Anesthesiology Nursing History

1
Anesthesiology NursingPast to Present
Slide Series Highlighting the History of
Anesthesiology Nursing as told by Marianne
Bankert
2
Watchful Care
3
CHAPTER I

• The MOTHER of Anesthesia

4
BARRIERS TO SUCCESSFUL SURGERY

• Anesthesia
• Infection

5
Virginia S. Thatcher

• To women and to the discovery of germs must go
  the credit for the greatest contribution to the
  relief of human suffering during the years 1860
  and 1900.

6
GOLDEN AGE (after 1900)

• MAYO CLINIC (1899)
• Surgeons
• Nurse Anesthetists

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THE MOTHER OF ANESTHESIA

• ALICE MAGAW
• THE MOTHER OF ANESTHESIA Given that title by
  Dr. Charles H. Mayo

8
GERMS

• 1850 - Surgical instruments were given no special
  cleaning (sterilization) from one case to another.

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INFECTION

• Sponges
• Washing hands of surgeon
• Clean cover gowns

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INFECTIONLouis PasteurJoseph Lister1867
Atomizer with carbolic acidPost-op dressings
were soaked with antiseptic solutions
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Surgeons still refused to wash their hands
Surgical instruments were not sterilized
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ASEPSIS

• Using sterile procedure to exclude
  microorganisms from the field of operation.

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Asepsis - Continued

• Steam and dry heat sterilization
• Wearing of sterile gowns
• Wearing of face masks to cover the nose and
  mouth
• Use only sterile metal instruments

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Increase in number of surgical procedures

• Use of these procedures made it possible for the
  number of surgical procedures to increase.

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Massachusetts General Hospital

• 1841 - 1845 - 37 procedures
• (The years immediately prior to Mortons
  successful demonstration of anesthesia)
• 1847 - 1851 - 98 procedures
• (The years immediately following Mortons
  demonstration of anesthesia)
• 1898 3,700 surgical procedures

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Massachusetts General Hospital
October 16, 1846, in the operating theater of
Massachusetts General Hospital, William T. G.
Morton, a Boston dentist, successfully
demonstrated the anesthetic use of ether during
surgery, providing a painless solution to an
otherwise fearful procedure. Within a year,
ether-a colorless, volatile, organic liquid-was
used worldwide to ease the anguish of surgery,
and the operating room became known as the Ether
Dome.
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Who "discovered" anesthetics ?
In a tangled web of rivalry, collaboration,
ideas, and experiments, four men claimed to have
"discovered" anesthetics as a surgical
accompaniment, and throughout their lives
bitterly fought for recognition. Horace Wells, a
dentist and a colleague of Morton, used nitrous
oxide successfully on his dental patients, but
when invited to demonstrate his technique in 1845
at MGH, the patient cried out due to an
insufficient dose. Wells, humiliated, left town
and later committed suicide. Dr. Crawford W.
Long of Georgia claimed to have used ether as
early as 1841 for minor operations. And finally,
Charles Jackson, a Boston MD and chemist-and
sometime partner of Morton's-claimed to have
discovered ether's uses with Morton. Jackson also
claimed that Samuel Morse stole his idea for the
invention of the telegraph. Morton himself had a
personal history checkered by various forms of
chicanery and was found attempting to conceal the
chemical identity of ether in order to patent it,
calling it "letheon."
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THE ROLE OF WOMEN

• 1873 - Three nurses training schools in the
  United States
• New York
• New Haven
• Boston

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Nursing Training Schools

• American schools followed the Nightingale model
  (1860 St. Thomas Hospital Nurses Training School,
  England)
• Foundation on Clean Patient and Clean Environment.

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Nursing

• Nursing Made Medicine Look Good.

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Nursing

• Medicines ultimate success, technological
  advances, and subsequent impressive social power
  were achieved through hospitals, and nurses made
  those hospitals work.

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Nurses - Hospitals

• The whole spirit of hospitals changed, from a
  place to die, to a place to get well.
• What is the current attitude of American citizens
  toward hospitals and medical centers in 1999?

23
Witness to 1846 demonstration of anesthesia stated

• Anesthesia needs to be
• Affect all patients similarly
• Consistently lead to insensibility to pain
• Have a predetermined length of duration
• Safe

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Early Administration of Ether and Chloroform

• Ether - by a sponge
• Chloroform - by a handkerchief
• With both techniques, little air could pass
  through the wet sponge or handkerchief
• Many cases of Ether pneumonia - death

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EARLY ANESTHETISTS

• Medical students
• Surgery residents
• Surgeons
• Each were more interested in watching the surgery
  procedure than monitoring the anesthetic and the
  patient

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ECONOMICS OF ANESTHESIA

• Early surgeons did not want to share the credit
  or payment for their work.
• The impression was that the anesthetists work
  were of little if any importance.
• If a surgeon charged 100-200, the anesthetist
  was given 5.

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Economics - Ghost Anesthesia

• Patient would request the best anesthetist and
  told it would cost an extra 25. The surgeon
  collected 225 (200 for him and 25 for
  anesthetist).
• Surgeon selected a student and gave him 5.

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Ghost Anesthesia

• Current use of term
• Patient request a specific anesthetist and that
  anesthetists begins the anesthetic and then
  another anesthetist completes the anesthetic.
• Could be an anesthesiologists or a Certified
  Registered Nurse Anesthetist.

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Early Nurse Anesthetists

• Sister Mary Bernard
• St. Vincents Hospital
• Erie, PA
• DATE 1877

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Sr. Mary Bernard

• One of the religious communities, the 3rd.
  Order of the Hospital Sisters of St. Francis from
  Muenster, Germany. The Order established a
  community in Springfield, Il in 1875.
• In 1879, they dedicated their St. Johns
  Hospital.

