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"We're concerned with the patient's psychological
well-being, as well as physical condition. We help manage
the patient's fear before surgery with our nursing skills,
rather than simply using drugs," Wooden said.
During preop interviews, CRNAs reassure patients and
families on the anesthesia procedures. This is usually
their first contact with the patient, unlike the surgeon
who likely has held several preliminary discussions
with the patient to discuss the operation.
"I have about five minutes after meeting the patient
to establish a rapport and have them trust me to put
them to sleep safely and wake them up again," Farrell
said.
Simple human contact like placing a hand on the patient's
shoulder provides great reassurance while doing the
preoperative interview, said Duane Laurelton, CRNA,
of Mid-Columbia Anesthesia PC in Hood River, Ore. Getting
the patient to open up is important, so that the CRNA
can uncover a medical condition or something the patient
has done that could compromise their well-being under
anesthesia.
"This could be something like undetected hypertension
or that a child ate some chips in the car on the way
to surgery," Laurelton said. "A CRNA must
talk to the surgeon about canceling surgery because
of patient safety, especially with elective surgery,
and the surgeon is more willing to defer to our judgment
in these circumstances."
Patients also have questions about what sensations
or awareness they may have during surgery and concerns
about pain after surgery. A patient may have had an
unpleasant experience decades before when ether was
used, recalling the overwhelming ether odor and terrible
nausea after the surgery. CRNAs assure their patients
that today's anesthetic agents allow more precise control
of consciousness, disappear more quickly from the bloodstream
and result in fewer side effects like nausea.
Because no single drug will put the patient to sleep
and relieve pain, CRNAs design a combination of agents
to meet the surgical and medical needs of each patient,
tailoring the time, depth of anesthesia and amount of
sedation. They administer inhalation anesthetic agents,
sedatives, muscle relaxants and many other drugs that
act to help maintain normal body functions, even reducing
the pH in the stomach acid to keep it from burning if
there is any nausea. Synthetic narcotics today provide
potent analgesic pain relief but last only a few minutes
after the surgery, unlike morphine, which affected patients
considerably after surgery.
A patient's greatest fear is waking during surgery,
Wooden said. Wooden assures patients that incidents
of awareness during surgery are extremely low because
the CRNA is always there to "monitor the monitors."
CRNAs prep the operating suite "like a pilot preparing
for flight, with an extremely thorough setup of the
anesthesia machines and any drugs and medication we
might need," said Susan Willis, chief CRNA at Parkland
Memorial Hospital in Dallas.
Parkland has 35 staff CRNAs delivering 50 percent to
60 percent of the anesthetics in 13,000 cases per year,
including 10,000 OB cases.
The nurse anesthetist stays with the patient throughout
the surgery, continuously monitoring vital signs and
medication levels with state-of-the-art equipment. For
example, a pulse oximeter attached to a patient's finger
gives a constant recording on a screen of whether the
patient has adequate blood oxygen.
"In the past, we had to look for symptoms to recognize
a problem, such as a patient beginning to turn blue,"
McKibban said. "Now, with our monitoring equipment,
we have a heads-up on what is happening to the patient
so we can intervene before there is a problem."
The CRNA oversees the patient's recovery until admitted
to a floor bed or until discharged from day surgery.
"As soon as the patient is awake enough after
surgery to have interaction, I bring in the family to
see them and facilitate the reconnection between family
and the patient. This is especially important when the
patient is a child," Wooden said.
Long hours, often without a break, and being on call
are downsides to working as a CRNA in both metropolitan
hospitals and in rural areas, where the CRNA may have
little backup.
"I've missed only one day due to illness in 26
years of practice, because if I did, cases would have
to be canceled," McKibban said. "This is a
common plight where one CRNA may cover two or three
hospitals, 24/7."
Sitting at the head of the operating table is stressful.
"We have a tremendous amount of responsibility,
and can literally have a patient's life in our hands
if something goes wrong," Farrell said.
Despite the downsides, Willis said CRNAs express significant
job satisfaction.
"The salaries help, and our caseload is varied
and challenging. We see immediate results because we
can complete cases start to finish several times per
day," she said.
Contact Margaret Watson at hotlinkcom@yahoo.com
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