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 an anesthesiologist is. 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 (“No More Supervision”).

          Nursing anesthesiology is a graduate prepared profession. In the United States, it is required to complete undergraduate school with a Bachelor’s of Science in Nursing (BSN). The next step is to 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 wouldn’t count because there aren’t a lot that would gain you experience for the CRNA profession. This is because CRNA ultimately works in the operating room as opposed to the emergency room. After that is the application to a CRNA school, which is a minimum of 27 months, depending on where the school is located. From there a choice must be made between a master’s degree in anesthesia or a doctorate degree – which, of course, takes longer, but with a doctorate degree, the student 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 (“Certified Nurse Anesthetist Salaries”). It wasn’t worth it for me to spend 12 years of my life learning and collecting debt 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.

          The reason I feel strongly about nurse anesthetists is because throughout my whole twenty years of life, I personally came across one. But that one encounter changed my life and my view on things years later. I was around seven or eight years old when I travelled to Vietnam for the first time in my life to visit my dad’s side of the family. Being a developing country, much of the transportation consisted of motorcycles and mopeds. It was common for kids like myself to sit in front and between the legs of the rider of the vehicle. The accident happened all too quickly. My aunt and I were on our way back from a carnival we had just attended. It was late at night and a little bit chilly. Because I sat in the front, I received most of the wind, and the fast blowing air melted the ice cream I was eating. Needless to say, I had it running down my forearms and dripping from my elbow. At the time, we had a house in the process of being built, and conveniently it was closer to the carnival than the house we were staying at. My aunt stopped by and let me run in to wash my hands. When I came out, my aunt was still propped on the moped, with her left leg as a stand and her right hand on the handle of the moped, waiting for me. I climbed under her arm and used the handle to balance myself onto the vehicle. Accidentally twisting the handle, I started the engine. It caught us both off guard, and the moped started going full speed in the quiet, empty neighborhood. My aunt tried to stop it but she ended up losing her balance and fell off to the left, sending the moped to the right with her weight. I, along with the vehicle, crashed into my neighbor’s brick wall gate and broke it. The bricks and dried cement came crumbling down on my tiny body as my head buried into the dirt. My mouth was filled with the taste of pennies and soil. I cried, but not because I was hurt, oddly enough I didn’t remember feeling a thing. I cried because it seemed appropriate.

          The next thing I knew, I was in a bright white hospital. I was laying on a hospital bed and staring up at blinding surgical lights. Blood dripped down from my forehead where it cracked open and my body ached from the weight that piled on me. I was surprisingly calm. Suddenly, a man in a white lab coat and a huge needle in his hand came at me. I was seven. I screamed. I threw a fit and demanded a female doctor because seven-year-old me felt more comfortable with someone of the same sex. A woman with the same lab coat came running in and she took the needle away from him. Her eyes were kind and she told me she was going to take my pain away; make all the blood and cuts and bruises disappear. I remembered telling her, “If you do a good job, I’ll take you out to dinner. My family has money.” She laughed and told me that I was tired from the carnival earlier that day, and that I should take a nap. She promised when I woke up she would take me to dinner instead. And then I blacked out.

          Back then, I did think I was tired from the long day so it made sense that I fell asleep. But now I know I was put under with anesthesia as the surgeon sewed up my forehead. I didn’t find out that she was a nurse anesthetist until years later when I returned to the hospital on my own time to find the woman (I didn’t see her after I woke up from surgery) and thank her. The point is when someone is panicking and hurt, needles and tubes and metal scissors are the last thing they want to see. It has been hotly debated in recent years whether nurse anesthetists or anesthesiologists provide a better level of care. According to American Association in Nurse Anesthetists, it is concluded unsurprisingly that there is “no significant difference regarding the quality of care rendered by anesthesiologists and certified registered nurse anesthetists” (Quality of Care in Anesthesia). Additionally, according to New York Times, “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” (“Who Should Provide Anesthesia Care?”).

          Healthcare is like a sports team; there is no “I” in team like there is no “I” in caring for a patient. To maintain the safety of a patient, there must be “effective communication and collaboration between all healthcare professionals especially ICU nurses and CRNAs” (Keith). The teamwork should be active for the entirety of the patient’s hospital stay up until the admission to discharge. This is especially true for areas that stabilize, transport, and care for high acuity patients, such as the emergency room, ICU, and the OR. When caring for a surgical patient, both certified registered nurse anesthetists and ICU nurse play vital roles. A CRNA will sometimes 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, a student who is going to CRNA school will be trained for this teamwork and integration between ICU nurses and CRNA’s.

          However, before anything happens in the hospital setting, critical care nurses and/or ICU nurses must fill out a report sheet. A report sheet is one of the many ways of communication between ICU nurses and nurse anesthetists. The purpose of this form is to record the patient’s state of being and self-history right after being admitted to the hospital or health care facility. Some of these include name, date admitted, age, room in the hospital, allergies, possible diagnosis, uses of medication and a few more. After the initial fill-ins, the ICU nurse keeps the report sheet with them and can check back every few hours to update the information needed, some of which include vitals, skin changes, cardiac changes, medications and notes. These are all needed to assess 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, which is an ultrasound test that can be used to “estimate the blood flow through the blood vessels by bouncing high-frequency sound waves off circulating red blood cell” (Sheps). A regular ultrasound uses sound waves to produce images, but can't show blood flow. If a nurse doesn’t use the Doppler, then he/she would simply have to check in higher places for the pules, 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. That report sheet will then go to a nurse anesthetist or an anesthesiologist, assuming the patient needs surgery. So why do I think nurse anesthetists are more qualified to administering anesthesia than anesthesiologists? Besides the fact that I have experienced first-hand the care and nurture of a CRNA, there has been no evidence in the difference of performance between anesthesiologists and CRNA’s – complication rates and mortality rates between the two are statistically the same (Dulisse et al.). There is also no difference between a nurse anesthetist performing alone versus under the supervision of another physician. In an operating room setting, as well as nurse anesthetists handle the stress and demands of their supervisors, if the outcome of both CRNA’s and anesthesiologists are the same, removing the supervisor might even increase the minimization of chances for unfavorable events (Roth et al.). Not to mention, if a CRNA and their supervisor failed to maintain good communication, it can cause staff conflict, which then could compromise a patient’s well-being (Perry).

          Regarding educational background, nurse anesthetists have been through hospital critical care before they attended anesthesiology school. This means that they were ICU staff nurses before they could administer anesthesia. They’ve been through bedside work, communicating with patients, cleaning and washing patients, and making the patients feel comfortable in an uncomfortable situation. Anesthesiologists go through undergraduate school, then straight to medical school, and then straight to residency, a total of twelve years altogether. According to Texas Wesleyan University, “they have less of a work-life balance and must wait longer to begin their career due to their grueling educational requirements” (“CRNA vs. Anesthesiologist: What's the Difference?”). Anesthesiologists basically spend eight years studying and then are forced into the hospital setting without prior experience with patients. It’s overwhelming to say the least. The man who scared me when I was seven was an anesthesiologist. He arrived by my bedside holding a big needle without saying anything. How uncomfortable and scary would that be for any person, let alone a kid?

          Anesthesia has come a long way from what it used to be. Although surgery can be a scary thing because family members aren’t allowed in operating rooms, it’s important to have someone make the patient feel at ease. Not only do nurse anesthetists have the ability to do that by starting a small conversation to calm patients down, but they are just as qualified to successfully get patients through the operation. Acknowledge them and know who they are. Thank them.

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