Nurse Anesthetists: The Face Behind the Mask
Friday May 4, 2007
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(Courtesy of American Assoc. of Nurse Anesthetists)
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Koch asked, “Are you the anesthesiologist?” The woman quickly and enthusiastically corrected him, explaining that she was a nurse anesthetist. Koch asked what she did, and he was intrigued by her answer.
He went on to earn a BSN and work in the OR, and then took a job as a research assistant in the anesthesia department. The assistant position strengthened his desire to pursue a master’s degree with the goal of becoming a certified registered nurse anesthetist (CRNA).
“I liked the scientific challenges, the one-to-one patient care, the procedural aspect, and the independence,” says Koch, CRNA, MSN, who has now been a nurse anesthetist for 20 years. He splits his time between Kaiser Permanente San Diego, the Naval Medical Center San Diego, and Global Cosmetic Surgery Center in La Jolla, Calif.
In 1877, Sister Mary Bernard, a Catholic nurse at St. Vincent’s Hospital in Erie, Penn., was the first nurse known to specialize in anesthesia. This nursing specialty has since grown to more than 35,000 CRNAs nationwide.
CRNAs are the hands-on providers of about 65% of all anesthetics given to patients each year in the United States, according to the American Association of Nurse Anesthetists (AANA). Depending on state law and hospital bylaws, they may provide anesthesia either as part of a care team with an anesthesiologist or under the supervision of a surgeon. In other facilities, they may practice independently without the direct supervision of an anesthesiologist or surgeon. Most large hospitals in urban or suburban areas use the care team approach, while rural hospitals often depend on a CRNA to provide all of the anesthesia services, either as a hospital employee or as an independent contractor.
Typically, patients first meet the CRNA for the preoperative anesthesia evaluation, when the nurse anesthetist assesses the patient’s surgical history, medical history, allergies, and any medications the patient may be taking. Usually the surgeon, the primary care provider, or a nurse practitioner has already done a history and physical, and the CRNA reviews this information as part of the evaluation. The evaluation may be done either the day before surgery or on the same day.
Hensley, who administers anesthesia mostly for outpatient surgeries, is the only anesthesia provider at Sierra Vista Hospital, a small 20-bed facility in Truth or Consequences, N.M. Her most common cases are hernia repairs, colonoscopies, endoscopies, breast biopsies, and gall bladder removals. After doing the preoperative anesthesia evaluation, she describes the anesthetic options and their respective risks and benefits to the patient.
According to Hensley, one of the most challenging moments for a CRNA is when a patient has a “difficult airway” — that is, when the patient’s anatomy makes it difficult to insert the endotracheal tube. Careful risk assessment in the preanesthesia meeting can go a long way toward determining whether a patient has a difficult airway and how to best prepare for it. There are a multitude of reasons why an airway might be considered difficult, and there are a number of ways to ensure that a potential problem doesn’t become a reality during the procedure.
After the surgery, Hensley gives a full report of the patient’s condition to a postanesthesia care unit (PACU) nurse, as well as any postoperative orders if the patient is suffering from nausea or pain. CRNAs are responsible for any complications that might arise during recovery while patients are still in the PACU.
Though CRNAs thrive on the challenges that come with being responsible for a patient during surgery, the job’s high risk requires them to have malpractice insurance. Due largely to the good safety record of CRNAs, the liability premiums are now 39% lower than they were 15 years ago, according to the AANA. Malpractice insurance is usually provided as part of the benefits package for CRNAs who are hospital employees, while those who are independent contractors must purchase their own insurance.
Frank Maziarski, CRNA, CLNC, MS, a nurse anesthetist at Evergreen Surgical Center in Kirkland, Wash., has been a nurse anesthetist for 40 years, and says modern technology allows CRNAs to monitor a patient’s condition with greater precision than in the past. For example, anesthetic gas analyzers are now standard and show the concentration of the gases given to the patient. Awareness monitors, which measure the depth of the patient’s anesthesia, are available for use in a number of facilities. They are reserved for certain patients who are at risk of regaining consciousness under anesthesia as determined by either their history or the type of surgery. Anesthesia has four stages: 1) the period between administration of the anesthetic and loss of consciousness; 2) the period after loss of consciousness; 3) the level at which surgery can be performed; and 4) an anesthetic crisis. The goal is to keep the patient in the third stage.
“It was somewhat of a setback,” Hensley says. “It would have been much easier and simpler to say on a federal level that physician supervision is not required. The new administration created a process that becomes very political because it is up to each governor.” Fourteen states have gone through the process of opting out: Alaska, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin.
Even though the supervision rules may vary from state to state, the consistent daily challenges of caring for patients have remained, and that is why Evan Koch, CRNA, MSN, enjoys his job. “Anesthesia involves vigilant observation of the patient and attention to detail. Being a nurse anesthetist is enormously gratifying,” Koch says. “The gratification is very personal.”
Heather Stringer is a freelance writer.
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