The Colorful History of Anesthesia Nursing
Sidebars: The Stuff of Nightmares, Party Drugs and The Mystery of Hua Tuo
The nurses who provide anesthesia to surgical, obstetrical or pain management patients today follow in the footsteps of some of the most colorful and outspoken members of the nursing profession. Thanks to the efforts of these pioneers, CRNAs (certified registered nurse anesthetists) became the first recognized group of advance practice nurses and later the first to qualify for independent Medicare reimbursement.
Both of those achievements are attributed to the efforts of the late John Garde, CRNA, FAAN, long-time president of the American Association of Nurse Anesthetists (AANA), who also moved education for CRNAs to the graduate level.
The progress this specialty has achieved did not come without a fight and the battles over nurse anesthetists’ scope of practice, payment and legal standing are not over. Lingering tensions have resulted in lawsuits throughout the years, including a spellbinding case in Los Angeles in 1934 that went all the way to the Supreme Court. (The nurse anesthetists won.)
From the Past
Nurses first administered anesthesia during the American Civil War, a conflict marked by high morbidity and mortality rates for surgical patients. Nurse involvement came about after some surgeons noticed that nurses gave full attention to the whole patient — unlike medical students, who were usually more interested in the surgery itself.
Catholic nuns also played a prominent role in the development of this specialty. Many of the country’s earliest hospitals were established by religious orders, whose sisters were often trained in administering anesthesia as a routine part of patient care. The first recorded example of a nurse anesthetist was Sister Mary Bernard, who began to practice in 1887 at St. Vincent’s Hospital in Erie, Pa. However, it was Agnes Magaw who was given the title of “Mother of Anesthesia” for her work in establishing the procedures of anesthesia, such as the drip mask method of administering ether and chloroform.
Magaw’s mentor was Charles W. Mayo, Jr., M.D., a physician at what was then called St. Mary’s Hospital in Rochester, Minn. Together, they made the Mayo Clinic an international showplace for advanced anesthesia and surgical technique. Eventually, Magaw was able to document more 14,000 procedures that had been performed without a single complication attributable to anesthesia.
One of Magaw’s earliest disciples was Franc Florence Henderson. Known for her superb clinical and interpersonal skills, Henderson awed visiting doctors with her ability to use gentle, calm conversation to ease patients through the excitement phase of induction. Practitioners unfamiliar with her methods were documented as using from 10 to 20 times the amount of anesthetic.
Anesthetist vs. Anesthesiologist
Despite her evident ability, Henderson became a victim of what has remained an ongoing issue: the efforts of physicians to limit the scope of practice for nurses administering anesthesia.
Despite her illustrious career, when Henderson left the Mayo Clinic and moved to Los Angeles to be with her family, she practiced for only a short while before being forced out of the profession. She remained active in nursing organizations, but earned her living by running a boarding house.
In 1934, a group of prominent Los Angeles physicians filed suit against nurse anesthetist Dagmar Nelson, claiming she had violated the California Medical Practice Act. Although the doctors claimed their goal was to protect the public from unqualified practitioners, the suit primarily reflected the doctors’ economic concerns about competition from nurses, who could provide the same service at a lower cost.
Both sides called numerous witnesses and experts to testify, including Henderson, whom the doctors attempted to implicate in the alleged violation of the act. Those attempts failed, as did the charges against Nelson. The medical board appealed the case all the way to the California Supreme Court, but the court ruled against them, creating a legal precedent for nurses to practice anesthesia. For Henderson, it was by then a moot point; she had retired.
Despite the court’s verdict, the issue never goes away entirely. In 1981, Virginia Cassady Clinton (Kelley), mother of future President Bill Clinton and an independent practitioner for 37 successful years in Hot Springs, Ark., lost her legal battle to practice without physician supervision. Again, economic issues were at stake as well as the ages-long battle between Adam and Eve. At the time, nurse anesthetists were primarily female and anesthesiologists were primarily male.
Service for and in the military has been a constant part of the history of anesthesia nursing. Since World War I, nurse anesthetists have been the primary providers of care in combat zones. In some situations, such as the U.S. invasion of Panama in 1989, nurse anesthetists have been the only providers of anesthesia care.
CRNAs have become prisoners of war, been wounded in combat and even died in the service of their country. The names of two CRNAs are engraved on the Vietnam War Memorial: 1st Lts. Kenneth R. Shoemaker, Jr., and Jerome Olmstead. Three nurse anesthetists have served as chiefs of the Army Nurse Corps: Col. Mildred Clark; Brig. Gen. William Bester, RN, MSN, CNAA, BC; and Maj. Gen. Gail Pollock, RN, BSN, MBA, MHA.
Infighting and Anti-Semitism
The organizational history of nurse anesthetists has been very rocky at times. Strong personalities prevailed, which inevitably led to clashes.
In 1931, Agatha Hodgins fulfilled a lifelong dream with the establishment of what was originally called the National Association of Nurse Anesthetists, something for which she had worked tirelessly for years. Hodgins became the organization’s first president. Her successor was Gertrude Fife, who guided the association through the creation of a program of certification, a national qualifying examination for nurse anesthetists and accreditation for nurse anesthesia training programs.
Establishing a national qualifying exam was also a battle. Although Fife considered the standardization of education to be the most pressing issue, she was opposed by Hodgins, who believed that nurses needed the safety of state registration as a safeguard against doctors’ legal assault on nurse anesthetists’ right to practice.
Fife prevailed and the profession followed the example of physicians, who at that time were beginning their own move toward specialization and certification.
The association’s third president, Hilda Salomon, served only a short time, but her role was pivotal. In the early years of the organization, she waged a valiant fight to persuade other members that black and male nurse anesthetists should be included.