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Hospital Sisters of the Third Order of St. Francis

• In 1912 - Mother Magdalene Wiedlocher, herself an
  anesthetist, organized a course in anesthesia at
  St. Johns Hospitals for Sisters who were
  graduate nurses.

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Sr. Martha Lawler (1871-1935)

• A member of the Daughters of Charity of St.
  Vincent de Paul started many schools of
  anesthesia for nurses, including the school at
  Charity Hospital in New Orleans in 1917.

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ALICE MAGAW

• Dinah and Edith Graham were the first nurse
  anesthetists at the Mayo Clinic. Alice Magaw, a
  friend of the Graham women was very skilled as an
  anesthetist and took over the anesthesia at the
  Mayo Clinic (est. in 1899)

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ALICE MAGAW

• The anesthetic technique of choice was open drop
  rather than pouring the ether.
• (Cone and pouring v. open drop)

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EARLY ANESTHESIA MACHINES
Foregger Machine with Copper Kettle
American Meter Company N20 Anaesthetometer
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Morton Ether Inhaler 1846
Wm Morton Ether Demonstration at MGH 1846
37
Open Drop Technique

• James E. Moore, a Minneapolis surgeon went to
  Germany Berlin in 1885 and brought back the
  open drop technique of the administration of
  ether.

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Observations in Anesthesia by Alice Magaw

• Anesthesia is an art.
• Each patient is different (tilt of the head).
• Watch for symptoms and prevent them.
• Use hypnotic suggestion.
• Surgeon stay with patient during induction.
• Talk to the patient soothingly all the time.

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Open Drop Technique

• America continuous method for the
• duration of the anesthetic, a drop on the mask
  every two seconds.
• Britain Pour 2 dr. or 3 dr. on the mask, then
  stop for a few minutes and then pour a few more
  drachms on the mask.

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Chapter 2

• Up Against That Sort of Thing

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Dr. George Crile

• Known for his work in dealing with shock, he
  stated that the intern was not suited to be an
  anesthetist, because he was more interested in
  the surgical procedure.
• Many patients died from the anesthetic when
  administered by an intern.

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Dr. George Crile

• In looking for an appropriate individual to be
  his anesthetist, selected a trained nurse.
• He selected Agatha Hodgins. Born in Toronto in
  1877 to prosperous parents, who was a woman of
  vision and determination.

43
Miss Agatha Hodgins

• Reported to be
• Punctual
• Frank
• Tidy
• Very patient
• Took her work seriously
• An excellent anesthetist

44
Miss Agatha Hodgins

• In 1908, Dr. Crile selected Ms Hodgins as his
  special anesthetist. She is reported to have
  said to Dr. Crile to remember that she will
  always do her best.
• Their work began with administering anesthesia to
  animals.

45
Agatha Hodgins
Cleveland Lakeside Hospital circa 1915 Agatha
Hodgins with Dr. Crile
46
Miss Agatha Hodgins

• Miss Hodgins is reported to have read everything
  she could concerning anesthesia and walked the
  halls of the hospital wards at night listening to
  the breathing of the patients, in order that she
  might detect subtle differences.
• She travel to the Mayo Clinical to observe the
  open drop technique.

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Anesthetic Technique at the Cleveland Clinic
Lakeside

• Dr. Crile noticed during his work with shock the
  deleterious effects of ether and chloroform
  anesthesia.
• Nitrous Oxide with oxygen would become the
  anesthetic of choice at the Cleveland Clinic.

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Dr. Mayo - Dr. Crile

• Dr. Mayo reported the successful anesthetics
  administered by for Ms Magaw.
• Dr. Crile reported the successful anesthetics
  administered by Miss Hodgins.
• 1911 - reported the successful anesthetics
  administered by Miss Hodgins as 10,787.

49
Miss Agatha Hodgins

• Just as visitors came to Mayo Clinical and Alice
  Magaw to learn open drop ether, so too they came
  to Lakeside for the nitrous oxide-oxygen
  technique used by Miss Hodgins.
• More and more visitors sent their anesthetics to
  the Cleveland Clinic to learn from Miss Hodgins.

50
Lakeside School of Anesthesia

• Dr. Crile and Miss Hodgins were proud of their
  school and believed it to be the first in the
  world. The school accepted trained nurses,
  dentists, and physicians. (1915)

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Earlier Schools of Anesthesia

• 1909 St. Vincents Hospital, Portland, OR
• 1912 St. Johns Hospital, Springfield, IL
• 1912 New York Post-Graduate Hospital
• 1914 Long Island College Hospital, Brooklyn

52
Nurse Anesthetist Service in the Great War (WWI)

• The Lakeside military unit went to France with
  the American Ambulance at Neuilly in 1914.
• The Lakeside unit introduced gas-oxygen Nitrous
  Oxide anesthesia into war surgery and into
  England and France.

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WWI - Lakeside Unit

• Dr. Criles work with shock and the success of
  Nitrous Oxide-oxygen had positive results. He
  returned to the U.S. after 2 months to organize
  other units in the U.S. to go to France in
  support of troops.

54
Lakeside School of Anesthesia

• Miss Hodgins returned from France in 1915 after
  training American, English, and French nurses as
  nurse anesthetists in the administration of
  Nitrous-Oxide-oxygen.

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Lakeside School of Anesthesia

• First graduating class (1916)
• Six (6) physicians
• Two (2) dentists
• Eleven (11) nurses

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WWI

• P48
• during the drives, patients same in so fast that
  all the surgeons could do was to remove bullets
  and shrapnel, stop hemorrhages and put iodoform
  packs in the wound and bandage it, then the next
  patient. Fast pace for the anesthetist.

57
British Nurse Anesthetists

• British nurses were trained in the art of
  anesthesia during the war with the BEF and
  according to Dr. Crile, if the Great War had
  gone on another year, the British army would have
  adopted the nurse anesthetist right in the middle
  of the war.

