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).
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.
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.
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).
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.
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.
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.
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 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.
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.
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
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!
I must say that finally learning about anesthetic drugs has elevated my spirits about this whole process. I cannot wait to be YOUR CRNA.
MAC or MAC?
I can’t wait to one day be able to teach all that I know to the people who are just starting off.
As the CRNA, (side note: who made up that name anyway… certified registered nurse anesthetist? I’m pretty sure I’m not getting a certificate when I complete 27 months of training … smells like politics to me & I hope future me can help tackle that) we will breathe, feel and think for you. As a control enthusiast, I am ecstatic that I can do that for someone. And to be able to be in sync (or lack thereof) with my fellow surgeon is a challenge I am looking forward to.
Happy Daylight Savings!
Gratitude and growing pains
Haven’t written here in a while and I must say, I thank every one of you who’s read my stuff and found it helpful or have been super supportive throughout my journey.
It’s been about two months since school started, and it’s almost 2018 — where does the time go? I have to say that whoever told us that anesthesia school was no joke.. was not lying.
This is the most stressed I’ve ever been in my whole, entire, life. And, I have been put to test a few times in my life and nothing comes close to this. I hate to admit it because admitting something is hard is a sign of weakness, right? No. I have come to realize that I am a very emotional person and I do cry sometimes… actually, I cry a lot and mostly because I lose control over a situation. Whether it be in the middle of a sentence when I’m talking about something or at home by myself. And, I hear it’s healthy. It’s my coping mechanism, and for those of you coping like I am right now, just know that you are not alone.
It’s normal to feel stressed, and depressed. And there is help out there. One thing I’ve learned this year is that mental health is just as important as every other disease, like hypertension or diabetes. With depression or high stress, your body will start to maladapt and can’t really function anymore and you will start getting sick and not want to do fun things or do anything at all… (shout to my patho professor Sally for making such a dry topic so passionately fun)
It will happen but to quote a classmate “nothing worth it comes easy” as we are being challenged to being the best version of ourselves. I would rather cry now than cry in the middle of a case while I have someone’s life in my hand – going through one of the toughest times in their lives, a surgery that was unexpected, and I’m the one making sure their anxieties are alleviated, and that I figure out the best concoction for them to not feel any pain in the safest and best way possible. That one day, I will have a family and I can tell them I too, went through what you’re going through. And you just have to trust the process. That these are just growing pains.
Again to quote Sally: “Stress response is meant to be short lived followed by respite.”
Understanding stress – this is normal.
Encountering stress on a regular basis, benefits us.
- Healthy stressors: they make us healthier, smarter, stronger. For example:
- Demanding mental activities: uncomfortable learning. So, pick up that hobby that you always wanted to do and keep at it! It’s meant to be uncomfortable. You can’t actually be learning anything if you are already comfortable with everything.
- Demanding physical activities: the benefits of exercise is undeniable.
- I recently tried out this boxing class called Rumble, it incorporates boxing and strength training all in one jam packed hour, and it is unbelievably hard but you feel SO good right after. Oh, it feels GREAT not being out of breath when I climb stairs, or be able to squat properly with good form 😉
- Overwhelming stress, however, can be detrimental.
- Cold stress, altitude stress (lower oxygen allows them to adapt and increase RBC count- increase oxygen capacity and help run more since more oxygen pumped to muscles)
Stress in an individualized response. Certain circumstances vary for each person. Good support at home, and available support system.
1.Adaptive stress response – when a person goes thru their last straw but have a good support system at home.
2.Maladaptive stress- when a person goes thru their last straw and copes with alcohol or drugs.
So, to wrap it all up I think the lesson is – you’re not alone. And, this is a lesson to myself. There are always people who want to listen to you and in my case, I have more than handful of people that love me, friends and even acquaintances that are willing to lend an ear. I appreciate you. Stress can be detrimental, or it could make us stronger, I guess at the end of the day you get to choose. Find a healthy balance and keep the hustle. After all, they don’t call us the greatest city in the world or the city that never sleeps for no reason – just have to be aware of your own behaviors and seek the help you may need and keep moving forward.
