Category: Topic Of The Week

Current topics in anesthesia. Review current clinical topics in anesthesia and add your comments and experiences. Topics include medications, clinical techniques, legal and practice issues. New topics are posted weekly. Student Nurse Anesthetists welcome to participate.

A walk in the park

GCSA

CRNA WEEK KICKOFF WALK

Family, Dogs and other CRNAs welcome

This event has been cancelled due to anticipated rain overnight Friday.  We will plan a different group activity in the spring.

walk post card

Where      McAllister Park, Turkey Roost Pavilion,

                Jones Maltsberge Entrance (enter at Money Tree street)

 

Address    13102 Jones Maltsberger Rd 78247

 

When       Saturday, January 19, 10:00 a.m. – noon

 

Walk at your own pace and meet at Turkey Roost Pavilion    after walk for Bottled water, fruit, granola bars. BYO lunch. Pavilion reserved ‘til noon.

 

Celebrate with the CRNAs and walk in the park with your friends

 

Please sign up by midnight Wed 1/16/19

Use the comment box below to sign up for the walk

Employee Wellness is No Joke

Employee Wellness is No Joke
liz fitness

By Liz Sanner Davis.  Liz is a Certified personal trainer and frequent author for procrna.com

 

It’s one of the biggest jokes in the lay community. Q. Where can you find the sickest people? A. In a hospital!   You probably don’t think that’s funny because every day you look at people with broken arms or legs, or repeat patients who have brutally aggressive melanomas or who live with the consequences of diabetes. Their pain is not amusing. But the joke, the cynically funny part, is that the joke is really referring to the hospital employees, your physician or physician’s assistant, the chief surgeon or anesthetist, the head of HR or the department secretary, YOU. The overweight and out of shape hospital employee appears as a huge disappointment to patients who are sick and seek your help.

Two-hundred-plus years ago, extra body fat was considered to be a sign of wealth. Abbigail Adams, after all, was short and fat. In spite of her years of physical labor on the farm and having to endure significant revolutionary war shortages, Abby still “enjoyed” a majority of her years ingesting quantities of comfort food. She and others of wealth and repute often made huge contributions to society whilst making ample time, following the years of economic travails of the war, for sitting, eating and being served often, if not well.

Is that you? Are you, in spite of 40-50 hours per week on your feet, in spite of regular paychecks and good benefits, in spite of wellness issues smacking you with direct hits daily, are you fat and flabby with chronic pain that plagues you all the way to the peanut butter cups and chocolate bars in the break room? Well, then, the joke’s on you, ‘though the patient isn’t laughing.

Don’t get me wrong. Being laughed at is ok on occasion, but laughing with is a whole lot more fun, and being the laughingstock? Not fun at all. In a new society that likes to outsource responsibility for their health to the healthcare industry, what part of your health problem is theirs, and what part of the problem is yours to fix or to prevent?

One can follow the history of workplace wellness in a timeline that begins with centuries-old Asian cultures, where employers dictated the wellness rules to employees. Throughout central Europe taxpayers supported and still support mandatory month-long employee holidays, thermal baths included. In the 1800’s, westward across the pond the wealthy elite offered workplace exercise activities to other wealthy elite. George Pullman, of rail fame, was one of the first to provide for general employee onsite wellness. (http://www.marketwatch.com/story/companies-meddling-in-employee-health-since-1880-2013-04-11)

The1970’s until the present have brought gradual changes to wellness in America. We have tried to approach wellness the same way we approach politics – by keeping The Nutrition Party and the Exercise Party separate. But over the last 45+ years, we have learned that exercise coupled with nutrition equals wellness. Along the way during those 45 years, the cost of living, the cost of healthcare and, therefore, the cost of taxes has risen exponentially. Fewer people carry the large economic burden and as medical know-how improves and the need for healthcare increases, the health of over-worked, over-stressed and over-tired employees has created a greater need than ever for wellness in the workplace. Employers are stepping up.

 

  • Broward, in Ft. Lauderdale, Fla, advertises, “We are a hospital-based fitness center with professionals certified by the American College of Sports Medicine and the National Strength and Conditioning Association. Our staff includes nutritionists and personal trainers who are educated in exercise physiology and nutrition, helping you create a healthier body, inside and out.”
  • Employees at The Johns Hopkins, Baltimore, MD provide a wealth of options presented on a monthly calendar that guides employees to the right location whether to enjoy a walking program or a smoking cessation appointment. Incentives are offered to encourage participation and commitment, and who doesn’t love praise and free stuff?
  • Grant Health and Fitness Center in Columbus, Ohio promotes “…health enhancement and disease prevention.” It is associated with a vast network of area hospitals and all locations have employee-friendly hours, a no-excuses kind of offer to help you maintain your status as an employee rather than as a patient.
  • The Cooper Institute, Dallas, TX has associated itself with healthcare entities for decades and offers certification for employees to return to the workplace and develop wellness/fitness programs. The Cooper’s credible certification program attracts healthcare, corporate and government clients worldwide. 

 

Providing employee wellness programs like these benefits the employer as well as the participant. Company insurance rates go down based on number of participants and proven results. Employee absenteeism is significantly reduced. People who work out together, work better together. They’re happier and, usually, just nicer to be around. And the quality of work provided by the healthy employee improves the entire company culture. Good health should reduce healthcare costs and reduced health care costs should lower our taxes!

But, be ready to pay if you want to play. Everyone wants something for free. If one thing has a fee and the other is free, we all know we will try very hard to make the freebie work, even if it really doesn’t. And if something costs nothing, the likelihood that we will follow through with the acquisition diminishes along with the return.

If wellness and fitness programs are not available at your place of work, get on it. the gym manager to your department chair. Head to Dallas to get certified at the Cooper Institute. After a rigorous week or two of classes and examinations, you could be qualified to blaze some trails to a clinic back home in Mississippi or Wyoming.