58
Anesthesia as Womens Work

• May 1918, Dr. R. Farr, a Minneapolis surgeon
  stated The war is going to have this influence.
  We are not going to have physicians enough to
  give anesthetics, and the nurses are being worked
  in to give anesthetics. And when the war is over
  they are coming back here, and they are going to
  continue to do it and we are up against that
  sort of thing.

59
Professional Anesthetists

• From the beginning, the economic factor played a
  major role in attracting individuals, especially
  physicians to become anesthetists.

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Professional Anesthetist

• Anesthesia was born a slave and she has ever
  remained the faithful handmaid of her master
  surgeon.

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Professional Anesthetist

• P50 Not surprisingly, surgeons found these
  qualities, as the imagery suggests, in women. As
  hospital administrator Olson reminded his nurse
  anesthetist audience in 1940, American women were
  recruited into anesthesia, a field shunned by
  physicians.

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Continued - Mr. Olsons address

• A fact which should never be lost sight of by
  doctors, lawmakers, the laity, or the nurses
  themselves is, that nurses were drafted to give
  anesthetics under the instruction and supervision
  of surgeons, after it had been found that medical
  graduates were often inept and lacking the
  deftness and tender touch which patients

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Continued - Mr. Olsons address

• Required for a successful anesthetic, or they
  were too much interested in the operators
  procedure and therefore failed to give a
  satisfactory performance as anesthetists.

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Gender Bias

• Just as females were seen as the natural
  handmaidens of surgeons, females entering
  medicine were viewed acceptable my many for the
  economic gain.
• The second class role for females helped them
  gain anesthesia but kept them from the economic
  gain they deserved.

65
Female Physicians

• Early female physicians did not support the role
  of the female nurse anesthetist. They made every
  effort to distance themselves from the nurse
  anesthetist.

66
Dr. Eleanor Seymour (1920)

• Stated concerning the first anesthetic It is
  cause for regret that there is no detailed
  account of the induction, maintenance of this
  first anesthetic but it is evident that the
  administration was considered of such importance
  as not to be entrusted even to the Angel Gabriel,
  much less an angelic nurse

67
Dr. Mary Botsford

• Identified as probably the first female
  anesthesiologist.
• Dominated the West Coast anesthesia for twenty
  years.
• Trained at least 46 female physicians in
  anesthesia -The Childrens Hospital of San
  Francisco.

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MDA - CRNA Conflicts

• In California, a female anesthesia intern refused
  to take instruction from a female nurse
  anesthetist and was removed from her training
  program, on appeal, she was re-instated and the
  nurse anesthetist lost her job.

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Chapter 3

• A Very Personal Property Right

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Continuing Conflict

• Dr. Farr and his colleagues reflected the
  continuing frustration that economics made
  anesthesia unattractive to physician specialists.
  Nurse Anesthetists were also establishing
  themselves in the field, adding a competitive
  dimension to the already difficult economic
  situation.

71
Father of Academic Anesthesia

• Dr. Ralph M. Waters, faculty at the medical
  school of the University of Wisconsin.
• Gave three reasons for being interested in
  anesthesia
• 1. The results of anesthesia which he observed
  were variable and offered something of a
  challenge.

72
Dr. Ralph M. Waters - continued

• 2. Extra-curricular experience in the
  administration of anesthetics while a student in
  Cleveland, together with occasional opportunities
  to observe the use of nitrous oxide had
  developed in me an unusual interest in the
  subject.

73
Dr. Ralph M. Waters - continued

• 3. One of the more surgical surgeons returned
  from an eastern trip in 1913 with a nitrous oxide
  apparatus (the first in Sioux City) the use of
  which he offered to me in other cases if I would
  anesthetize his patients.

74
Dr. Ralph M. Waters - continued

• I hear that some surgeon in this state is using
  a nurse or an office girl-Im not sure which-to
  administer anesthetics to his patients. Do you
  know why? The only honorable reason he could give
  is because he believes that she can given an
  anesthetic better than any practitioner of
  medicine available in his community.

75
Dr. Ralph M. Waters - continued

• surgeons with this handicap can be found in
  many communities in the United States today.
  It is not a nurses job which you must be
  ashamed to have to perform - to feel concerning
  it as you would at being caught giving a soapsuds
  enema. It is a physicians job an art, just as
  much as surgery is an art

76
Dr. Ralph M. Waters - continued

• These comments are perhaps the most telling
  glimpse into the dilemma of a physician moving
  into a field associated with nursing.

77
Organized Anti-Nurse Anesthetist Activity
78
Professional Anesthetist

• What was required to be an anesthetist
• be satisfied with the subordinate role that the
  work required.
• Make anesthesia their one absorbing interest.
• Not look on the situation of anesthetist as one
  that put them in a position to watch and learn
  from the surgeons technique.

79
Professional Anesthetist - continued

• What was required to be an anesthetist
• Have the natural aptitude and intelligence to
  develop a high level of skill in providing the
  smooth anesthesia and relaxation that the surgeon
  demanded.

80
Organized Anti-Nurse Anesthetist Activity

• The center of organized anti-nurse anesthetist
  activity rested in Dr. Francis Hoeffer McMechan,
  a native of Cincinnati, Ohio.

81
Francis McMechan

• Third generation physician
• Before medicine, was into journalism with the
  Cincinnati Post newspaper
• Became interested in anesthesia in medical
  school
• In 1911 he developed arthritis and was confined
  to a wheelchair for the rest of his life

82
Francis McMechan

• Confined to a wheelchair, he became interested
  in better organizing the field of anesthesia
• He used his journalism talents to publish his
  belief that there was no place in anesthesia for
  a nurse
• He felt he had a property right to practice
  anesthesia

83
Francis McMechan

• In 1935, he addressed the Council on Medical
  Education and Licensure of the A.M.A., Should
  the Radiologist, the Pathologist, and the
  Anesthetist be Licensed to Practice Medicine.
• He argued that the practice of anesthesia was
  the practice of medicine.

