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.
Do have a story to tell about your experience as a CRNA?
Abby Di Gaetano, MSN, CRNA
Patients are more than their illnesses. This guiding principle helped Abby DiGaetano, MSN, CRNA, provide the best possible care for a male patient who presented during her 24-hour trauma shift, which led to a connection beyond the anesthetic.
“Bob was a healthy man in his 60s out for a bicycle ride when he somehow ended up on the side of the road with serious injuries. Unlike most patients in this situation, he was very calm when telling us about the accident and that he could not feel his body from the chest-area down,” recalled Abby. “You could tell it was important to him to relay as much information to us as possible, which made me wonder about his family.”
The situation required Bob to have several scans done, while remaining flat. A breathing tube was needed to protect the airway, and an anesthetic was administered for endotracheal intubation. “I explained to Bob why he required intubation and tried to keep him as calm and comfortable as possible,” said Abby.
Abby moved on to her next patient, but Bob remained in the back of her mind. When a lull in her day occurred, she checked on Bob and inquired about his family. “Healthcare providers who work in the intensive care unit (ICU) are required to work at a very fast pace and may not be able spend much time with a patient’s loved ones, so I inquired and was told where to find Sue Hassmiller, PhD, RN, FAAN. On my way to see her I grabbed a water and some snacks because I knew she would be at the hospital for awhile,” Abby remembered. “I just kept thinking how distressing it is that one minute you’re perfectly fine and out for a bike ride and the next minute you’re in an ICU. When I found Sue, I knew there was not much I could do for her, but I wanted to make sure she knew how calm and brave Bob was when I met him and that he was able to speak prior to being intubated.”
After being away from work for a few days, Abby returned and discovered that Bob had been moved to another facility for treatment. Having a compelling desire to learn the outcome of Bob’s health from the injuries he sustained while bike riding, she researched to find Sue Hassmiller’s contact information. It was then that Abby found Sue’s blog.
“Although I’m just three years out of nurse anesthesia school, you’re taught there’s a fine line that healthcare providers have between perceived professionalism when caring for the patient and taking it beyond the treatment facility or hospital,” explained Abby.
“I found Sue’s blog online. That’s also when I found out Sue was a very accomplished nurse with a prestigious position. I had no idea she was a nurse; however, in situations like this, you’re a wife whose husband has been severely injured,” said Abby. “Sadly, Bob had passed away from his injuries. Nevertheless, I decided to reach out to Sue using the email at the end of her blog. A few days later she emailed back, and from there our friendship began.” Sue even read some of Abby’s emails at Bob’s funeral.
“CRNAs do not usually have much time to connect with their patients and reassure them prior to surgery or emergency interventions. Nevertheless, when they combine their education and experience, with a holistic component that allows them to care for the whole patient including their loved ones and not just the illnesses of the patient, it raises the standard of care.”
Note: Abby and Sue Hassmiller remain friends and colleagues and have gone on to co-present together at professional healthcare meetings on the topics of compassionate care and patient/provider relationships.
Abby has been a Certified Registered Nurse Anesthetists for 4 years.
Patti Bright Parolari, MS, CRNA
Virginia Beach, Virginia
The only thing better than making a living doing what you love, is combining a satisfying career with your passion. More than 10 years ago, Patti Parolari, MS, CRNA, saw an opportunity to do just that during a Virginia Association of Nurse Anesthetists (VANA) state leadership workshop. “We were brainstorming ways to engage CRNAs in Virginia and reach out to the community. As an avid runner for over 25 years, I came up with the idea to participate in the Rock ‘n’ Roll Half Marathon as a group,” said Parolari.
The CRNAs at the meeting readily agreed and plans were made to encourage CRNAs to run, walk, or volunteer at the CRNA-sponsored water station. Still, Patti desired to make the run a little more meaningful and suggested they use this event to raise funds for a local charity. VANA chose a charity named People in Need (PIN), a Virginia Beach organization that provides hot meals, personal hygiene supplies, clothing, medical and dental care and job training to the homeless and poor. PIN also assists with a recovery program for people with addictions. Patti wanted to educate others about CRNAs, PIN, and show how all people are interconnected.