“Many harsh words were exchanged,” she said later. “It wasn’t until 1944 that my original idea was accepted.” Sadly, much of the opposition to Salomon’s views stemmed from the fact that she was Jewish.
The organization changed its name to AANA in 1939. Among its most influential subsequent leaders was Florence McQuillen, who spent 22 combative years as the organization’s executive director until she was forcibly replaced in 1970. During her tenure, described by some members as a “benevolent dictatorship,” the Department of Health, Education and Welfare recognized the AANA’s authority to grant accreditation and certification. The title CRNA was formally adopted and a policy on optional continuing education was instituted.
Earlier in her career, McQuillen and John S. Lundy, M.D., had established Anesthesia Abstracts, which for decades offered summaries of the most significant research developments in the field. It quickly became a one-woman project, although both McQuillen and Lundy were credited as authors. When McQuillen gave it up, the project died.
One CRNA recognized by the AANA as a “Living Legend” is here in Southern California: Joyce Kelly, CRNA, Ed.D., MHA, the founding director of the Kaiser Permanente Medical Care Program School of Anesthesia.
In the mid-70s, during her tenure as director, Kelly engineered the program’s affiliation with Cal State Long Beach, which began to offer the first master’s level program in nursing anesthesia. She is also the recipient of the AANA’s Agatha Hodgins Award for Outstanding Accomplishment, the group’s highest honor.
Today, nurse anesthetists are recognized in all 50 states. Fewer and fewer states require physician supervision and all can opt out of the Medicare requirement for supervision at the discretion of the state’s governor.
Anesthesia nursing is the most highly paid of nursing specialties. In 2012, the average annual salary was $157,000, with more experienced CRNAs earning nearly $215,000.
Physician, Steel Thyself
Surgery has been practiced for at least 2,500 years, but for much of that time, most procedures were harrowing for both patient and provider. Any nurse understands how hard it can be to manage a patient who’s in pain, even during routine housekeeping tasks. Early surgeons needed nerves of steel to perform delicate operations on patients who were often writhing and screaming
The word “anesthesia” in its modern sense was coined in the 19th century by writer and physician Oliver Wendell Holmes Sr., but the idea of rendering patients unconscious (or at least insensate) during surgery is far older. Unfortunately, reliably accomplishing that without further injuring or even killing the patient was easier said than done.
Lacking proper anesthetic, surgeons sometimes resorted to bloodletting, suffocation, thumps on the head or that old standby, alcohol. (After the procedure, the surgeon sometimes needed a drink almost as badly as the patient did!)
The Stuff of Nightmares
Since the mid-1800s, surgical anesthesia has become so sophisticated that the most painful part of modern surgery is often the bill. However, anesthesia is still not an exact science. There are occasional cases of patients emerging from general anesthesia with detailed, often disturbing memories of the procedure, sometimes in the form of dreams.
An unlucky few patients, like Jeanette Liska, Ph.D., have even reported being awake and in pain throughout a major surgery, aware but paralyzed and mute.
You can take some comfort in knowing that intraoperative awareness with recall (as awareness under anesthesia is formally known) is quite rare. Cases like Liska’s are rarer still, although even if there’s no physical pain, the memories can still be very traumatic.
For most non-trauma surgeries on adult patients, the incidence of intraoperative awareness is less than 0.2 percent. There is a greater likelihood of unintended awareness if the anesthetist or anesthesiologist can’t use normal anesthetic dosages (for example, in trauma cases where the patient’s vitals are too low) or if the patient’s age or other factors make it difficult to calculate an appropriate dosage. For example, anesthetic awareness occurs more frequently among pediatric patients.
As upsetting as these incidents can be for patients, few would argue that anesthesia has come a long way. Less than 200 years ago, after all, it was a rare patient who survived surgery without lasting physical and emotional scars.
The Mystery of Hua Tuo
One of the earliest known practitioners of surgical anesthesia was a Chinese physician of the Han dynasty, Hua Tuo (c. 110–c. 208). Hua Tuo is reputed to have developed a narcotic oral anesthetic called Mafai San, which he reportedly used to successfully perform surgeries as complex as colectomy.
Sadly, any books Hua Tuo may have written no longer survive, so we don’t know what ingredients he used, although modern historians have several theories. Mafai San may have been similar to a formula developed in the early 1800s by Japanese physician Seishū Hanaoka (1760–1835), which used Datura alba, aconite and several other herbs to form a potent cocktail of scopolamine and atropine.
Hanaoka first used this mixture as a general anesthetic during a lumpectomy in October 1804, although the anti-Western policies of the Tokugawa era meant that his work wasn’t disseminated outside Japan until many years later.
You might think that the availability of reasonably reliable surgical anesthesia in the 1840s would have been cause for celebration. Instead, the practice drew widespread criticism from both religious and academic authorities, who warned that the artificial suppression of pain (particularly during childbirth) was a threat to decency and an affront to divine and natural law.
One reason for this moral outrage may have been that most early surgical anesthetics were also well-known recreational drugs. Nitrous oxide, for example, was called “laughing gas” decades before it was ever used for dental work.
English chemist Humphrey Davy, the first scientist to seriously study the effects of nitrous oxide inhalation, noted in 1800 that the gas “may probably be used with advantage during surgical operations.” However, Davy soon became more interested in nitrous oxide’s euphoric effects, which inspired him to fits of laughter and poetic and philosophical eloquence. Davy had many socially prominent friends and by the 1830s, nitrous oxide had become a popular party drug among the intelligentsia.
Even chloroform, which briefly displaced ether for surgical use in the late 1800s, was sometimes used as a recreational intoxicant, as of course were later opioid anesthetics like morphine and heroin.
-- Sidebars by Aaron Severson
This article is from workingnurse.com.