84
Francis McMechan

• McMechan argued that, every significant advance
  in its (anesthesia) science and practice has been
  contributed by doctors, dentists and research
  workers of similar standing. In contrast,
  technicians have added nothing of any
  consequence.

85
Francis McMechan

• In 1911, McMechan helped found the New York
  Society of Anesthetists, which succeeded the Long
  Island Society of Anesthetists. In 1912, the New
  York society petitioned the A.M.A. to create a
  section on anesthesia at its annual meeting, but
  was not successful.

86
Interstate Association of Anesthetists

• Organizers in 1915
• Dr. McMechan - Ohio
• Dr. McKession - Ohio
• Dr. Long - Kentucky
• This organization became the nucleus for further
  regional societies in the United States and
  Canada.

87
Physician Anesthesia Groups

• 1921 Canadian Society of Anaesthetists
• 1922 Pacific Coast Assoc. of Anesthetists
• 1922 Southern Assoc. of Anesthetists
• 1923 Eastern Society of Anesthetists
• In 1926, the Interstate Assoc. of Anesthetists
  became the Midwestern Association of Anesthetists.

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Political and Legal Challenges to Practice for
Nurse Anesthetists

• In the early part of this century, McMehan was
  involved directly or indirectly in most of the
  political and legal challenges to the practice of
  anesthesia by nurses.
• His articles in anesthesia journals were well
  written and pointed out that anesthesia was the
  practice of medicine.

89
Challenge to Practice

• McMechans repeated public charge was that nurse
  anesthetists were violating medical practice acts
  (or, to use McMechans phrase, infringing on
  physicians very personal property rights).

90
Challenge to Practice

• In New York, 1911, an opinion by the New York
  State Medical Society, declared that the
  administration of an anesthetic by a nurse was in
  violation of the law of the State of New York.

91
The Challenge to Lakeside Hospital

• In 1912, action began in Ohio, home both to
  McMechan and Lakeside Hospital, against its nurse
  anesthesia program. Dr. Crile received a letter
  from the secretary of the Ohio State Medical
  Board informing him of its postion that no one
  other than a registered physician could
  administer an anesthetic.

92
The Challenge to Lakeside Hospital School of
Anesthesia

• In 1916, the Interstate Assoc.. of Anesthetists
  (organized by McMechan) petitioned the Ohio State
  Medical Board to take action against Lakeside
  Hospital as the chief source of the
  nurse-anesthetist abuse.

93
The Challenge to Lakeside Hospital School of
Anesthesia

• The Ohio State Medical Board issued a resolution
  that in effect said they would discontinue all
  recognition of the Lakeside Hospital as an
  acceptable Training School for Nurses and its
  graduates as Registered Nurses denied, unless the
  training of nurses in the administration of
  anesthesia stop.

94
The Challenge to Lakeside Hospital School of
Anesthesia

• To prevent denial of recognition of its nursing
  school, Lakeside Hospital discontinued the
  anesthesia school.
• Hearing were held followed by the withdraw of
  the edict.
• In 1917 the program reopened with increased
  enrollment.

95
Frank v. South

• (1916) The Interstate Association of
  Anesthetists adopted a resolution to bring to an
  end the administration of anesthetics by
  unlicensed persons in every state in the middle
  West in which such action can be secured.

96
Frank v. South

• The Louisville (KY) Society of Anesthetists
  submitted a resolution that an anesthetic should
  be administered only by one who had medical
  knowledge and training to the Attorney General,
  who gave a supporting opinion.

97
Frank v. South

• The House of delegates of the Kentucky State
  Medical Association subsequently passed a
  resolution sponsored by its Committee on Medical
  Ethics calling for an end to the evil of
  non-physician anesthetists.

98
Frank v. South

• The call was for physicians to not refer
  patients to hospitals where nurse anesthetists
  were utilized.
• Ironically, nurses, who were called into
  anesthesia because it was a field shunned by
  physicians, were now to be themselves shunned.

99
Frank v. South

• A Louisville surgeon, Dr. Louis Frank, and his
  anesthetist, Miss Margaret Hatfield, a graduate
  nurse with special anesthesia training, insisted
  that the State Board of Health be party to a test
  court case.

100
Frank v. South

• The original finding was against Frank and
  Hatfield. This was appealed and reversed. The
  opinion by Judge Hurt discussed the significant
  issues of property rights versus public good
  and the overlapping provinces of various
  healing professions.

101
Frank v. South

• Appeals Court Opinion While the practice of
  medicine is one of the most noble and learned
  professions, it is apparent that such a
  construction ought not to be given to the
  statute, which regulates the profession, that the
  effects of it would be to invade the province of
  the professions of pharmacy, dentistry or trained
  nursing, all of which

102
Frank v. South - continued

• are professions, which relate to the alleviation
  of the human family of sickness and bodily
  afflictions, and to make duties belonging to
  those professions, also the practice of
  medicine within the meaning of the statute.

103
Frank v. South - continued

• We are of the opinion that in the performance of
  the services by appellant, Hatfield, in the way
  and under the circumstances as agreed upon, as
  being the facts in this case, that she is not
  engaged in the practice of medicine within the
  meaning of the statute laws upon that subject...

104
McMechan

• Despite losses with Lakeside Hospital and in
  Frank v. South, he and other physician
  anesthetists continued their efforts
• The issue continues, the right to practice as
  nurse anesthetists.

105
Chapter 4

• A Matter for Felicitation

106
Chapter 4 - A Matter for Felicitation

• 1930 - Adeline Curtis (Los Angeles)
• I said we can get nowhere without an
  organization. Were in the minority, of course,
  but we must organize. And so that night started
  the organization of a Nurse Anesthetist
  Association.