For added impact, Patti and other CRNAs hosted a traditional pre-race pasta dinner with PIN clients as honored guests. The only rule for the PIN guests was that if they participated in the pasta dinner, they had to help CRNAs at the water station the next day. More than 60 PIN clients volunteered the first year and nearly 80 to 100 have volunteered every year thereafter. The pre-race dinner also is attended not only by the homeless and CRNAs, but also the mayor of Virginia Beach, state representatives and even Virginia’s members of Congress. An invitation goes out to all state and federal legislators to attend this event. The race promoters were so interested in what CRNAs were doing, they gave the “CRNAs ROCK!” team a free booth. After a few years of participating in the Rock ‘n’ Roll Half Marathon under their belt and being named a designated charity, Patti thought to herself, what more can we do?
“Although at this point, even the event organizers were helping us with our charitable efforts by asking marathon participants to donate toiletry items on the day of the marathon. I still wanted to further engage the PIN clients,” remarked Parolari. “In a leap of faith we asked homeless or recovering individuals if they wanted to be a part of our team and train for the half marathon. To our delight, we had two takers.”
The two individuals, a homeless man, and a woman who was in recovery, stepped up and began the 16-week training regimen. The training was at 5 a.m. during the week and a long run on the weekends. With each mile they worked out with their CRNA coach, the two volunteers’ lives were transformed. By marathon time, the male was no longer homeless, had two jobs, and a savings account; and the female in recovery had become a straight “A” college student, had quit smoking and lost 20 pounds. To date, eight homeless people have trained, learned life skills, and crossed the finish line strong.
Each year the CRNAs ROCK! team is highlighted in the newspaper (even a front page above-the-fold story with pictures) and on television. One year a four-minute human interest story was aired several times during the evening news and on the day of the race. For 11 years VANA ran with the motto, ”CRNAs ROCK! Nurse Anesthetists Changing Lives One Mile at a Time for PIN!” and lived up to it.
“Although we know wellness is complex, promoting wellness and giving back to others makes all of us more whole,” expressed Patti.
Patti has been a Certified Registered Nurse Anesthetists for 28 years.
Juan Quintana, DNP, MHS, CRNA
Juan Quintana, DNP, MHS, CRNA, first began traveling to Neiva, Colombia with Healing the Children in the early 2000s at the urging of colleague and friend Antonio Luciano, BSNA, CRNA, CNOR. It was there that Quintana developed a passion for mission work and bringing anesthesia services to areas with few healthcare resources. Today Quintana exemplifies the large contingency of CRNAs who devote their time and other resources to traveling abroad to help those in need.
“Neiva is the largest southern-most city in Colombia, and we work at the county hospital,” said Quintana. “The city was poorer then than it is now. Their operating rooms now rival anything here, but back when I started, there were broken windows and things like that. There are six operating rooms, of which we use four. The other two are used for OB and emergencies. We divided each of the four ORs into two, set up dividers and put two beds in each of the four, so we are able to perform eight surgeries at the same time.”
Quintana has returned each year to the area, either in his capacity as a Certified Registered Nurse Anesthetist (CRNA), or as an administrator, always working with surgeons from different areas of the world as well as the local doctors. On occasion, he will teach anesthetic blocks or difficult intubation skills to the local doctors.
Among the different types of surgery performed, cleft palate, cleft lip, foot deformities such as a clubbed foot, and different syndromes such as congenital heart issues are all part of the team’s repertoire. “Kids are ostracized, their cleft palates are seen as a curse by God,” said Quintana. “After surgery, they can go to school. It changes their lives and their family’s lives. In some small way it changes the world.”
Administering anesthesia for cleft palate or cleft lip surgery involves establishing an intravenous (IV) line where drugs can be administered. There is also a rounded tube that is inserted into the patient’s airway, but instead of pointing up when it reaches outside the mouth – as it would get in the surgeon’s way – it points down, so the nurse anesthetist can administer to the patient’s anesthesia and not get into the surgeon’s working area for the palate or lip.
“It’s very rewarding,” said Quintana. “Kids we operated on 10-15 years ago are now teenagers or older. They come back, help us guide people on where to go – sometimes we have 300 people waiting to be reviewed. They come to say hello, give us a hug. It’s great.”
“It’s why we all got into healthcare in the first place,” he says. “If you can find a volunteer group you’re comfortable with, that has a good reputation, you like meeting people from elsewhere and helping people, believe me, the blessings will all be yours.”
Juan Quintana has been a practicing CRNA for 20 years.
