Month: March 2018

 

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

 

 

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/