If wellness and fitness programs are available at your place of work, get to it. Join a program or help design a new one. Arrange to work with a qualified trainer. Get a work-out buddy and give and get the support that a partner provides, even and especially if you get to make a new friend doing it. For quality results, be certain to follow an integrated program that includes nutrition along with fitness. Be prepared and willing to pay the fee if it isn’t free.

So, what card will you be at work – the joke or the joker? Peanut butter and banana sandwiches may be how many of us got through college, but not through life. Take advantage of the whole-meal-deal offered by the employer at your place of work, and remember: The changes you make, the integrated health that you display to the patient, increases their trust and respect in the entire healthcare industry. Together, the patient’s trust and your good health will leave a permanent impression on history.

 

More:

http://www.corporatewellnessmagazine.com/worksite-wellness/the-evolution-of/http://www.bethesdaweb.com/employee-wellness-programshttp://www.beckershospitalreview.com/hospital-management-administration/18-most-popular-wellness-programs-for-hospital-employees.html

http://www.fiercehealthcare.com/story/what-hospitals-are-doing-employee-wellness/2012-03-15

http://www.amnhealthcare.com/the-roi-of-hospital-employee-wellness-programs/

http://www.cooperinstitute.org/pub/class_list.cfm?course_id=303

Volunteer Opportunity: CRNA Teachers Needed

A new opportunity for volunteering has emerged.  As the need for qualified anesthesia providers in developing areas of the world increases, there is a great need for anesthesia education in Sierra Leone (western Africa).  I am working with Johns Hopkins University and Health Volunteers Overseas with this project to educate CRNAs.  If you are motivated to teach our critical anesthesia skills (basics regarding drugs, techniques and use of the anesthesia machine) please contact me so that we can discuss this opportunity.  I have worked with this education team for many years providing education and mentoring in Eritrea (eastern Africa).  We expect eager and dedicated students and positive results at this site.  Please consider volunteering.  I can be reached at pc_crna@yahoo.com

And please share this information with every anesthesia professional that you can.

CRNA Topic: Volunteer Your Time and Talent.

Hello everyone.  I want to tell all of you about another exciting opportunity for us to pay it forward.  Earlier in the year, I wrote an article about volunteerism.  My first opportunity to teach other nurses anesthesia education outside of the United States was in Eritrea (Eastern Africa).  Now I am honored to have another opportunity to again be the Nurse Anesthesia program director for a joint venture between Health Volunteers Overseas and Johns Hopkins University.  I worked with Dr. John Sampson of Johns Hopkins for many years in the advancement of anesthesia education.  We first met and worked together as colleagues at Walter Reed Army Medical Center when I was on active duty in the early 2000’s.  Since then, Dr. Sampson and I have collaborated on anesthesia education overseas with great success.  Our next site is Sierra Leone in Western Africa.
The primary lecture site in country will be the Prince Christian Maternity Hospital.  Johns Hopkins already has a presence in Sierra Leone, so no one needs to worry that we are going to the site as the first educators from the U.S.  Currently one of the goals of the Hopkins program is to implement a distance-learning program for anesthetists in Sierra Leone.  Instructors in the program would be from Johns Hopkins, but also interested volunteers from HVO may be invited to participate.  Another CRNA colleague of mine, Terry English and I would screen and mentor HVO nurse anesthesia volunteers for involvement in Sierra Leone.  Length of engagement would be a minimum of 2 weeks.  Pending funding for the next iteration of nurse anesthesia students from the health ministry, the goal is to begin sending volunteers in March 2013.

The following list is the desired structure of the HVO / JHH program developed by Dr. Sampson and his colleagues at Hopkins.

•    There shall be an anesthesiology program director and a nurse anesthetist program director.
•    The two program directors will need to continuously communicate with each other about the activities and problems encountered in their respective areas.
•    Volunteers will come from a nation-wide pool of applicants and all volunteers will have to pass through the usual HVO process for registering and serving as a volunteer.
•    A Johns Hopkins based meeting will take place monthly where nurse anesthetists and anesthesiology physicians will discuss methods of enhancing the impact of educational efforts and methods of assessing this impact.
•    An effort will be made to teleconference and video-teleconference interested individuals who are remote to Johns Hopkins Hospital so that they may participate in the development of nurse anesthesia education in Sierra Leone.
•    Every effort will be made to accommodate the time of year choices made by the volunteer applicants.
•    Every effort will be made to coordinate the trips so that experienced travelers make trips in pairs with novice travelers.
•    All volunteers are asked to keep a record of both the intellectual and material contributions that they make toward improving nurse anesthesia education in Sierra Leone.
•    A discussion group web site will be established whereby Sierra Leone nurse anesthetists are able to discuss clinical and academic questions with past and future volunteers to the program.

According to Dr. Sampson, the latest information is as follows.  Current airfare ticket prices are approximately $1300.  Of course this will vary and the individual volunteer will need to research this accordingly.  The hotel rate negotiated is currently $80 per day (breakfast included) other meals are $7 per day.  Transportation from the hotel to hospital via taxi is about $5 each way.  Regarding cabs, we will generate a list of cab drivers with cell phones and encourage visitors to use the same drivers daily because in the morning the cab drivers are so busy picking up groups of people that finding a dedicated cab to the hospital can be a challenge.
The hotel is the Kona Lodge (http://thekonalodgesl.com).  The distance to the hospital is about 7 miles.  But due to traffic congestion, the trip can take up to 45 minutes.  The best time to travel to the hospital in the shortest amount of time would be in the early morning hours.
Our goal is 12 volunteers per year.  A standard classroom is available and is dedicated to nurse anesthesia education. An LCD projector can be arranged for presentations.  Johns Hopkins will assist with education program development.
Even though the country made headlines in the 90’s because of hostilities in the nation, since the peace of 2002 Sierra Leone has become a vibrant city attracting investors and holiday travelers alike.  Reconstruction is evident in many parts of the country.  However, Freetown has the usual Western comforts.  Plus the beaches are beautiful and not yet crowded by commercial ventures.  Leisure activities are centered around the Aberdeen Beach area.  Regarding attire for the volunteers, shorts pants  (shorts, mini skirts) are not recommended. Casual to business casual dress is appropriate attire.  Scrubs are to be worn in the hospital only.  Standard urban precautions against petty theft are prudent and plenty of Christian churches from a variety of denominations are present.
I urge any of you who read this to strongly consider volunteering.  Visit the HVOusa.org website and learn about what we do on a large scale.

