First-hand accounts of how CRNAs are helping healthcare providers deliver safe, high-quality, cost-effective anesthesia care in today’s ever-changing healthcare environment.
Debra Barber, CRNA, DNP
It has been said that “When the heart speaks, the mind finds it indecent to object.” Perhaps that was the case for Debra Barber, CRNA, DNP, who listened to her heart in 2001 while working at Jewish Hospital in Louisville, Ky. Barber didn’t object when asked to work on the anesthesia team in the world’s first fully implantable artificial replacement heart transplant. Despite objections of her participation by a staff anesthesiologist, the lead surgeon of the case recognized Barber’s qualifications and insisted on having her be a part of his team, and so Barber became a part of this historic team, as did fellow CRNA Carla Hobbs.
The implantation of an artificial replacement heart is a surgical procedure performed on critically ill patients with end-stage heart failure, whose conditions preclude receiving a traditional donor heart, and who have a projection of 30 days to live. In most instances, this sort of case presents a series of challenges due to the medical state and fragility of the patient. As a 22-year veteran of nurse anesthesia, Barber had spent eight years of her career providing anesthesia for heart transplants, which is one of the reasons why the performing surgeon personally selected her to be a part of this groundbreaking procedure.
On July 2, 2001, Barber’s years of experience were instrumental in her ability to successfully anesthetize the 50-year-old recipient of the first implantable artificial replacement heart during the four-hour long procedure, in which the patient fully recovered from his anesthesia. Unfortunately, weeks after the procedure, complications arose (unrelated to the anesthesia) and the patient passed away. Nonetheless, medical science had taken a giant step forward.
Barber was recognized for her exceptional care in the widely publicized procedure, and was asked to participate in a second surgery of its kind. Once again, listening to her own heart, Barber accepted the case.
During the second case, which involved a 70-year-old male, the surgery presented various obstacles. On September 13, 2001, Barber and those who were a part of the anesthesia care team worked diligently as they were faced with such complications as bleeding and failure of the blood to clot throughout the surgery. Ordinarily a surgery that would have taken four to five hours resulted in a 14-hour procedure. In the end, the patient pulled through the surgery without experiencing any complications from his anesthesia care. He lived for 17 months following his surgery, which, to date, is the longest period any implantable artificial replacement heart recipient has survived. During those 17 months, he celebrated birthdays, his wedding anniversary, and the birth of his first great grandchild.
The hospital’s surgeon, who placed the first two fully implantable artificial replacement hearts, performed four more procedures, and for each case he insisted that Barber be a part of his team. Barber participated as the sole anesthesia provider in five of those six cases. Carla Hobbs, CRNA, also provided anesthesia on the first case.
Debra Barber has been a practicing CRNA for 22 years.
Mike MacKinnon, CRNA, MSN, APN
Often, being on weekend call at a rural, level 4 community hospital is standard: perform a few epidurals, do a few cases and maybe place a breathing tube or an adult central line in a 24-hour call period. However, for Mike MacKinnon, CRNA, MSN, APN, recently it was a different story.
After doing cases all morning, MacKinnon was called to the pediatric floor for a difficult IV. This is not an uncommon occurrence and he responded as usual. After entering the room, it was clear to MacKinnon that the 12-month-old boy was quite sick. He looked lethargic and dehydrated, and he had been poked for IVs more than nine times; the emergency room personnel had failed at an intraosseous (IO) attempt on each leg. After looking for options, it was clear to MacKinnon that the only one that would work would be a central line.
As full service anesthesia providers, CRNAs are expected to meet the needs of the facility, surgeons and patients independently. In this case, a very sick little boy needed vascular access and MacKinnon was able to provide that service. In effect, he saved the child’s life by placing a femoral central line with ultrasound guidance. It is because CRNAs are able to work to the full extent of their abilities and have put in the time to be proficient at every skill and level of anesthesia that MacKinnon was able to help this boy. “Days like this are where I really love my job – when I am the fine line between a good and bad outcome,” MacKinnon says.