107
Hilda Solomon

• Miss Hilda Solomon organized a local group of
  nurse anesthetists at the Jewish Hospital in
  Philadelphia.
• Compare notes among nurse anesthetists
• Case presentations

108
Agatha Hodgins

• In 1923, organized the Alumnae Association of the
  Lakeside School of Anesthesia.
• Inactive for 3 years
• 1926 re-organized as a local group

109
Agatha Hodgins

• Re-organization of Alumnae group - 1931
• At first meeting Hodgins presented her plans for
  a national organization of nurse anesthetists. A
  constitution and bylaws were written.

110
Agatha Hodgins

• Proactive in organizing nurse anesthetists.
• One of her chief problems was her impatience in
  dealing with the American Nurses Association.
• Gunn called it a civil war.

111
Agatha Hodgins/ANA

• 1909 Miss Henderson and Miss Hodgins were invited
  to present lectures at the ANA convention.
• Henderson - Ether
• Hodgins - Nitrous Oxide, Oxygen
• Neither felt they received appropriate
  recognition for their presentations.

112
Agatha Hodgins

• 1921 - League of Nursing Education meeting.
• Hodgins spoke on Nurse Anesthetist Service to
  counter anti-nurse anesthetist publications
  (McMechan).
• Hodgins did not feel adequately appreciated by
  the nurses at the meeting.

113
Agatha Hodgins/ANA

• By 1930 - other nursing groups were organizing
  within the ANA.
• Miss Beddow (Alabama) proposed Office Nurses and
  Nurse Anesthetists.

114
Agatha Hodgins/ANA

• 1930 meeting
• Hodgins presented a paper which she felt helped
  to make nurse anesthetists there present, realize
  the importance of nurse anesthesia service as a
  separate division of hospital service - not a
  section of nursing.

115
Agatha Hodgins/ANA

• 1930 ANA meeting.
• Resolution for Office Nurses and Nurse
  Anesthetists, was reviewed by the ANA and there
  was a call for further study.
• The resolution subsequently died.

116
Agatha Hodgins/ANA

• Following the 1930 ANA meeting, Ms Hodgins moved
  quickly to form a national organization.
• May 1931, she invited Lakeside Alumnae as well as
  other nurse anesthetists from around the country
  to attend a meeting for the purpose of
  considering the organization of a national
  organization of nurse anesthetists.

117
Agatha Hodgins/NANA

• June 17, 1931 - Forty (40) nurse anesthetists
  from twelve (12) states met in a classroom at
  Western Reserve University. They formed the
  National (International) Association of Nurse
  Anesthetists.
• Name changed to AANA in 1939.

118
Seal of the AANA

• If you are connected to the internet as you view
  this, click on the seal to read a brief history
  of the official seal of the AANA.

119
National (International) Association of Nurse
Anesthetists

• President - Agatha Hodgins
• First Vice President - Laura Davis
• Second Vice President - Aida Allwein
• Third Vice President - Helen Lamb
• Treasurer - Miss McFadden

120
Agatha Hodgins/ANA

• Miss Hodgins stated the call for the meeting and
  Mrs. Fyfe moved, seconded by Miss Allwein, that
  a National (International) Association of Nurse
  Anesthetists be formed. The motion passed
• Assembly also decided to affiliate with the
  American Nurses Association.

121
Hodgins/NANA/ANA

• Miss Hodgins felt certain that nurse anesthetist
  services did not belong in nursing service.
• In November 1931, Hodgins began a lengthy
  correspondence with the ANA.
• 1st. issue was the name, International Assoc. of
  Nurse Anesthetists and the ANA a national
  organization, name was changed.

122
Hodgins/ANA/NANA

• March 1932, Hodgins again wrote to the ANA for
  acceptance of NANA.
• April 9, 1932, at a meeting of the ANAs Board
  of Directors, Hodgins proposal for affiliation
  was rejected.

123
Hodgins/NANA/ANA

• Hodgins stated to Miss Rice, a small
  organization with high standards will accomplish
  our objectives more successfully than a larger
  one half-heartedly concerned with anesthesia and
  nursing.

124
Hodgins/NANA/ANA

• The ANA Boards position was that membership to
  the ANA was already available to nurse
  anesthetists through their alumnae and state
  association. That these established avenues
  should continue to be utilized. It took the ANA
  six (6) months to resolve the issue.

125
NANA/American Hospital Association (AHA)

• John Mannix, Assistant Director of University
  Hospitals of Cleveland and Miss Fyfe working
  together in 1933, created a well organized and
  structured organization for the NANA.
• AHA welcomed the Association to participate in
  annual meetings.

126
Objectives of the NANA

• 1) To advance the science and art of
  anesthesiology.
• 2) To develop educational standards and
  techniques in the administration of anesthetic
  drugs.
• 3) To facilitate efficient cooperation between
  nurse anesthetists and the medical profession,
  hospital, and others.

127
Objectives of the NANA/Continued

• 4) To establish and maintain a central bureau for
  information, reference, and assistance in matters
  pertaining to the science and art of
  anesthesiology.
• 5) To promulgate an educational program to
  enlighten the general public as to the importance
  of the proper administration of anesthetics...

128
NANA - Additional Activities

• 1) Call for committees to investigate all schools
  of anesthesia with the objective of creating a
  list of accredited schools.
• Reason?
• 2) There should be a national board examination
  for nurse anesthetists.
• Reason?

129
State Associations of Nurse Anesthetists

• 1st state to organize was
• Alabama in in December 1931.
• Florida (11th state to organize) was in
  December 1935.
• Ref Textbook, page 207.

130
Chapter 5

• Worlds At War

131
Chapter 5

• Fueled by the economic pressures of the Great
  Depression, anti-nurse anesthetist activities had
  intensified.
• Anti-nurse anesthetist activities culminated in
  1934 in the test court case of Dagmar Nelson in
  California.