If you have any questions please contact me at lexterrae1230@gmail.com.

Pamela Chambers, CRNA

Topic of the week: An opportunity to excel

In the Army, one is often tasked to do a job that most consider undesirable (i.e. 20 push-ups in full combat gear, pulling weeds in the parking lot in full combat gear, or painting the commander’s office in full combat gear); at the completion of said task the assigning officer or Drill Sergeant may state (re: yell) “Well, what do you have to say…”  The appropriate answer to convey your honor at being chosen to do the push-ups, pull the weeds, or paint the office would be, “Thank Sir/ Drill Sergeant for the opportunity to excel”.

I often think of that phrase when, in my professional life I take on tasks or assignments that no one else wants, or no one else has yet chosen to perform.  I was given a wonderful opportunity by a good friend of mine who was, and is, a professor of Critical Care Medicine and Anesthesiology at Johns Hopkins.  The task was to help educate nurses and nurse practitioners to learn how to provide anesthesia safely to patients in an austere environment.  For Free.  This was my first opportunity to do two things that I love – teach and talk about anesthesia – to people who were in dire need of a willing volunteer.

Here in the United States, we take safe anesthesia care for granted.  It is a luxury that we expect when we undergo surgery or diagnostic procedures.  But I soon learned, in grave detail, that safe anesthesia care is not available to everyone.  My first opportunity to volunteer in this capacity was in Asmara, Eritrea in 2003.  In Asmara, I met and worked closely with a wonderful nurse anesthetist named Kessette Tweldebrhan.  Kessette founded the schools of nurse anesthesia in both Asmara the capital of Eritrea, and in Addis Ababa the capitol of Ethiopia.  Among the many, many things that I learned from Kessette was not only the need for anesthesia providers and educators in his and nearby countries; but I also learned about many of the horrible conditions that the citizens in his part of the world endure every day because of the lack of anesthesia providers and a quality anesthesia education.

One problem that I learned about was obstetric fistula.  Kessette was fortunate enough to work with Drs. Reginald and Catherine Hamlin in the fistula hospitals in Ethiopia.  He gave me the book that they wrote about their experience learning about and devising a plan to combat obstetric fistula.  Fast forward 9 years.  Recently, I was contacted by another physician who has made it his lifes work to combat obstetric fistula – in Niger.  The physician is Dr. Steven Arrowsmith.  I came across the accompanying article about Dr. Arrowsmith and his fistula program.  Currently they are in dire need of qualified American anesthesia professionals who have the knowledge, skill, will, and desire to step up to the plate and help the women of Niger.  I intend to answer the call.  Please review the article that I found about Dr. Arrowsmith and visit his website.  I’ve also included a few pictures from my travels in Eritrea teaching anesthesia at the Orrota Hospital of Asmara University.

With all of the blessings that we have, consider this as your opportunity to excel.  If not you, then who?

Click here for the article by Dr Arrowsmith

Clinical Topic: Handwashing Standards

New patient safety guidelines require increased vigilance in handwashing by healthcare providers.  Previous guidelines established by OSHA required soap and water handwashing between every patient contact.  Over the past few years, alcohol based handwashing agents have been introduced to the hospital setting raising the question about their efficacy and risk.

An article By Gina Pugliese, RN, MS; Judene Bartley, MS, MPH, CIC; Tammy Lundstrom, MD, reviews the topic of the use of alcohol based handwashing solutions.  They state:

“The evidence is clear; HCW compliance with hand hygiene can reduce the 2 million healthcare-associated infections that occur in patients annually, as well as reduce the risk of infections transmitted to workers. But the use of these waterless alcohol-based hand antiseptics, the centerpiece of the new CDC guideline, has been perceived to be in conflict with existing healthcare safety regulations. These include, for example, handwashing requirements from the Occupational Safety and Health Administration (OSHA), flammability issues from the National Fire Protection Agency (NFPA), and corridor obstruction issues from Centers for Medicare and Medicaid Services (CMS).”

The article goes on to discuss the fire risk related to the use of alcohol based handwashing solutions.  As CMS tightens enforcement of handwashing in the healthcare workplace, this information is essential for CRNAs.  Click here to read the article and return to PROCRNA.COM to share your comments.  ( If the link takes you to an ad, wait about 5 seconds and it will go on to the article)

Legal Topic: Documentation

Same Song Different Verse – If It Wasn’t Documented…..

Consider for a moment, that you or a colleague is facing legal action that, on the face of things, appears absurd.  How absurd? Well, think for a moment about the first time that you learned how to place an intravenous (IV) line.  The first thing that you were taught to do (after determining the correct patient, catheter size, and limb selection) was – clean the site.  Traditionally we used alcohol either provided in an IV start kit or provided by our facility.  How many of us thought about, or consulted the relevant science, regarding which preparation solution was actually better for patient care?

Now lets take it up notch. Consider what you do as an anesthesia provider when you are preparing to place an epidural catheter or a subarachnoid block.  Most of the kits that we used in school and current practice have supplied within them a skin cleansing preparation.  According to one manufacturer, B. Braun (bbraunusa.com/images/bbraun_usa/bbrauncatalog.pdf; F3), the supplied cleaning preparation in standard single dose epidural trays is povidone iodine.  Again, how many of us question the skin preparation solution provided in a kit by a manufacturer that our facility has chosen to select for us?  Relevant science indicates that a better skin preparation solution for neuraxial blocks is chlorhexidine.  Furthermore, this solution is optimal when used from a single use package, instead of poured from a multi-use container.

