Ralph Waters and the Establishment of Anesthesia

History of Anesthesia

• 1927: Ralph Waters established the first medical academic anesthesia department, bringing anesthesia into the realm of medical practice, which was previously a nursing practice.
• Physicians were reluctant to become anesthetists due to money and the refusal to acknowledge contributions of innovative nurse anesthetists.
• Denial to nurse anesthetists of a just place in the literature of the field.

Agatha Hodgins and the National Association of Nurse Anesthetists (NANA)

• Agatha Hodgins suggested nurse anesthetists organize into a “coherent and acting body” at the American Nurses Association biennial convention.
• 1931: NANA was established in Cleveland, OH.
• 1936: American Society of Anesthesiologists (ASA) was established.

Challenges to Nurse Anesthetists

• The US has seen 3 challenges brought against nurse anesthetists for illegally practicing medicine:
  • Frank v South (1917)
  • Hodgins v Crile (1919)
  • Chalmers-Francis v Nelson (1936)
• These cases were found in favor of the nursing profession, with the premise that the surgeon was the person practicing medicine.
• Montana Society of Anesthesiologists v Montana Board of Nursing (2007) reaffirmed CRNA practice.

Scope of Practice

• CRNAs have a unique role in providing physiologic support, monitoring, and intervention, whereas surgeons focus on patient anatomy.
• "Our job is to keep patients alive while the surgeon does things that could kill them." - Dr. James Cottrell, ASA President
• CRNAs continuously monitor vital signs and other parameters, counteracting untoward reactions, and balancing dosages of analgesics to levels of surgical pain.
• Numerous studies show anesthesia care by CRNAs to be safe and of high quality.

Politics

• Courts have upheld the concept of anesthesia practice by both physician and nurse anesthetists.
• State legislation: no state in the US requires supervision by an anesthesiologist, and 33 states do not have a physician “supervision” or “direction” requirement from CRNAs.
• Within hospitals, bylaws may require supervision, but such restrictions have denied patients access to the full scope of anesthesia services.

Code of Ethics for the Certified Registered Nurse Anesthetist

• The AANA Code of Ethics is a guide for CRNAs to make ethical decisions in all practice roles.
• The CRNA’s ethical responsibility is primarily to the patient, but also to the profession, other healthcare providers, self, and society.

Scope of Practice

• CRNA scope of practice includes:
  • Performing and documenting preanesthetic assessment and evaluation
  • Developing and implementing an anesthesia plan
  • Performing anesthesia techniques
  • Managing a patient’s airway and pulmonary status
  • Facilitating emergence and recovery from anesthesia
  • Implementing acute and chronic pain management
  • Responding to emergency situations
• Additional responsibilities may include administration/management and supporting AANA documents.

Standards of Care

• Definition: “Something set up and established by authority, custom, or general consent as a model, example or rule for the measure of quantity, weight, extent, value, or quality.”
• Standards of care are customs and behavior of the members of the profession, and what others in the profession would do under similar circumstances.
• Expert witnesses provide testimony to assist judges, juries, and attorneys to understand the evidence and make factual determinations.

Documentation

• (No specific information provided)