The 89-bed rural hospital where MacKinnon works, Summit Health Care, treats patients from pediatrics through adults, including major vascular cases. The hospital was rated #1 in the state of Arizona in 2014 for vascular surgery outcomes, including anesthesia. The next nearest facility is 3.5 hours away.
Mike MacKinnon has been practicing for seven years in independent CRNA practice.
Bob Gauvin, CRNA, MS
As the business owner and president of Anesthesia Professionals Inc., with roughly 50 Certified Registered Nurse Anesthetists (CRNAs) and anesthesiologists on board, Bob Gauvin, CRNA, MS, strives to operate a business that serves as a conduit for safe, quality, cost-effective anesthesia care. Sometimes the facility administrators who make use of Bob’s anesthesia professionals insist on only having anesthesiologists. And sometimes, those same facility administrators are surprised to learn firsthand that CRNAs provide the same excellent, safe, quality anesthesia care with a cost-effectiveness they had not anticipated.
In 2011, Bob was contacted by a surgeon who was in the process of opening an ambulatory surgical center. The surgeon was looking to contract with anesthesia providers from Bob’s company.
Upon meeting with the surgeon, Bob explained that he employed both CRNAs and anesthesiologists who were accustomed to working in an all-CRNA practice model or an anesthesiologist-CRNA care team model, as well as in ambulatory surgical centers and hospitals. The surgeon was impressed by Anesthesia Professionals, Inc., and decided to employ the company’s services with the stipulation that his center consist of a physician-led anesthesia team. Bob cautioned the surgeon of the disproportionate cost for anesthesiologists in comparison to CRNAs in relation to the equal quality of care provided by each group of providers. Nevertheless, the surgeon firmly requested that his facility have a physician-led anesthesia team.
Bob assured the surgeon that his request would be honored, and worked out an agreement with his new client. In finalizing the agreement, Bob informed the surgeon that if his resources, reimbursement, and business volume supported the physician-led model, there should be no problem. However, as a precautionary step and common practice, Bob designed the contract to include a stipulation that in the event the surgeon’s business volume did not enable him to meet the contracted payment for services, the surgeon would pay a stipend equal to the unmet amount.
A year passed and both Bob and the surgeon were pleased with their working relationship. However, over the course of the year, the surgeon realized that during some months his business volume was not as projected; consequently, he was frequently forced to pay the agreed upon stipend. To Bob’s surprise, the surgeon called him out of the blue one day and admitted that he saw no difference in the care provided by CRNAs and anesthesiologists. The surgeon realized that he was paying an unnecessary higher cost. He then requested all CRNAs from Bob’s company, and since then his surgical center has successfully functioned in the all-CRNA model.
Bob has been a practicing CRNA for 24 years.
Brian Bradley, CRNA, MS
Most days Brian Bradley hits the road at 7 a.m. for his commute to one of two hospitals where he provides fluoroscopic injections and other pain management services to patients referred to him by an orthopedic spine surgeon and a neurological surgeon. “I view my relationship with these two physicians as being just one of the spokes in the surgeons’ treatment plan wheel,” he said.
When asked if he has ever had anyone—hospital administrators, legislators, other healthcare colleagues—balk at the idea of a CRNA providing pain management services, Bradley answered emphatically, “No.” He said many of his patients are seniors who “have spinal issues due to the back breaking work they did in the mines many years ago.” While Bradley commutes an hour one way to either hospital, his patients would have to travel much further if not for his presence. “The nearest pain management services are 90 minutes away,” said Bradley, who currently provides pain relief for between 1,500 and 2,000 patients each year.