132
Chapter 5Dagmar Nelson Case

• The outcome of Dagmar Nelsons trial in
  California definitely established the legality of
  nurse anesthetists (1934).

133
Chapter 5

• The Frank v. South case and the expert witness
  of surgeons were considered the major
  contributors to the outcome of the Dagman Nelson
  case.
• - Implications for present CRNAs?

134
Chapter 5Medicines Internecine Conflict

• Anesthetics, by the 1930s had reached
  significant economic proportions.
• In 1938, Dr. Hedden observed Someone recently
  stated that there were probably 5 million
  paid-for anesthetics administered every year in
  the U.S. by nurse anesthetists.

135
Medicines Internecine Conflict

• This represents a cash income of 50 to 75
  million, so is it any wonder that when doctors
  realize this, they should hope to recapture the
  field which they have spurned and scorned in a
  large measure as being unworthy of their
  professional attainments.

136
Medicines Internecine Conflict

• In this war against nurse anesthetist, a unified
  physician front was never achieved. There were
  too many surgeons who favored, defended, and
  depended upon nurse anesthetists.
• - Implication for current CRNAs?

137
Chapter 5

• Editorial in the American Journal of Surgery,
  stated that the use of nurse anesthetist is a
  question to be answered by the surgeons. There
  is only one question, do surgeons desire nurse
  anesthetists to administer anesthetics, if the
  answer is yes then the laws should be changed to
  include this function in the nursing profession.

138
Chapter 5American Journal of Surgery

• Cont. If surgeons are opposed to nurses as
  anesthetists, no legislation is needed. It
  merely remains for the profession (medicine)
  discontinue the use of nurses in this capacity
• McMechan continued to write articles to the
  Anesthesia Supplement calling for the abolition
  of the present menace of N.A.

139
Chapter 5

• McMechan challenged surgeons for fee-splitting
  with nurse anesthetists as a violation of the
  Medical Practice Acts and ethics.

140
Chapter 5 - California

• Hodgins noted in 1922, that in California,
  pressure was being brought to bear in a great
  number of hospitals who were employing nurse
  anesthetists. Physician anesthetists objected
  most to those nurse anesthetists working on the
  fee basis.

141
Chapter 5 - California

• Sophie Winton, moved to California following her
  service in WWI. Her reaction to anti-nurse
  anesthetist activity was to become an independent
  practitioner.
• Became a partner in a private dental clinic
• Published research on dental anesthesia
• Opened an out-patient plastic surgery clinic in
  Hollywood

142
Chapter 5 - California

• 1928 - California State Board of Medical
  Examiners.
• Adopted a resolution calling for the end of the
  use of nurse anesthetists. The resolution was
  sent to surgeons and hospitals in California.

143
Chapter 5 - California

• When Highland Hospital in Alameda County received
  this communication, challenging the right of its
  nurse anesthetists, Eva Wilson, it moved to
  defend her. Dr. Benjamin Black, director of the
  institute said she is acknowledge by all the
  surgeons as probably the best anesthetists in
  this section...

144
Chapter 5 - California

• Dr. Black took the matter to the District
  Attorney and asked for a ruling on the legality
  of Eva Wilsons practice as a nurse anesthetist.
• The result was a finding that, the anesthetist
  was under active orders while giving anesthetics,
  of the operating surgeon, and was not practicing
  medicine...

145
Chapter 5 - California

• Dr. Black concluded
• Dr. H. Smith, who specializes in anesthesia, is
  the chief of the department of anesthesia but
  except for demonstration and teaching purposes he
  does not give anesthetics but is quite satisfied
  as are the surgeons here, with the work of Miss
  Wilson.

146
Chapter 5 - California

• Another case Miss Adeline Curtis, had been a
  staff anesthetist at the Johnson-Wickett Clinic,
  Anaheim, since 1921. She gave anesthetics for 3
  surgeons in 4 different hospitals.
• When her clinic was notified by 1928 of the
  resolution of the State Board of Medical
  Examiners, she stopped giving anesthetics.

147
Chapter 5 - California

• Miss Adeline Curtis. She hired her own attorney,
  Thomas McFadden of Anaheim, to discover the
  reality of the California law regarding the
  administration of anesthetics. He found her work
  was not in violation of California law and she
  was re-hired as a nurse anesthetist in December,
  1928.

148
Chapter 5 - California

• Miss Adeline Curtis
• Following her re-hire as a nurse anesthetist she
  spread the word and encouraged the formation of a
  state organization. In February 1930 the first
  meeting of the California Association of Nurse
  Anesthetists was held in Los Angeles

149
Chapter 5 - California

• Miss Adeline Curtis
• Agatha Hodgins did not want state associations
  to form until the formation of the national
  association with bylaws.
• In 1935 the California State Association of
  Nurse Anesthetists became an official affiliate
  of the national group.

150
Chapter 5 - California

• Mr. McFadden, Miss Curtis lawyer in 1931 asked
  the Attorney General had his office ever
  rendered a legal opinion to the State Medical
  Board to the effect that the giving of an
  anesthetic by an unlicensed person was a
  violation of the medical practice act.
• The answer was, no, it had not.

151
Chapter 5 - California

• The State Board of Medical Examiners were next
  to ask the Attorney General for an opinion.
• The response from Mr. Webb, the Attorney
  General, on September 26, 1933, began by noting
  the specific questions posed

152
Chapter 5 - California

• Questions asked
• 1) Whether a registered nurse may administer
  anaesthetics for general surgical procedures in a
  hospital.
• 2) May a registered nurse administer anaesthetics
  in the office of a physician or surgeon for minor
  work.

153
Chapter 5 - California

• 3) May a registered nurse administer anaesthetics
  in homes for obstetric work.
• The Attorney General stated that the preface to
  each question is that the administration of such
  anaesthetics shall always be under the
  supervising surgeon of the attending physician
  and surgeon.
• What does this imply?