What is the importance of such minutiae?  Well, suppose a post-partum patient presented to the ER 4 days after discharge from the mother-baby unit of Smallville Community Hospital with the following symptoms: low grade fever, back ache, intermittent weakness of the right lower extremity.  During her ER workup, the on call anesthesiologist, Dr. Nurves, is consulted since the patient had an epidural for labor analgesia.  After his physical exam, Dr. Nurves suspects the patient has an epidural abscess.  He orders an MRI that confirms his suspicions.  Now fast forward 18 months.  The patient decides to file a claim against her anesthesia providers for causing the pain and disability from which she now suffers.  She suspects her current problems are from the epidural abscess…….

When an attorney is tasked to evaluate this type of claim, the attorney will seek a healthcare professional who is familiar with the standards of care surrounding the activities related the client’s labor epidural for analgesia.  Imagine the professional conundrum provided by the following clause on the anesthesia record “Sterile prep and drape” without further elaboration.  Would it make any difference if we added another detail: the epidural was placed by a trainee (either physician or nurse) and the use of the trainee was NOT noted on the anesthesia record.  Additionally, the patient, and her spouse, recalls multiple attempts at placing the epidural; this is also not noted on the chart.  So how does one determine if standards of customary practice were met in such a situation?  The use of the trainee, and the multiple attempts at placing the epidural catheter are not documented in the records.  These items are not facts in evidence.  It is a fact however, that if cultures are obtained from an epidural abscess with bacterium that are not normally found in the epidural space, AND the patient’s physical exam prior to the placement of the epidural does not specifically indicate a bacterial infection in the area where the epidural catheter was to be placed AND (perhaps most importantly to us) the modality for transmission of bacterium into the epidural space is under the exclusive control of the anesthesia provider, then supporting data can be introduced to create a scenario whereby the anesthesia providers who placed the epidural catheter caused the epidural abscess AND the related sequela.  What type of supporting data?  Standards of care regarding neuraxial blockade; sterile skin preparation; and care documentation.  Documents of professional standards, along with several peer- reviewed clinical reports regarding sterile skin preparation are readily available in any medical library (electronic or traditional) or via the world wide web.

A well researched review providing the who, what, when, where, and why of how we are supposed to practice our craft can speak volumes to a trier of fact (a judge or a jury) as to whether or not a patient’s claim has merit.  So what is the take home message: Know and adhere to your professional standards of care (review them if necessary) and keep up with the state of your science.

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

References
Barash, P.G., Cullen, B.F., & Stoelting, R.K. Clinical Anesthesia 3rd Ed.  Ch 26 Epidual and Spinal Anesthesia p 651 Lippincott Raven, New York 1997

Birnbach D.J. et al, Povidone Iodine and skin disinfection before initiation of epidural anesthesia. Anesthesiology. 1998; 88:668-672

Nagelhout, J. J., Zaglaniczny, K.L. Nurse Anesthesia 3rd Ed. Ch 44 Obstetric Anesthesia p 1066     Elsevier Saunders, St. Louis 2005

Stoelting, R. K., Miller, R.D. Basics of Anesthesia 3rd Ed., Ch. 12  Spinal and Epidural Anesthesia p 173, Churchill Livingstone, New York. 1994

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

Clinical Topic: Defenses to Negligence

In earlier articles, I discussed some basics about medical malpractice. Now I want to briefly review some defenses to negligence.  Keep in mind that all negligence claims are not credible; and even if a credible claim exists, there are many avenues to resolution.  If the required elements of negligence are present and cannot be contested, defenses to negligence may be considered.

One method for mounting a defense to medical malpractice is to assert that the plaintiff caused their own injury, and because of the plaintiff’s action the defendant should not be held liable for the injury.  A jurisdiction that recognizes contributory negligence would bar recovery by the plaintiff if the plaintiff is found to have contributed to the cause of his injury.  A jurisdiction that recognizes comparative negligence (of the plaintiff) would decrease any award for a plaintiff’s claim based on the amount of fault the court determines the plaintiff contributed to the injury. Additionally, if the defense can establish the plaintiff knew the risks involved in an activity and voluntarily performed the activity, then assumption of the risk might be the appropriate defense to relive the defendant of liability. Adherence to these theories is ascertained by reviewing relevant case law in the applicable jurisdiction, and review of relevant statutes in the applicable jurisdiction.

Consider this example: Priscilla Patient arrives at Sunshine Valley Ambulatory Surgical Center (ASC) for a laproscopic appendectomy.  After completing and signing all of the required forms in the admitting office, Priscilla is led to the dressing room to disrobe and to change into her gown for surgery.  Priscilla disrobes leaving only her underwear remaining under the gown. As Priscilla gathers her belonging and opens the door to exit the changing room, Priscilla’s right great toe makes contact with the door of the dressing room.  The contact doesn’t initially bother her so she doesn’t tell anyone about it.  The next day, during the follow-up post-operative call, when asked if she has any questions or concerns about her procedure the prior day, Priscilla states, “My surgery went fine, but my right big toe is really hurting where the door hit it.  Now it’s swollen and really hot.”

This example is hypothetical.  However, at this point many options can occur.  If Priscilla decides to sue the ASC for her injured toe, all of the required steps (such as fact gathering and determining if the claim is credible) will begin to be pursued by her legal team.  In a claim of negligence against the Sunshine Valley ASC, if a defense to negligence for a claim like this were considered, it is reasonable to suggest that Priscilla had something to do with the injury that she now has because she didn’t tell anyone about it when it occurred.  If a court believed that proposition, any award to which Priscilla may have been entitled to would be either barred in a contributory negligence jurisdiction, or reduced in a comparative negligence jurisdiction.  If the defense can establish that Priscilla chose to exit the dressing room without foot coverings, knew she was injured before she had surgery, and before she left the facility, and she chose not to inform medical personnel who were readily able to assess and treat any injury if any were present, then assumption of the risk might be the choice to rebut Priscilla’s claim of injury to her toe.  The legal team will evaluate the facts of the case and apply the law as indicated.

Pamela Chambers, MSN, CRNA, EJD

About the author:  Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted.  Click here to learn more about Lex Terrae Legal consulting services.