Andy Johnson, MS, CRNA
When you administer anesthesia in Olivia, Minnesota, your patients are more than just your patients. In a town where the population is just under 2,500, Andy Johnson, MS, CRNA, may be called upon to administer anesthesia to his neighbor, his child’s elementary school teacher, or a coworker on any given day. “Every patient is unique, and the procedures and anesthesia required are different,” Johnson said. “Being the sole anesthesia provider at my facility, I am capable of handling everything from the intubation of a patient with a difficult airway to the anesthesia care for a scheduled cesarean section.”
Only 12 babies were born at the local hospital in Olivia the year that Johnson moved to the small town. Prior to that, expectant mothers weren’t able to receive long-lasting pain relief from a labor epidural. Today the hospital averages 70-80 deliveries requiring anesthesia each year, many of them emergency situations.
“My coworker went into preterm labor and could not be airlifted to one of the Twin Cities 90 miles away because of her condition,” Johnson recalled. “Another premature baby needed manual assistance to breathe for three hours straight before the infant was airlifted to a hospital with a neonatal unit. Premature babies do not have fully developed lungs, which can negatively affect their heart and eyesight, so in addition to providing care to the mother I also must tend to the newborn in emergency situations.”
Other patients Johnson now works with at the hospital used to drive more than 90 miles for chronic pain management treatments that prevented them from having to be on continuous opioid therapy. “If I were not allowed to practice pain management and anesthesia care to the full extent of my education and abilities, I would not be able to provide adequate care to the patients at my hospital,” Johnson said.
Johnson shares that he is grateful to be able to provide OB anesthesia, pain management, and other essential healthcare services to the residents of his community. “Your geographical location should not dictate the type of healthcare you receive,” he said.
Andy Johnson has been a practicing CRNA for 10 years.
Kimmerle Miller-Leonard, MAE, CRNA
Kimmerle Miller-Leonard, MAE, CRNA, works in rural Washington state at a small community hospital where a total of two CRNAs are contracted to provide all of the anesthesia care, working 24/7 on-call shifts. Miller-Leonard and her colleague alternate with each other: Some days Kimmerle works from dusk till dawn, other days she spends checking her phone to make sure it works, because the hospital has not called. There is an active OB department at the hospital, where epidurals, cesarean sections (C-sections) and other emergencies are always looming.
In the wee hours one morning, Miller-Leonard arrived at the hospital a little later than anticipated. She had been called in to provide anesthesia for a C-section delivery. She was late because her left ankle had been broken in a freak accident along a rural highway – her car collided with a dead horse in the road. The horse had been killed only moments before by a van, which was off to the side of the road when Miller-Leonard came through. Her car was on cruise control when she saw the van, and in the time it took for her to turn her head from looking at the van to the road in front of her, the car collided with the horse and she was sent rolling, sliding and flipping into a field about 30 feet from the road and 50+ feet past the dead horse.
Miller-Leonard freed herself from the car, and even with her ankle painfully broken, went to check on the occupants of the van, then talked with 911 to have some help sent to the location. She then called her husband to either come take her to the hospital so she could get to work or to stay and help with the accident on site if she were able to flag down another car.
Determined to get to work, she was able to hitch a ride. The driver misunderstood and thought Miller-Leonard was in need of the C-section, which gave her a moment of laughter and helped to restore her focus in a crazy situation.
Miller-Leonard arrived at the hospital and changed into her scrubs. The OB-GYN doctor hugged her as now she would not have to do the C-section under a local anesthetic without an anesthesia professional. “Once I’m in the OR, I focus on doing my job,” says Kimmerle. “The spinal went well and the baby did great.”
Later it was learned that Miller-Leonard’s ankle was broken in two places, but not out of alignment. “Keep your weight off of it, and it will heal without surgery,” the orthopedic surgeon she works with told her.
When asked, “Why did you go to the hospital and do the case?” Miller-Leonard simply responded, “Who else was available to do it? I was not dead, I was able to go and do the case.” Previously, she had worked “‘crash hearts and life and death cases.’ Anyone who has been there knows you just do your job, as well and as fast as you can. People need you.”
Kimmerle Miller-Leonard has been a practicing CRNA for nearly 27 years. Thanks to Kimmerle Miller-Leonard, Dennis Gundersen, Peter Strube and CRNABiz.com for this story.
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.