In the United States alone, nurse anesthetists have been providing anesthesia care for over 150 years. In addition to that, they are the nurse specialty group that has been around the longest in the US. Today, they are the primary anesthesia providers for the United States service men and women at home and overseas. So why hasn’t anyone really heard about nurse anesthetists unless they know of people in the profession and/or want to go into that field themselves?

          Many people have heard of anesthesia and know of what it does. A lot of younger adults are exposed to it firstly from wisdom teeth extractions. Some people might be familiar with it if they have undergone certain surgical procedures. And if none of that has occurred to an individual yet, they hear about it through someone else: “it’s that stuff that makes you go to sleep” or “you don’t feel anything if they give you anesthesia”. However, people often assume that the person providing the anesthesia is an anesthesiologist – at least those that know of what they are. In some settings, that is true. However, certified registered nurse anesthetists – also known as CRNA’s for short – have been performing independently for a while now, and it’s unfair to credit anesthesiologists when nurse anesthetists are the ones taking away your pain. Not to say anesthesiologists don’t do their jobs, or that they aren’t as good as CRNA’s, because they are, and a lot of the times they’re better. But as similar as they are to each other, to confuse the two is an insult to both professions. It would be like comparing fraternal twins – they do similar things and they’re from the same family, but they’re just not completely the same.

          According to the Health Care Financing Administration (HCFA), certified registered nurse anesthetists are no longer required to be supervised by physicians when they administer anesthesia to Medicare patients. Currently, physician supervision is required for hospitals and other ambulatory surgical centers to receive Medicare reimbursement for patients’ anesthesia care, but not for the CRNA’s reimbursement. Seventeen states opted out of this requirement. These states include: North Dakota, South Dakota, Washington, Wisconsin, Iowa, New Mexico, Montana, Alaska, Oregon, Colorado, Idaho, Kentucky, Nebraska, Kansas, Minnesota, New Hampshire, and California. This means that in these states, it is legal for a CRNA to give an anesthetic without a surgeon or an anesthesiologist overlooking the procedure. According to the American Association of Nurse Anesthetists, having CRNA’s work without supervision creates a major advancement in the medical setting because it allows hospitals and ambulatory surgical centers to perform more efficiently in the operating rooms with less complications by the book (Stewart).

          Nursing anesthesiology is a graduate prepared profession. In the United States, one must complete their undergraduate school with a Bachelor’s of Science in Nursing (BSN). After that, they must pass the NCLEX to be licensed as a registered nurse (RN). CRNA schools require at least 1-2 years of experience in an intensive care unit (ICU) or critical care unit; whether that be surgical, cardiovascular, neuro, or another one of the other ICU branches. Working in the ER won’t count because there isn’t a lot that would gain you experience for the CRNA profession in the emergency room setting. After that, one would have to apply to a CRNA school, which is a minimum of 27 months, depending on where you go. One can choose to earn a Master’s degree in anesthesia or a doctorate degree – which, of course, takes longer, but with a doctorate degree, one can proceed to teaching if they decide after a while that the hospital setting is no longer for them. Personally, I am going for a Master’s degree in anesthesia, and this whole process would take me about 8 years and some change before I become a certified registered nurse anesthetist and get paid as one – a median annual salary of $171,882 as of January 30th, 2017 (salary.com). Anesthesiologists spend a lot more time in school and residency; four years of undergraduate school, four years of medical school, and then another four years in residency before making around $359,990 as of January 30th, 2017 (salary.com). It wasn’t worth it for me to spend 12 years of my life learning before being able to work.

          Other than the potential supervision required for CRNAs, the process of putting a patient under anesthesia is the same for both nurse anesthetists and anesthesiologists. Smaller medical offices are more likely to have nurse anesthetists. Larger hospitals typically employ both anesthesiologists and CRNAs. While both work in urban areas, about 2/3 of all anesthetics in rural areas are administered by CRNAs.

          It has been hotly debated in recent years whether nurse anesthetists or anesthesiologists provide a better level of care. According to the New York Times, two studies conducted in 2010, it is “concluded that there is no significant difference in the quality of care when the anesthetic is delivered by a certified registered nurse anesthetist or by an anesthesiologist.” Additionally, “Analysts at the Research Triangle Institute found that there was no evidence of increased deaths or complications in 14 states that had opted out of requiring that a physician (usually an anesthesiologist or the operating surgeon) supervise the nurse anesthetists.”