Clinical Topic: National Nurse Anesthetist Week

Every year the last full week in January is designated as National Nurse Anesthetist week.  This is our opportunity to capture media coverage and let the world know who we are and what we do.   PROCRNA.com encourages you to offer “CRNA for a day” to your local nursing school.  Welcome students at the head of the table as they rotate through the operating room.

The picture on this posting and the suggestions below come directly from the AANA web site.  Click here to view the original posting from the AANA.

National Nurse Anesthetists Week Ideas

 

There are countless possibilities for promoting your profession during National Nurse Anesthetists Week, January 22-28, 2012.  Have you considered the following?

1.                  Legislative Day.  Invite your state legislators to a breakfast or coffee at a gathering place near the state capitol, or recruit state association members to pay a visit to your legislators’ offices.

 

Many state associations have had success with legislative days in years past.  If you are interested in organizing a legislative day for your own state association, be sure to contact your state lobbyist for input on state rules and regulations concerning giving gifts to, entertaining, and lobbying legislators.

 

  1. Community Calendars.  Contact your local newspapers and radio/television stations and ask to have your National Nurse Anesthetists Week activities included in their Community Calendars.

 

  1. Proclamations.  Some states are already contacting their legislators, governors, and community leaders to have the week of January 22-28, 2012, publicly proclaimed as National Nurse Anesthetists Week.  Try contacting the appointment secretary at the state capitol or governor’s office for information on how to proceed.  (See the sample proclamation included in this section of the website.)

 

  1. Career Days.  Contact local junior high schools and high schools, junior colleges, and colleges/universities regarding speaking and exhibiting opportunities to promote careers in nurse anesthesia.

 

  1. Public Speaking.  Opportunities for public speaking are limitless.  Contact your chamber of commerce, community center, high school, park district, local chapters of professional associations, or clubs, to name a few possibilities.  Or stay closer to home and arrange to give a presentation at the hospital or healthcare facility where you work.  Target the general public or specific market segments like senior citizens, other healthcare professionals, expectant mothers, etc.

 

  1. Billboards.  For previous Nurse Anesthetists Weeks, a few states purchased billboard advertising space and reported great results.  The Delaware Association of Nurse Anesthetists borrowed from the 2005 Nurse Anesthetists Week materials (“How Do You Say Quality Anesthesia Care?”) to create a billboard that appeared along a busy highway during Nurse Anesthetists Week 2006.  AANA has some information concerning billboards that is available upon request.  For more comprehensive information, however, search “billboards” on the Internet.  Also, if you would like to find out more about DANA’s billboard project, contact Del Price, Jr., CRNA, MSN, via email at delsleeper@aol.com.

 

  1. Table-top Displays.  Obtain permission from your hospital, ambulatory surgical center, or physician’s office to set up a table-top display during National Nurse Anesthetists Week.  Put out brochures, giveaways, and a bowl of candy, tack up a poster or two, or get more elaborate and run the videotape The Best Kept Secret in Healthcare: Certified Registered Nurse Anesthetists, which is available through the AANA Bookstore.

 

  1. Educate Acquaintances about CRNAs.  Make it a point during Nurse Anesthetists Week to explain to as many family members, friends, patients, and others as possible, exactly who you are and what you do.  The world needs to know, and you are the best ambassador to deliver this message on a one-to-one basis.  In fact, make delivering the message part of your daily routine.

 

  1. Phone-System Message.  Obtain permission to record a message about CRNAs and Nurse Anesthetists Week on your hospital’s phone system.  When callers to the hospital are put on hold, they will hear the educational/promotional message.

 

  1. Cinema Ads.
    The following information consists of generalized pricing that may vary depending on the number of movie screens at your local cinema complex.  For instance, if the cost to show a 30-second public service announcement during the 20 minute preview portion of the movie were $40 per screen, and the theatre has 20 screens, it would cost a total of $800 per week to advertise in that theatre.  However, if the theatre complex has four screens, the cost would be $160 per week.  In addition, most theaters show an ad for an average of four times per day (at no additional cost), and there may be a one-time cost to digitize the ad. Most theatres contract with a third part company who handles all of their advertising.  National CineMedia places advertising in the following movie theatres: AMC, Regal, Century, United Artist, Edwards, and Cinemark.  The contact number is 1-800-828-2828. Please call for current figures.

 

11.       Magazine Covers.  Northeast Medical Center in Concord, N.C., won an honorable mention in the 2003 PR Recognition Award contest for creatively educating patients and their families about nurse anesthetists.  The CRNAs there purchased magazine subscriptions for the hospital’s waiting rooms, and placed each issue of the magazines in clear, protective plastic covers.  On each cover they then placed a large sticker that stated the magazines were compliments of the anesthesia department and provided information about nurse anesthetists.  The information was read by countless people throughout the year.

 

Special thanks to those CRNAs who offered ideas and suggestions for Nurse Anesthetists Week.  Additional ideas and suggestions are always welcome!  Please send to Christopher Bettin, AANA Senior Director of Communications, at cbettin@aana.com.

Standards, the Expert Witness

Submitted by Pamela Chambers, MSN, CRNA, EJD

Click here for Lex Terrae consulting

As we all know, legislative bodies enact the laws that we must all abide by – whether we are aware of them or not.  Ignorance of the law is rarely a defense to violating it, whereas professions set their own standards of care.  Ignorance of the standard of care while not illegal, may be described as poor practice.  But how does the public – or the courts, know what constitutes poor practices? How would a court determine the standard of care for nurse anesthesia practice in Temple, TX; or in Dallas, TX; or in Bay City, TX?

The United States Supreme Court held that expert opinion is only admissible when it is generally accepted as reliable the relevant scientific community Frye v. United States, 54 App.D.C. 46, 293 Fed.1013 (1923). The decision handed down in Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993) went a step further in clarifying that expert testimony must have a valid scientific connection to the issues of a particular case.  So why is this important to know?