I joined my father for our usual dinner catch-up sessions. Well, you know, more like me analyzing my food as he talks to me. You see, our relationship has never been an ideal one. But the unconditional love is understood.
He starts telling me about a construction site and piles and piles of gravel and how it’s never fun to look at gravel when you look at a building being built because I mean.. who does? And it takes months and months for them to finally get the gravel out of the way and start building the building they were planning on.
Then he said, well, that’s kind of what you’re going to be going through the next couple of months. Nobody likes the beginning, and it’s not fun at all because you don’t even know what the future is going to look like. But you need a strong foundation and the foundation takes time. And it’s going to be hard but that’s how it was like for me during medical school. Things only got fun during clerkship years. This too shall pass in like six-seven months….And, sometimes you need to read the textbook not once but twice, and that’s ok.
God. I needed to hear that so badly.
I always found writing to be my escape and I never thought I would say that. I never liked writing growing up, probably because I wasn’t good at it. Well, my best friend who majored in English said that like everything in life it’s something you have to practice and do it everyday.
And I think thats what we tend to forget. Practice makes perfect. Grit. You can essentially do anything if you put in the time and effort into it. Ha, so my point is actually pointing back to the fact that I feel this very thing right now. About CRNA school. They weren’t lying. I already feel the depression looming in as I exchange my free time with pages on gas laws, pharmacokinetics, and membrane potentials. The FOMO is real.
Here I am – stuffy nose, head, and hacking cough the night before my first anesthesia school exam. First pharm exam (on hormones, diuretics, pharmacodynamics/pharmacokinetics, and COPD& asthma). My cortisol level has to be at least 150mg (stress response). Normal secretion per day is 20-30mg. Please let be a test question.
Here’s more on cortisol. So, it is secreted by the adrenal glands and it is primarily responsible for your stress response.
- Increases gluconeogenesis, inhibition of glucose uptake — fancy way of saying helps your body make sugar!
- Breaks down protein –to mobilize to the liver to make sugar
- In excess can cause muscle wasting. So, don’t stress or you’re going to lose all your gains!
- Mobilizes fatty acid – used for energy and metabolism
- Has anti-inflammatory effects
- May help cardiac function and improve blood pressure
- Increases number or responsiveness of β-adrenergic receptors.
- Promotes normal responsiveness of arterioles to catecholamines (norepinephrine, epinephrine)
- Inhibits bone formation
- Can lead to fractures 😦
Ciao for now! And wish me luck …
The physical manifestation of stress in the crook of my neck (and several of my other classmates), the inability to take a deep breath, the pounding heart rate when you wake up in the morning and when you step out of class, are signals enough that finals week is fast approaching. I mean, how is it Thursday already, oh and August? I feel like I just started. My friends are off getting married, at their honeymoons, and planning Halloween costumes.
But here I am slugging along for the next two exams: Health assessment (learning all about heart murmurs, peripheral vascular disease, skin disorders, STDs, pediatrics and all of their heart murmurs and developmental stages and all of their different types of assessments, neuro assessments, & Musculoskeletal for adults) and pharmacology (everything you need to know about Infectious Diseases). Whew. To many of you, it may seem like oh, it’s just another exam but for us
To many of you, it may seem like oh, it’s just another exam but for us SRNAs we kind of have to get this 4.0 as we hear the ominous stories from the GAS2s (Graduate Anesthesia Student Yr. 2s) that the fall is nowhere near as easy as the summer semester. Next semester, we learn about principles of anesthesia, the pharmacology of anesthesia, and pathophysiology.
So, wish me luck in learning/understanding/cramming two exams’ worth of stuff in the next 7 days! After next week Thursday, I am a free soul for about 3 weeks (one of which I will be in Peru!).
Then, 24 months of CRNA school to go… Le sigh.