“Being able to practice to the full extent of my capabilities has allowed me to make an impact on the quality of my patients’ lives,” he said. “For example, there was a 10-year-old boy who was electrocuted and lost both of his arms. In order for his prosthetic arms to work correctly, he had to wear a wrap that went around his neck and rested where his arms would have normally been. After years of wearing the wrap, it caused a disc herniation in his neck. I treated him with cervical epidurals and eventually the condition of his neck reached a point where he was able to begin wearing the wrap again and using his prosthetic arms. If I did not work in this area of Montana, this young boy and his parents would have had to travel two hours to receive these services instead of 10 minutes to the local hospital where I worked. Today, the boy is a man in his 30s with impeccable handwriting, married with children and employed.”
Brian Bradley has been a practicing CRNA for 22 years. He specializes in pain management.
Tracy Castleman, CRNA, MS
Freehold, New Jersey
It seemed like an ordinary case, but looks can be deceiving. The 60-year-old patient had been diagnosed in the early stages of prostate cancer, and his surgeon had determined that the best course of action was a robotic prostatectomy. The procedure, which can last from 2-6 hours, requires the patient to be placed in a steep Trendelenburg, a head-down/feet-up position where the patient lays on his back with his feet elevated at least 30-40 degrees higher than his head.
Upon reviewing the patient’s chart during the preoperative visit, Castleman noticed what no one else had: The patient’s left eye had been removed when he was 19 years old due to a degenerative disease that had threatened to spread to his healthy right eye. Moreover, the 20/800 vision in his right eye was fragile, which required him to apply four different eye drops daily to maintain use of that eye. Add a history of hypertension and the impending increase in eye pressure caused by the surgical position to the list of vision considerations, and it gave the 23-year CRNA veteran cause for concern.
Alarmed by these pre-existing conditions, Castleman used her knowledge of and experience with the possible effects of anesthesia and surgical positioning on the eyes to determine her next steps. She was well aware that when a patient is in the “head-down” position, the blood flow pressure changes to all of the organs, including the eyes. If the patient stayed in the “head-down” position for the length of time the surgery required, there was a very real possibility he could lose the sight in his right eye due to increased intraocular pressure.
Despite the surgical team’s desire to start the case on schedule, Castleman pulled the surgeon and the anesthesiologist aside and made her concerns known. As a result, the surgeon had a long discussion with the patient and his wife, which included a phone consultation with the patient’s ophthalmologist. After weighing the risks and benefits of alternative treatments for his prostate cancer, the patient accepted the possibility of permanent blindness and chose to go forward with the robotic prostatectomy. He was appreciative of the information and the time spent discussing his treatment options.
After six and a half hours of surgery, the results were successful and the patient’s eyesight was unaffected.
Tracy Castleman has been a practicing CRNA for 23 years. Tracy specializes in general and obstetric care.
Candy Chapman, CRNA
Looking back on her 46 years as a nurse anesthetist, Candy Chapman knows this for certain: she has been the sole anesthesia provider during surgeries and other procedures throughout most of her career. “I can’t think of the last time I wasn’t in charge of the anesthesia portion of a surgery,” said Chapman, who has spent 26 years working in hospitals, taken 15 volunteer healthcare trips to Mexico to repair cleft palates, and owned an anesthesia company. “I’m an independent thinker, so I have no problem working in a care team setting or as an independent anesthesia provider. However, working with other anesthesia providers has been such a tiny percentage of my career,” she said.
Through her all-CRNA company, Emerald Anesthesia Services, Chapman has worked in 33 hospitals. Most of the time they have been smaller facilities, primarily staffed by CRNAs like many of the rural hospitals across the United States.
“Many times it’s more collegial when you’re in a smaller setting,” she said. Chapman added that in larger hospitals where there are a greater number of professionals on the healthcare team, an adversarial sense can arise quickly. In 50-bed facilities, everyone clearly understands their individual responsibilities.
Chapman recalled a time in a smaller hospital when a surgeon recommended performing a procedure on a young child even though Chapman felt strongly the patient should be transferred to a better-equipped facility. Life threatening complications arose during the procedure and the child went into cardiac arrest. Fortunately, they were able to resuscitate the patient, and he recovered.