Upon review of Carolan v. Hill, 553 N.W. 2d 882, Iowa 996, the issue on appeal was the admissibility of expert testimony.  The harm suffered by the plaintiff (Carolan) was ulnar nerve damage sustained during the administration of anesthesia for a surgical procedure unrelated to plaintiff’s arm. The trial court refused to allow the plaintiff’s expert witness testimony.  The trial court relied upon its interpretation of the Iowa Code regarding who could establish standard of care. On appeal, the Iowa Supreme Court clarified the interpretation of the law in Iowa.  The relevant code noted that a “person” qualified to provide expert testimony shall be so qualified based on medical or dental qualifications that relate directly to the issues in the case at bar. Furthermore, if the legislature had intended qualified individuals be restricted to physicians and dentists, it would have done so explicitly. In this instance, this issue was reversed (overturned the jury verdict for the defendant anesthesiologist) and remanded to the lower court.  Plaintiff’s expert witness was a Nurse Anesthetist.

The Federal Rules of Evidence, rule 702, state the following with regard to expert witnesses: A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if: the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; the testimony is based on sufficient facts or data; the testimony is the product of reliable principles and methods; and the expert has reliably applied the principles and methods to the facts of the case.  This rule is based largely on Daubert, but has been amended and modified as other landmark decisions (such as Kumho Tire Co. v. Carmichael, 119 S.Ct. 1167 (1999) have been decided regarding expert testimony.

Daubert set forth a non-exclusive checklist for trial courts to use in assessing the reliability of scientific expert testimony. The specific factors delineated by the Daubert Court are (1) whether the expert’s technique or theory can be or has been tested—that is, whether the expert’s theory can be challenged in some objective sense, or whether it is instead simply a subjective, conclusory approach that cannot reasonably be assessed for reliability (i.e. an opinion); (2) whether the technique or theory has been subject to peer review and publication; (3) the known or potential rate of error of the technique or theory when applied; (4) the existence and maintenance of standards and controls; and (5) whether the technique or theory has been generally accepted in the scientific community. The Court in Kumho held that these factors might also be applicable in assessing the reliability of nonscientific expert testimony, depending upon “the particular circumstances of the particular case at issue.” 119 S.Ct. at 1175.

So what does all of this mean?  How does affect your practice if it affects it at all?  Consider this,  when you make a decision as to which nondepolarizing muscle relaxant you will use (when you have a choice) ask yourself if the decision you’ve made is accepted practice.  When you decide to conduct your anesthetic in a manner that you deem best for your patient, ask yourself if the methods that you use are (still) relevant and valid? If any of us are practicing the “way we’ve always done it”, ask yourself this question – Is this defensible in a court of law?

About the author:  Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted.  Click here to learn more about Lex Terrae Legal consulting services.

Radiation Exposure to Anesthetists

Radiation exposure has long been a concern to Radiologists and their assistants.  Lead aprons, thyroid shields and more recently leaded eyeware have reduced their exposure to radiation.  Anesthetists are frequently assigned to sedate / anesthetize patients in the interventional radiology suite.  Like the Radiologist, the anesthetist is exposed to radiation danger.

In a study by Anastasian, ZH, et al published in Anesthesiology, the facial exposure to radiation was compared between the Radiologist and the Anesthetist.   Both providers wore lead aprons.   The Radiologist wore leaded eyeglasses and stayed behind a leaded acrylic shield to the extent possible.  The Anesthesiologist also was instructed to stay behind a leaded shield to the extent possible and to keep maximum distance from the source of radiation.

The authors of the study demonstrated that the Anesthesiologist had a 3 fold increase in facial exposure to radiation than did the Radiologist, thus increasing the risk of developing cataracts.  Exposure of the Anesthesiologist was correlated to the number of pharmacologic interventions performed during the case.

The best ways to reduce exposure to radiation are distance and shielding.  Lightweight leaded eyeglasses reduce exposure of the cornea by 98% and are recommended for those spending significant time administering anesthesia for interventional radiology

Click here to review the work by Anastasian, ZH et al.

Please return to this site and leave a comment

Opioid-Induced Respiratory Depression

The Anesthesia Patient Safety Foundation is committed to the safe and reliable administration of every anesthetic.  An area of concern has been respiratory depression in the immediate postoperative period secondary to narcotic administration.  The following information comes directly from the foundation;

The APSF believes that clinically significant, drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality since it was first addressed by the APSF in 2006.1 The APSF envisions that “no patient shall be harmed by opioid-induced respiratory depression in the postoperative period,” and convened the second multidisciplinary conference on this serious patient safety issue in June of this year in Phoenix, AZ, with 136 stakeholders in attendance. The conference addressed “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period.”

Click here to read the full report by the APSF regarding drug-induced depression in the postoperative period.  After reading the report, click the back arrow to return to this site and leave a comment for your colleagues.

Ketamine Supplement for Anesthesia

Ketamine is an old drug which has come in and out of favor many times over the past decades.  Currently, articles are emerging touting the advantages of Ketamine as a supplement for  both general anesthesia and monitored anesthesia care.  Below is a description by Pamela Chambers, CRNA regarding her clinical experience using Ketamine as a supplement.  Read her excellent review, scan the articles and leave a comment to share your experiences with your colleagues.

Submitted by Pamela Chambers, CRNA

Lexterrae legal consulting service

For the EP case that lasted 6+ hours, GETA with .5 mac Desflurane and Propofol infusion at 30 ug/kg/min, the Propofol Ketamine mixture performed very well.  I mixed 50mg Ketamine in each 50ml bottle of propofol.  I used less than 3 bottles for the case and never used more than .5 mac Des.  I used a total of 25 ug Fent, just after intubation, for the case.  The patient was 83 yo male, approx 90 kg, EF 20%.

Upon emergence the patient denied any pain or discomfort.  He was appropriately responsive to verbal and did not cough on extubation. VS were stable and he was A&O x3 on arrival to the EP room for phase 2 recovery.

