].

Retrieved from http://edweb.boisestate.edu/instituteforthestudyofaddiction/pp/Historical_Trauma_and_Grief.ppt

Rich, J. & Grey, C.M. (2005). Pathways to recurrent trauma among young Black men: Traumatic

stress, substance abuse, and the “code of the street.” American Journal of Public Health. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449260/

Wall, L.L. (2006). The medical ethics of Dr. J. Marion Sims: a fresh look at the historical

record. Journal of Medical Ethics. 32(6): 346–350. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563360/

 

 

New Year; Better Me

Hi Everyone!

Happy 2018!
Long time no post.

I must say the ending of last semester seemed like an impossible feat. Looking back at it, it really seemed insurmountable but the funny thing about life — if it’s meant to be, it somehow happens and we go through it, and just like that life goes on!

Few updates, first of all, congratulations to all of my friends and colleagues who got into a CRNA program of their choice! Second, to those of you going through it – push, push, push through those prereqs, that tough ICU experience on nights and hard-to-please-preceptors and attendings. The journey here is a strenuous one and some people are looking for alternate paths (AAs are looming in the background) but I hear it’s worth it 😉 Apparently, there have been no accounts of a CRNA who hates their job.

I shadowed my senior mentor the other day, let’s call him John Smith, for the sake of his privacy. I was wowed by his expertise, knowledge of meds, lack of fear when he had a question (to the attending who was covering, jeez!), ease in setting up the room then after intubating his patients and guiding patient care. Railroad tracks! For those of you who don’t know what that means yet — his patient’s vital signs were smooth as it could be. No abrupt changes and if there were any, were promptly addressed. It’s so amazing how you can learn to appreciate everything you learn when you actually see it in practice.

My point is, there is a method to the madness. You just have to be patient and trust the process. It will all somehow make sense, and I hope that next year I am close to being as adept as John (Thank you for your continuous wisdom, strength, and support throughout this program 🙂 )

This semester I am taking: Principles & Practice of Anesthesia II where we get to learn more about airway anatomy, management and the tools of our trade (hi MAC and Miller!), Principles and Practice of Anesthesia Lab, Coexisting Disease and Anesthesia, Pathophysiology II, Regional Anesthesia, Professional Role of  CRNA. Keep yall posted!