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  • Anesthesiologist Tells it Like it REALLY is! Amazing!

    CRNAs: A short history of nurse anesthesia and the future of anesthesia care.

    What's old is new again. I have always had a keen interest in anesthesia history and as a resident in anesthesia, presented some articles and papers for the International Anesthesia History Association on Chauncey Leake and the development of divinyl ether and at the Anesthesia History Association here in the US on Sir William Macewen and early attempts at intubating patients under general anesthesia. I am a firm believer, as a scientist, clinician and physician leader, that one must truly know history and have a thorough understanding of the present in order to help predict, but more importantly, prepare for and shape the future.



    It's human nature to constantly make attempts to build a better mousetrap. It's also human nature to adapt to our environment. Professional nursing developed in the 1850's and is largely credited to Florence Nightingale's efforts during the Crimean War. Nurses began to administer anesthetics during this time period as well using open drop techniques. Nurses and nurse anesthetists were absolutely vital providing care to wounded soldiers during the American Civil War. 150 years ago, administering anesthesia was, at best, a crude exercise with no monitoring save a finger on the pulse and a conscientious effort to observe breathing patterns and the color of the patient's skin.

    Alice Magaw remains the most famous nurse anesthetist of the 19th Century. Born in Coshocton, Ohio in 1860, she attended nursing school in Chicago and ultimately became the anesthetist for both of the Mayo brothers in Rochester, Minnesota. In 1899, she became the first nurse anesthetist to publish a scientific article for the Northwestern Lancet. Five more articles would follow. She was well known as a master of open drop ether and Charles Mayo dubbed her the "Mother of Anesthesia." She administered no fewer than 14,000 anesthetics with no deaths recorded. This is a remarkable track record given the lack of monitoring and advanced techniques, medicines and technology to help rescue a patient from imminent tragedy.

    Alice Magaw, nurse anesthetist

    Because she was not an MD, MD anesthesiologists remain unaware of Alice Magaw's contributions. Formal, academic, MD anesthesia training developed after nurse anesthesia. Dr. Ralph Waters created the first medical academic anesthesia department in Madison, Wisconsin in 1927. He established the first residency program for anesthesia in the US, and his trainees spread throughout the US and were commonly referred to as The Water Babies. Ralph Waters wanted to bring anesthesia back into the fold of medical practice, not what it had mainly been up to that point--a nursing practice.



    Ralph Waters, MD

    Before Waters' program was created, Agnes McGee, nurse anesthetist, founded the first educational program on anesthetics at St. Vincent's Hospital in Portland, Oregon in 1909. It was a 6 month course on relevant anatomy, physiology and pharmacology of anesthetics. Between 1912 and 1920, 19 nurse led anesthesia schools were opened. It's plainly obvious the nurses were blazing the trail toward formal education in anesthesia long before the MDs. We physicians were a little late to the table.



    Agnes McGee receiving an award for her contributions to nurse anesthesia, 1953.

    Meanwhile, across the Atlantic, anesthesia had already advanced in an academic setting in Scotland. Sir William Macewen, a surgeon working in Glasgow, pioneered efforts in aseptic technique, neurosurgery and orthopedic surgery. Rarely mentioned, but equally important, he was the first individual to make an attempt to intubate patients while under general anesthesia. His attempts resulted in complications and one death, so he no longer pursued intubation for his patients undergoing general anesthesia.

    Dr. Macewen did, however, recognize the need to formally train physicians on the use of anesthesia, and one of the first known certificates given to MDs for completing training in anesthesia was given to a student of surgery named Broughton Head in 1903. It's hanging on the wall behind me as I write this, and I am it's humble owner until it can find a more satisfactory home back in Scotland where it belongs for all of the Scottish citizens to enjoy as a part of their own noble history for their countryman's contribution to the advancement of anesthesia.



    Broughton Head's Certificate in Anesthesia, 1903.

    Though I digressed a bit, in 1930, at the biennial convention of the American Nurses Association, Agatha Hodgins presented a paper suggesting the organization of nurse anesthetists into a "coherent and acting body." The following year, in 1931, the National Association of Nurse Anesthetists (NANA) was founded on June 17, in Cleveland, Ohio (It later became the American Association of Nurse Anesthetists or AANA.)

    The history of the current American Society of Anesthesiologists (ASA) began in 1909. Known originally as the New York Society of Anesthesiologists, the organization became the American Society of Anesthesiologists in 1936. Within five years, both nurses and MDs recognized the need to create a formal society. It's not a coincidence.

    What I find fascinating now is the continued conflict between CRNAs and MDs with regard to scope of practice, independence, education and organization. Nurse anesthetists, before we used the word "certified," administered thousands of anesthetics without complication. They continue to do so in mixed practice settings, independent settings and for the US military. CRNAs are providing professional, excellent care for patients everyday throughout the US. This issue always rears its head every time CRNAs attempt to alter state laws with regard to scope of practice and/or independence.

    Here in Arizona, there was an effort to allow CRNAs to independently practice. I supported their efforts. The arguments from the MDs were simple: they are not physicians. It's a turf war, and MDs feel threatened. We shouldn't. At my Alma Mater, UCSF, I studied under the leadership and guidance of Dr. Ronald Miller and Dr. Mark Rosen. We had approximately 5 to 6 CRNAs working alongside us at San Francisco General Hospital (SFGH), and yes, they helped with Level 1 Trauma. The stakes don't get any higher.