A few days later, I used Ketamine as an analgesic adjunct for another long case (10 hr bilateral mastectomy and tram flap).  I used a total of 195 mg Ketamine.  The patient was an ASA 1.  After 100 ug Fent (and 3mg Versed) prior to induction, I used 30 mg Ketamine approximately 3 mins prior to incision.  Then I administered 30 mg Ketamine at hr number 2, and hr #3.  Around hr #4, I decreased the Ketamine to 15mg for each hrs successive dose with a plan to halt Ketamine admin when I believed the case was 2 hrs from completion.  My last Ketamine dose was at 1430 during the last phases of the case. The patient began spontaneous ventilations after reversal of NDMR at approximately 1640.  The case ended at approximately 1730.  The patient

received a total of 2200 ug Fent dosed approximately 100 ug every 30-45 mins.

Intermittent rescue doses for SNS spike were not required. Pressor agents were not used. Hemodynamics were extremely stable, almost like the proverbial railroad track!

Total fluid administered was 2 liters NS and 1 liter 5% Albumin, UO was 150 ml, EBL 300ml. I also adminstered 2 mg Versed at 1600 to facilitate decreasing the inhaled agent level and to ameliorate any emergence delirium associated with the Ketamine.  The patient was appropriately responsive to verbal prior to extubation, and did not cough during extubation.  She also denied any c/o pain immediately post-operatively. No emergence delirium was appreciated.

Click here to read a review article by Laskowshi et. al regarding Ketamine use

Click here to read an article by McCartney et al regarding the role of the NMDA receptor

The Sticky Situation of Adhesion

Submitted by Pamela Chambers, MSN, CRNA, EJD

Click here for Lex Terrae consulting

Two years ago, Joe Sixpack was admitted to your facility to undergo vasectomy.  His clinical course in your fine medical center was uneventful. Today, you are seated in the office of the facility mediator and all relevant parties are present: Joe Sixpack, Mrs. Sixpack, little baby Sixpack who will celebrate his first birthday next week, and everyone involved in the clinical care of Mr. Sixpack on that fateful day 2 years ago.

Before beginning the mediation process, the facility’s attorney presents the admitting forms that Joe signed upon arrival to the facility and prior to receiving any sedation for his procedure.  One of the forms, a two sided form, contains an explanation of the procedure that Joe has requested on side one, along with the risks, benefits, and options of the procedure and several blank lines at the bottom of the form in case Joe wanted to add anything to the form. Side two of that same form contains the following statement “I hereby release Smallville Medical Center and it’s employees and contractors, from all liability arising from any injury to me resulting from my requested therapeutic procedure to be performed by Dr. Kuttemup and his staff at Smallville Medical Center.”  Immediately after this paragraph is Joe’s signature with the date and time the form was signed.

When a healthcare provider has this type of statement in a contract for services for the express purpose of limiting liability relating to the provision of those services, this is termed an exculpatory clause.  When this type of clause is a condition to obtaining the requested service this creates a contract of adhesion. While most courts attempt to enforce contracts by trying figure out what the parties intended when the contract was written; courts often find contracts of adhesion unenforceable as a matter of public policy (Weaver v. American Oil Co., 257 Ind. 458, 276 N.E.2d 144 (1971).

The contract to provide health care services is not usually between 2 similarly situated (i.e. equally knowledgeable) parties.  If a contract is deemed grossly unfair to one party it will usually be held unenforceable in court.  Consider the following release from Olson v. Molzen (558 S.W. 2d 429, Tenn., 1977) “…I therefore release Dr. Molzen and his staff from responsibility associated with any complications that may come up or be apparent in the next 12 months…”  The court in this case found the exculpatory clause particularly distasteful because an individual in such a profession, a physician, should not be permitted to hide behind such a shield as a license to commit professional negligence.

Regarding all contracts, there lies a duty to read.  This is small comfort to a plaintiff but a court will evaluate the parties intent to contract by evaluating the terms of the contract.  Terms that appears grossly unfair (i.e. unconscionable), violate public policy (i.e. one cannot receive the healthcare service with out agreeing to the term), or lack true assent will likely lead to a ruling that the contract is unenforceable.

About the author:  Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted.

DNR in the Operating Room

You are scheduled to do a patient coming from the ward with Do Not Resuscitate orders.  What does that mean and what do you do?  Some would argue that General Anesthesia is a controlled resuscitation on every case, and, therefore either the DNR orders should be suspended or the case should be canceled.   Does that choice afford the patient the quality care that he/she expects and deserves?

Across the nation, patients with terminal conditions come to the operating room for procedures that will not extend their lives but will improve the quality of life.  Stabilization of a pathologic fracture or the insertion of a feeding tube are but two examples.   Click here to read the excellent review of DNR in the operating room from the University of Washington Medical School and then come on back to www.procrna.com.   Leave a comment and share your thoughts with your colleagues

LMA in the Prone Position

The LMA (Laryngeal Mask Airway) has been a common airway management device used by the Anesthesia community for two decades.  Because the device does not “secure” the airway like a cuffed endotracheal tube would, anesthetists are selective about the patient population and type of surgery when deciding whether or not to use the LMA.  Our international colleagues seem to have been bolder with the use of the LMA and report its use in the lateral and sitting positions.   An Article by Ng Published in Anesthesia and Analgesia reported a series of over 200 patients who were safely induced in the prone position with the LMA inserted after induction.  Click here to read the article and then return to procrna.com and leave a comment.  Let us know about your experience using the LMA in the non-supine patient.

Res Ipsa Loquitur

This is a theory of liability that basically states “the thing speaks for itself”.  This doctrine is applied in medical malpractice usually in cases where the injury is in a location of the body distinct from the proposed procedure or operation.  The classic case is Ybarra v. Spangard, 25 Cal.2d 486, 154 P.2d 687 (1944), here the plaintiff underwent an appendectomy but awoke from surgery with pain in his arm.  The court applied Res Ipsa Loquitur to the facts, finding (in part), “the defendant had control at one time or another the of…instrumentalities which might have harmed the patient…”

 

Three conditions must be met for application of this doctrine: The accident must be the kind that does not ordinarily occur in the absence of someone’s negligence; it must be caused by an agency or instrumentality within the exclusive control of the defendant; and it must not have been due to any voluntary action or contribution on the part of the plaintiff. Dobbs, The Law of Torts Sect 249 (2000).