154
Chapter 5 - California

• The opinion of the Attorney General cited in his
  response the precedent Frank v. South case from
  the Kentucky Supreme Court in 1917.
• Nurse anesthetists were not practicing medicine.

155
Chapter 5 - California

• Attorney General cont.
• 1) Nurse anesthetists did not present themselves
  as physicians.
• 2) Did not hold a medical license.
• 3) Administered anesthetics at the direction of a
  surgeon.

156
Chapter 5 - California

• Attorney General cont.
• 4) Did not have an office or announce to the
  public her readiness to treat the sick or
  afflicted.
• 5) Never prescribed for anyone.
• 6) Did acknowledge that nurse anesthetists use
  their own judgment in the administration of
  anesthetics.

157
Chapter 5 - California

• Attorney General cont
• Attorney General Webb noted that there was no
  legal support for the position that the mere fact
  of being a physician conferred an expertise in
  the administration of anesthetics.
• Missouri court case Spain v. Burch, that gave
  the same opinion as Frank v. South.

158
Chapter 5 - California

• In 1933, the Anesthetic Section of the Los
  Angeles County Medical Association asked Dr. W.
  Chambers-Francis, to test legally, the right of
  nurse anesthetists to administer anesthetics.

159
Chapter 5 - California

• The Nurse Anesthetist target was Dagmar Nelson, a
  graduate of the Mayo Clinic who had been invited
  by a surgeon, Dr. Verne Hunt to come to St.
  Vincents Hospital, Los Angeles to work as a
  nurse anesthetist.

160
Chapter 5 - California

• Dr. Hunt had had the death of a patient from
  asphyxiation (a 23 year old patient for minor
  surgery) by an anesthetist with little training.
• The physician anesthetists first sought an
  injunction to restrain permanently Dagmar Nelson
  from administering anesthetics.

161
Chapter 5 - California

• Test case
• Plaintiffs
• Dr. W. Chambers-Francis
• Dr. W. Wightman
• Dr. A. Waller
• Along with the Anesthesia Section of the Los
  Angeles County Medical Association.

162
Chapter 5 - California

• Test case
• Defendants
• Miss Dagmar Nelson
• Dr. V. Hunt
• St. Vincents Hospital

163
Chapter 5 - California

• Test case
• Judge Roth of the Superior Court, (1934) ruled
  that the Anesthesia Section could not be part of
  the suit.
• (Issue they as a group did not have property
  rights to contest)

164
Chapter 5 - California

• Test case
• July 12, 1934, Superior Court of Los Angeles,
  Judge Allen B. Campbell presiding, Miss Dagmar
  Nelson went on trial for violating the California
  Medical Practice Act practicing medicine without
  a license.

165
Chapter 5 - California

• Test case
• The physician anesthetists argument was that
  the administration of anesthetics was, in effect,
  the practice of medicine for the following
  reasons
• 1) The surgeon, being separated from the
  anesthetist by a screen, could in no way
  supervise the actual adm. of an anesthetic.

166
Chapter 5 - California

• Test case
• 2) That an anesthetic was a drug. That in
  administering the drug the anesthetist used his
  own judgment as to the amount and that in so
  doing he was treating the patient.

167
Chapter 5 - California

• Test case
• 3) That in observing the signs of anesthesia and
  acting as those signs indicated he should, he was
  making a diagnosis of the patients condition.

168
Chapter 5 - California

• Test case
• The witnesses for the plaintiffs were physician
  anesthetists.
• The witnesses for the defense depended chiefly
  on the testimony of surgeons.

169
Chapter 5 - California

• Test case
• The defense stated that it was an established
  practice within the law for registered nurses to
  give anesthetics as a nursing duty.

170
Chapter 5 - California

• Test case
• The 12-day trial ended on July 27, 1934. The
  judgment followed shortly.

171
Chapter 5 - California

• Test case ruling
• 1) That at the times mentioned in the complaint
  defendant Nelson was engaged as a nurse
  anesthetists under the direction and supervision
  of operating surgeons, and with the knowledge of
  defendant, St. Vincents Hospital, a corporation.

172
Chapter 5 - California

• Test case ruling
• 2) That the acts of the defendant Nelson under
  the evidence introduced in this case, do not
  constitute practicing medicine or surgery under
  the Medical Practice Act.

173
Chapter 5 - California

• Test case ruling
• 3) That the evidence in this case is insufficient
  to make out a case against defendants, or either
  of them, of practicing medicine without a license
  in violation of the Medical Practice Act.
• Issued by Judge Allen B. Campbell on July 31,
  1934.

174
Chapter 5 - California

• Test case ruling
• The physician anesthetists appealed but the
  judgment was upheld by the Supreme Court of
  California, on May 18, 1936.

175
Chapter 5 - Agatha Hodgins

• My Chief Interest Is in Education.
• Agatha Hodgins, June 20, 1932

176
Chapter 5 - Agatha Hodgins

• When the U.S. entered WWI in 1917, Ms Hodgins
  stayed behind to run the anesthesia school at
  Lakeside Hospital in Cleveland for physicians,
  dentists, and nurses in anesthesia.

177
Chapter 5 - Agatha Hodgins

• Agatha Hodgins in a letter (1932) she stated
  that the need for establishing uniform and
  stringent criteria for the education of nurse
  anesthetists was the motive behind her drive for
  national organization.
• There were nurses with little or no training
  giving anesthetics causing serious problems.

178
Chapter 5 - Agatha Hodgins

• In a letter to Adeline Curtis regarding the
  national organization. Ms Hodgins wrote,
  although I am very willing indeed to do what I
  can in regard to the organization, my chief
  interest is in education and I do not feel that I
  would be able to accept responsibility of this
  sort for a long period of time. Ms Hodgins was
  in poor health.

179
Chapter 5 - Gertrude Fife

• There were others than Ms Hodgins interested in
  the education of nurse anesthetists.
• One was Miss Gertrude Fife.