Afterward, the surgeon wrote Chapman a letter saying that from then on, whenever a CRNA recommended not doing a case, he would suggest a preoperative transfer. “That sense of equal footing between members of a smaller surgical team is something that must be ingrained in all patient care team members alike,” Chapman said. “If our patients are supposed to be our top priority, then egos can’t get in the way. I’ve been lucky in that my knowledge and expertise have been respected throughout the years and my patients were able to get the healthcare they needed to live happier lives.”
Candy Chapman has been a general practice CRNA for 46 years.
Debra Dahlke, CRNA, APNP
In 2011, Debra Dahlke was working as part of a care team on a bowel surgery case. CRNAs are taught to take into account all factors when assessing a patient; in this particular case, the patient had mild cardiovascular risk factors and required an awake fiber optic intubation.
“The case was going well until I noticed a decrease in the patient’s oxygen saturation levels,” Dahlke recalls. “The anesthesiologist thought the patient was experiencing heart failure and asked me to initiate an infusion of epinephrine. I respectfully disagreed.” Prior to becoming a CRNA, Dahlke had been a full-time registered nurse in a high-level Coronary Intensive Care Unit for seven years, taking care of patients in every stage of heart failure. Her assessment skills were well-honed and she understood the pathophysiology behind heart failure. She determined that the patient’s blood pressure and heart rhythm were unchanged, the breathing tube was in perfect position, and the patient had no clinical reason to be in heart failure. “As an RN, I exercised my right to not start the epinephrine drip, as it is not a benign drug and could cause harm to the patient,” she said.
As Dahlke was working through her assessment, she recalled the patient’s breath smelled of benzocaine, an oral local anesthetic used prior to awake fiber optic intubations. Although Dahlke had not administered the local anesthetic, she immediately recognized that the patient had received too much of the drug. She gave the anesthesiologist her assessment and supportive facts, and insisted on administering methylene blue to counteract the benzocaine. Shortly thereafter, the patient’s oxygen saturation level began to rise and further negative effects had been avoided.
“In the end, the anesthesiologist was grateful for my judgment call. She was very respectful of my experience as a strong clinician,” Dahlke remembers. “That is a vital element of working together as a team. CRNAs are patient advocates when patients cannot advocate for themselves. As a CRNA, I rely on my rigorous education, as well as my foundation as an ICU nurse, to quickly assess, recognize and intervene for changes in patient conditions before they become problems.”
Debra Dahlke has been a general practice CRNA for 18 years.
Dennis Gundersen, CRNA
Dennis Gundersen became a chief CRNA in a rural Minnesota hospital one year after graduation. “The physicians never ‘supervised’ the CRNAs in the sense of telling us how to provide anesthesia, but relied on our education and training to determine the best anesthetic plan,” said Gundersen. “We would discuss the surgeons’ needs for a particular case and then develop the anesthesia plan. We anesthetized infants, children, adults and the elderly—some healthy, others very sick—for routine, trauma, obstetrical and emergencies cases. In the seven years I practiced at this hospital, when seeking anesthesia consultation, I consulted other CRNAs; the closest anesthesiologist was an hour away.”
Relocating to Portland, Ore., and specializing in obstetric anesthesia, he recalled, “OB anesthesia was very fulfilling. I learned new techniques and developed a much better understanding of obstetric anesthesia. While private practice anesthesiologists worked in the main operating rooms, scheduling themselves for elective Caesarian sections, the CRNAs were on the birthing unit 24 hours a day, providing anesthesia for laboring patients and utilizing spinal, epidural or general anesthesia for the unplanned and emergency C-sections. Even in a high-risk birthing center, CRNAs were not supervised by anesthesiologists.”
Five years later, working in an HMO practice, he explained, “An anesthesiologist met the patient, discussed risks and developed the anesthesia plan. Rapport was difficult to establish in the limited time I had to talk to the patient, and I did not always agree with the plan the anesthesiologist ordered.”