 

Some courts have resisted use of this doctrine because of concern that healthcare providers would be in constant fear of liability from rare bad outcomes.  In Siverson v. Weber, 57 Cal2d 834, 22 Cal.Rptr 337 P.2d 97 (1962) the court acknowledged this doctrine would place an undue burden on the medical profession and limit the use of innovations even if due care is exercised.

 

Some states allow a jury to infer negligence vis-à-vis Res Ipsa, others treat the doctrine as a presumption that a defendant must rebut.  Appropriate review of recent caselaw is prudent for defense against this type of allegation.

Strictly Speaking

Most of us take comfort in the fact that each day that we come to work to serve our patients, we intend to perform at our very highest caliber.  We hope that our stellar reputations will shield us from liability if anything unplanned should occur and injury befalls a patient.  Well, strictly speaking – this just isn’t the case.

Strict liability is a theory in which fault can be determined regardless of intent or even knowledge of wrongdoing. 

Strict liability can apply to crimes or torts. An example of a strict liability crime is the act of serving alcohol to minors. Strict liability in tort is generally focused on objects (not actors) that cause harm (i.e. strict products liability).

To prevail in a cause of action based on strict products liability (SPL), the plaintiff must prove: 1) the product was defective, 2) it was defective when it left the defendants hands, and 3) the defect was the proximate cause of the harm suffered.  It is also necessary that the product be expected to and does reach the consumer without substantial change from it’s condition when sold.  Liability will attach if a product is sold in a defective condition and the defect causes a foreseeable user of the product to suffer personal injury as a result; any party involved in the commercial supply of that product will be held strictly liable for the injury.  Mandatory considerations in a SPL cause of action include: 1) proper plaintiff (any user or consumer), 2) proper defendant (any entity in the marketing chain, not occasional or used dealers), 3) proper context (personal or property harm not harm to the product), 4) defect type (manufacturing, design, or warning), 5) cause in fact (“but for” the defect the plaintiff would not have been injured), 6) proximate cause (the harm was reasonably foreseeable from the defect; no superceding conduct present – like misuse or alteration of the product), and 7) actual harm.  A product is considered “defective” if based on it’s design, manufacturing, or lack of adequate warning it constitutes a danger to the average consumer that is greater than the social utility of the product.

So you may be thinking, you are safe from this type of liability because you NEVER intend to harm any of your patients or use any defective equipment.  But what if a patient has an injury after surgery that they did not have before surgery, and the injury is such that they could not have contributed to its occurrence and last, but not least, the injury stems from a modality that was under your (the anesthesia provider) exclusive control……Res Ipsa Loquitur – The thing speaks for itself.

Pamela Chambers, MSN, EJD

Prevention of Intraoperative Awareness in a High-Risk Surgical Population

To Bis or not to Bis….the controversy continues.  A study reported in the New England Journal of Medicine (Avidan et al, August 18,2011) evaluated using BIS versus end tidal agent concentration in the prevention of intraoperative awareness.

In this study, 6041 patients were randomly assigned to either have BIS or end tidal agent to determine anesthetic depth.  After surgery patients were assessed regarding intraoperative awareness.

Findings were that the superiority of BIS was not established and fewer patients had awareness in the end tidal agent group than in the BIS group.

Click here for article

In the same issue of NEJM, an editorial by Gregory Crosby, MD reviews the evolution of patient monitoring with regard to awareness and cautions that end tidal agent in and of itself may not be the answer to the problem.

Click here for editorial

Review the original article and make a comment….to Bis or not to Bis, that is the question.

Risks of Anesthesia Care in Remote Locations

From the ASPF Newsletter

Patients receiving anesthesia in remote locations tend to be older and sicker than those in the Main OR.  In addition, they tend to receive MAC anesthesia more frequently.  Below is a case scenario.  Read the entire article from the ASPF newsletter and add your comments.

A 75-year-old, 100-kg, ASA 2 man was scheduled for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). Monitors, including pulse oximetry, blood pressure, and ECG, were placed and the patient was turned prone for the procedure. He was given midazolam 2 mg and fentanyl 50 mcg IV, and he remained anxious. Additional midazolam 2 mg and fentanyl 150 mcg IV were given, but the patient could not tolerate insertion of the endoscope. Propofol 20 mg IV, followed by an infusion of 50-70 mcg/kg/min, was administered, and the procedure was begun with O2 saturations 88-92% on 4 L/min O2 by nasal prongs. After 20 minutes, the O2 saturation decreased to 70%, and the patient became severely bradycardic, and was treated with atropine 1 mg. Attempts at bag-mask ventilation and placement of a laryngeal mask airway failed. Blood pressure was not obtainable and the procedure was aborted. It took 2-3 minutes to push aside the heavy endoscopy equipment, move in a gurney, and turn the patient supine to begin CPR. Although the patient was resuscitated after 10 minutes of CPR, he sustained severe anoxic brain damage, and life support was eventually discontinued.

Cost Effectiveness Evaluation of Anesthesia Providers

Anesthesiologists and certified
registered nurse anesthetists
provide high-quality, efficacious
anesthesia care to the U.S.
population.

This research and analyses
indicate that CRNAs are less
costly to train than anesthesiologists
and have the potential for
providing anesthesia care efficiently.

Anesthesiologists and CRNAs
can perform the same set of
anesthesia services, including
relatively rare and difficult procedures
such as open heart
surgeries and organ transplantations,
pediatric procedures,
and others.

CRNAs are generally salaried,
their compensation lags behind
anesthesiologists, and they
generally receive no overtime
pay.

As the demand for health care
continues to grow, increasing
the number of CRNAs, and permitting
them to practice in the
most efficient delivery models,
will be a key to containing costs
while maintaining quality care.

Read the Full article in Nursing Economic$, 2010;28(3):159-169.