          There is no “I” in healthcare. The continuity of patient care is essential to maintaining the safety of the patient. This is accomplished through effective communication and collaboration between all healthcare professionals especially ICU nurses and CRNAs. The goal should be an active and dynamic teamwork approach the entire time the patient is in the hospital all the way from admission to discharge. This holds true especially for areas that stabilize, transport, and care for high acuity patients, such as the emergency room, ICU, and the OR.

          Certified registered nurse anesthetists and critical care nurses both play a vital role when caring for the surgical patient. A CRNA often times will go to the ICU to pick up a patient that is having surgery, and for a short period of time will assume care of that patient. Part of the scope of practice includes performing a thorough and complete pre-anesthesia assessment before surgery, and giving a clear and concise report when transferring the patient’s care back to other qualified providers. This inter-professional practice ensures that all the relevant information necessary for providing quality care is passed on to the healthcare professional assuming responsibility for that patient.  Normally, one who is going to CRNA school will be trained for this teamwork and integration between ICU nurses and CRNA’s.

          In small hospitals, a critical care nurse is likely to provide care across the age spectrum; whereas in large medical centers, intensive care units are likely to be separated into adult and pediatric units. In small hospitals, critical care nurses care for patients with medical and surgical crises. Large medical center intensive care units are commonly divided into specialized units.  Examples of specialized intensive care units include:  cardiac, medical, surgical, burn, and neurological intensive care units. Critical care nurses provide most of the direct care to patients in life threatening situations within intensive care units. They assess, plan, implement and evaluate health care services for patients suffering with a broad range of health conditions. Types of patients cared for depends upon the type of intensive care unit which nurses are employed in. However, all intensive care unit nurses care for extremely ill patients.

          Nurses in general intensive care units commonly provide care to patients suffering from cardiac disease and brain injuries. Accident victims and patients recuperating from complex surgeries frequently need nursing care from critical care specialists as well. Intensive care unit nurses work closely with physicians and other members of the health care team. They are skilled in assessment of patients and capable of using high tech equipment.

          However, before anything happens in the hospital setting, critical care nurses and/or ICU nurses must fill out a report sheet. This is crucial because the report sheet contains information like medical/drug history as well as the condition of the patient, and a lot more – which are all needed before assessing what needs to be done to the patient. For surgery patients who need anesthesia, it’s vital for an anesthesiologist or a CRNA to know what kind of anesthesia is appropriate to use on the patient according to that report sheet.

          In order to fill out a report sheet, the nurse must do an ICU head to toe assessment. The first part of the assessment is neuro: are the patients responding to the nurse when they walk into the room; are the patients answering the questions appropriately; are they moving their extremities; can the patients feel the nurse touching them; and this depends if they are on a ventilator or not. A lot of the time, ICU nurses will do “sedation vacations,” which is when the patient is on a ventilator and the sedation is turned down to see how they will react. Also, if the patient is ventilated, it’s important for the nurse to check their pupils because their neurological assessment would be limited; if the pupils are reactive and/or the size of them.

          If the patient is not a neuro specific patient, meaning they haven’t had strokes or measures of the sort where a ventilator is needed, then the ICU nurse would ask basic questions: what their name is, what their date of birth is, who the president is, if the patient knows where they are etc.; the basic neurological assessment. This happens the second they walk into the room.

          Next is heart and lungs. The ICU nurse would listen to how the heart sounds and if there are any bowel tones present. Then the nurse would proceed to look at lines, drains, tubes and monitors. The patient’s skin would be next. The patient will be checked to see if they have any skin break down and/or any incisions. As the nurse goes from head to toe, they will check for pulses. The common ones are usually checked first are the radial pulses (by the wrist) and the dorsal pedal pulse (by the big toe of the foot), because if the pulses are present there, then the pulses should be present in other places in the body. If the pulses are not present there, the nurse would then have to pull out the Doppler or check in higher places, such as the neck area. If the patient is at that point, then they either have severe circulation compromise or that their blood pressure is low, which is bad because it’s not a normal assessment finding. The patient will then be assessed every four hours to see if anything changed, and the lines/drains/tubes will have to be assessed every two hours.

          Everything that’s been assessed by the ICU nurse goes onto a report sheet.

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