Eventually moving to rural Oregon, he joined an all-CRNA practice in a community hospital. “The final 10 years of my practice proved most fulfilling. We contracted our services and, whenever the contract was renewed, we asked if the medical staff felt the need for us to bring on an anesthesiologist. Their response every time was “why?’”
Dennis Gundersen has been a practicing CRNA for 39 years. Dennis specializes in rural community anesthesia and urban obstetric anesthesia.
Mark Odden, CRNA, BSN, MBA, ARNP
As a Certified Registered Nurse Anesthetist (CRNA) and the owner of Iowa Anesthesia LC, Mark Odden’s business philosophy blends quality anesthesia with civic responsibility. The Iowa Anesthesia LC imprint reaches far beyond the operating room to touch local economic development and job creation, ensuring the company’s clients are better off having worked with Odden and his team than before.
Odden and the company’s seven other CRNAs work independently throughout Iowa and Wisconsin providing anesthesia and other services to large primary hospitals, pain management facilities, ophthalmologists’ offices and small critical access hospitals for everything from general surgery to obstetrics to chronic pain management.
Perhaps it’s the influence of his master’s degree in business that causes him to view hospitals not just as healthcare facilities, but as revenue generators. “We offer the most cost-effective services possible. In order to be able to do this, one of the first things I do when I go into a hospital that could potentially become a client is to take in everything I can, and I mean everything. For instance, what’s going on in the community around the hospital? What happens to patients when they leave the hospital? These sorts of things are indicators of what the hospital should be equipped to offer its patients,” Odden said.
Iowa Anesthesia LC serves as a consultant to many hospitals, helping them make the necessary changes to become as profitable as possible, receive maximum reimbursement for Medicare patients, and become a job source to community residents. As part of his mission to influence real change at facilities that employ his company’s services, Odden or a member of his staff often sits on hospital boards and receives full voting privileges. Thanks to positive examples like CRNA businessman Mark Odden, confidence in CRNAs is strong in Iowa, evidenced by the fact that 88 out of 119 hospitals employ only CRNAs compared to five hospitals that employ only physician anesthesiologists.
Mark Odden has been a general practice CRNA for 29 years.
Steve Wooden, CRNA, DNP
After graduating from his nurse anesthesia program Steve Wooden and a classmate opened a private anesthesia practice. The timing was right because Nebraska had just passed legislation requiring a CRNA or physician to administer anesthesia. Because of the large area their practice covered and the need to be readily available for emergency situations, Wooden decided flying was the best means of transportation in order to save on both travel time and cost.
Wooden attained his pilot’s license and has since logged over 400,000 flight miles in his career, servicing as many as 12 hospitals in rural Nebraska.
“I have worked on countless emergency situations in my career, but an emergency involving a cowboy and cattle medication is my most memorable,” Wooden recalls.
The patient had accidentally injected himself with a fatal dose of cattle medication, according to poison control. He arrived at the emergency room with a faint heartbeat and only supported respirations. The physician in charge had consulted with both the university and poison control, but nobody had a clue what to do except continue CPR. The medication was a veterinary drug and was not listed as a benzodiazepine, but it had a similar molecular structure to benzodiazepine, which Wooden was familiar with.
Fortunately, a new drug had just been released called Romazicon, which reverses the effects of benzodiazepines. Wooden suggested trying it, but did not receive much support. After asking, “What do we have to lose?” the emergency room physician told him to go ahead. Within a minute, the patient sat up on the cart and started talking. “Everyone was shocked,” Wooden said. “We supported him through the night with additional doses of Romazicon and close monitoring, and he recovered without any complications. The family and patient told me many times how grateful they were, and how lucky the hospital was to have a CRNA on staff. “
Wooden’s education as a CRNA, and his ability to get to the remote hospital quickly by air, were both instrumental factors in effectively treating this patient.
Steve serves patients in rural communities as far as 200 miles away from home.