    In 2017 there are currently 47 CRNAs at UCSF. Times certainly have changed in the last decade since I left. Obviously, if a program of UCSF's caliber has embraced CRNAs, then their care is certainly being respected and valued as members of a larger care team model. I myself learned a tremendous amount from the CRNAs with whom I worked with at SFGH in the early 2000's.

    Not once did I ever view any of them as somehow inferior to us with regard to ability or capability. We relieved them, they relieved us, and we definitely had each other's back when, on Friday night, the gunshot and stabbing victims rolled into our ER. We bonded with them as part of the team, and the adage that old age and treachery will overcome youth and inexperience was a mantra I believed. The CRNAs taught us a tremendous amount, and I am an MD.

    Unfortunately, the tradition of not recognizing nurse anesthetists as equals has been at the forefront of debate for one hundred years. In 1916, The Lakeside Hospital School of Anesthesia closed after a conflict with the Ohio State Medical Board over the legality of nurses administering anesthesia. It reopened in 1917. Also, in 1917, in Frank v South, the Kentucky Court of Appeals ruled that nurse anesthetist Margaret Hatfield was not engaged in the practice of medicine when she administered anesthesia for surgeon Louis Frank’s cases.

    Flash forward one hundred years to what has recently happened in Arizona. Here's the current law:
    A certified registered nurse anesthetist may administer anesthetics under the direction of and in the presence of a physician or surgeon in connection with the preoperative, intraoperative or postoperative care of a patient or as part of a procedure performed by a physician or surgeon.

    This means the 'physician' can be a dermatologist, etc. There is no mention of what type of physician in this current law. Most of the time, the 'physician' does happen to be a surgeon.

    Let's examine this situation through the lens by which it must be examined. Somehow it's acceptable for an MD, not trained formally in anesthesia, to supervise a nurse who has been trained in anesthesia? Isn't this a blind man leading someone with 20/20 vision through a jungle? I have been practicing anesthesia for 12 years in a private setting in community hospitals here in southern Arizona, and I have not seen one surgeon manage an airway, administer propofol, muscle relaxants or flip the switch on a ventilator. And somehow these MDs are capable of telling a CRNA what to do during an anesthetic emergency? I rest my case.

    Let's be clear, the US healthcare system is facing both fiscal issues and provider shortage. First, the cost of healthcare is too high. Second, there is increasing need for anesthesia services as baby boomers age. Third, there are not enough MD anesthesiologists being trained to replace those who are retiring while we face increased demand for service.

    The take away from this is clear. CRNAs will most likely fill the gaps in care either independently or under a medically supervised model. Yet the battle cry from the MDs and the ASA is simple: CRNAs didn't go to medical school, attend a four year intensive post-graduate medical education in residency or take the written and oral Board exams. It's simply not fair that CRNAs can be viewed as our equals and peers. And so the battle continues, and I don't think it's necessary or constructive.

    Call me a heretic, but what if both the AANA and ASA created a joint anesthesia conference to discuss the future of anesthesia and current concerns? The ASA has its annual conference in October in Boston this year; one month prior, in Seattle, the AANA has its meeting. Not only are the two meetings literally at different times but on different coasts.

    My perspective on providing excellent care for our patients is my unrelenting focus on the team model. No one practices medicine or nursing in a vacuum unless they are literally a solo practitioner in an office based setting without a nurse. This, of course, doesn't take place in our operating rooms or outside areas where we perform anesthesia, such as the cath lab, MRI suite or ambulatory settings.

    Can't we call a truce, stop the madness and toss an olive branch out in the ring? I am asking my fellow MDs and DOs this question, not the CRNAs. We have a difficult time as it is earning respect from the other medical professions without circling our wagons and pointing the guns inward.

    We should be jointly meeting to discuss salient issues regarding anesthesia care, care team models, efforts to create surgical care homes, pre-operative clinics, post-op care team models, in house acute pain management models, etc. We could accomplish much more if, instead of battling each other in the state legislatures, we recognized we are all on the same team working toward a common purpose. We should set our egos aside, as MDs, and fully embrace the future and recognize the contributions of our nurse colleagues. We could learn a lot from them.

    CRNA programs recognize the increased complexity for providing anesthesia care, and the education of nurse anesthetists has been a priority since the founding of the AANA. Although not implemented until 1952, accreditation of nurse anesthesia educational programs was discussed as early as 1934. The AANA’s certification exam was first administered in 1945, a voluntary continuing education program was approved in 1969, and mandatory continuing education became effective in 1978. In 1986, a bachelor’s degree in nursing or a related degree was required for admission to nurse anesthesia programs, and by 1998 all programs were required to be at the graduate level, awarding at least a master’s degree. In 2007, the AANA adopted a position statement supporting doctoral education for entry into practice by 2025. The AANA is supported and led by talented, well educated, forward thinking nurses. I am listening and observing.

    The American Board of Anesthesia has also changed certification requirements, and new diplomates, such as myself, must participate in the Maintenance of Certification of Anesthesia program, also known as MOCA. Our parent organizations, both the ASA, the AANA and the ABA realize the need for all of us to adapt and maintain up-to-date education and training. We need to take the next step after decades and decades of unnecessary conflict to come together.

    I have no doubt it will happen. Both the leaders in the AANA and a few members of the ASA, such as much myself, who are leading departments composed primarily of CRNAs, will provide the support necessary going forward. To all my nurse and physician colleagues who practice anesthesia: we are in this together.

    --Matthew Mazurek, MD

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