180
Chapter 5 - Gertrude Fife

• When Gertrude Fife addressed the first national
  convention of the National Association of Nurse
  Anesthetists in 1933, she called for a committee
  to investigate nurse anesthesia schools for the
  purpose of accreditation and for a national board
  examination for nurse anesthetists.

181
Chapter 5 - Gertrude Fife

• Miss Fife stated that these steps would
  safeguard the surgeons interest, the interest
  of the hospitals, and the interest of the
  public.
• What was not known at that time was the role
  that physicians had had in shaping the
  professional association and educational
  programs. Page 96

182
Chapter 5 - Gertrude Fife

• Physician input. Ms Fife reported that a Dr.
  Karsner, Professor of Pathology at Western
  Reserve University, who had been involved in
  starting the national Board of Examinations for
  doctors, offered to help her with the
  establishment of standards for schools and a
  national examination for nurse anesthetists.

183
Chapter 5 - Gertrude Fife

• Dr. Karsner had worked out a plan for Miss Fife
  on the subjects and asked her to put the plan
  into her own words because the members would
  accept it only if it came from a nurse
  anesthetist.
• Miss Fife later administered an anesthetic to
  Dr. Karsner when he required surgery.

184
Chapter 5 - Gertrude Fife

• Gaining acceptance for Ms Fifes plan of a
  national exam and accreditation of schools was
  not easy, chiefly because Hodgins favored another
  approach state registration.
• Perhaps because of charges over the years from
  physicians that nurse anesthetists were not
  licensed.
• A contest of wills Fyfe and Hodgins.

185
Chapter 5 School of Nurse Anesthesia

• Minimum standards set by the NANA Board of
  Trustees at its first national meeting in 1933
• Standards were revised in 1935 and 1936

186
Chapter 5Schools of Nurse Anesthesia

• 1937 at the 4th Annual meeting of the NANA, a
  Recommended Curriculum was adopted and
  published.
• Chairman of the education Committee was Miss
  Helen Lamb.

187
Chapter 5Schools of Nurse Anesthesia

• 1937 - Education Committee
• Issued a statement that schools must give to
  their students training both theoretical and
  practical which is equivalent to the curriculum
  that the Education Committee recommended.

188
Chapter 5Schools of Nurse Anesthesia

• Minimum standards (1937)
• Length of course - 6 months (1 year
  recommended)
• Hrs of recorded classroom instruction - 45
• Hours of recorded O.R. instruction - 18
• Number of cases administered - 325

189
Chapter 5Schools of Nurse Anesthesia

• Of the 325 cases
• 250 must be general surgical
• 25 should be obstetrical
• 25 may be dental
• 25 divided between spinals/locals

190
Chapter 5 - National Exam

• 1935 Fyfe proposed a plan for a national exam to
  the NANA Board of Trustees
• Select 7 people on the exam board.
• Include 2-3 outstanding surgeons.

191
Chapter 5 - National Exam

• This group would prepare the test questions and
  the exam. To be administered to every student
  before graduation from any school of anesthesia
  that wished to be recognized by the NANA. Those
  who passed would be issued a certificate.

192
Chapter 5 - National Exam

• Miss Fyfe was correct in her predication that in
  a few years the superintendents and surgeons
  generally would require their anesthetist to be
  recognized by the National association.

193
Chapter 5Question of Happy Relationship

• 1936 the Education Committee under Miss Helen
  Lamb proposed that the NANA join with
• American Board of Surgery (ABS)
• American Hospital Association (AHA)

194
Chapter 5

• The American Board of Surgery tried to obtain a
  working relationship between the NANA and the
  American Board of Anesthesiology (formed in
  1937).
• The American Board of Anesthesiology rejected
  any relationship with the NANA.

195
Chapter 5The Department of Education

• May 1940 Hodgins, announced in the Bulletin of
  the AANA a new AANA Department of Education
  representing the educational teaching programs of
  the Association.
• The Bulletin was to be used to present articles
  on physiology of respiration, etc. to upgrade the
  knowledge of members.

196
Chapter 5 - Nurse Anesthetist Service in World
War II

• 1920 - Beatrice Quin, RN of the Army Nurse Corps
  spoke at the annual meeting of the NANA. She
  stated that the Army gave nurses relative rank.
  It was many years later the nurses in the Army
  Nurse Corps obtained the right to retire.

197
Chapter 5 - WWII

• During WWII, the U.S. Army opened programs for
  nurse anesthetists in Washington, D.C. and at
  other Army hospitals.
• The army sent Army nurses to civilian school
  for training in anesthesia.
• 50 nurse anesthetists were on duty in the Army
  Nurse Corps.

198
Chapter 5 - WWII

• Quin stated, these nurses are not appointed
  for assignment to special duties, but any nurse
  having special training is usually given the
  opportunity of using this knowledge.

199
Chapter 5 - WWII

• It was this lack of assurance that the nurse
  anesthetist would serve as a nurse anesthetist
  that caused difficulties between the Army Nurse
  Corps and the American Association of Nurse
  Anesthetists.

200
Chapter 5 - WWII

• There was the problem of maintaining morale
  among overworked nurse anesthetists in the Army.
• Worked 8 hours or more days.
• 16 - hours of on-call.
• Other Army nurses worked 8 hour days with 16
  hours off.

201
Chapter 5 - WWII

• Major Julia Flikke, Superintendent of the Army
  Nurse Corps (ANC) wrote the following statement
  to the AANA Nurse anesthetists in the ANC in
  the grade of nurse, with the relative rank of
  2nd. Lieutenantsince there is a need for
  anesthetists in the Nurse Corps at present, they
  are usually assigned to that duty.

202
Chapter 5 - WWII

• Major Flikke continued
• However, in some of the smaller Army hospitals,
  where more than one nurse anesthetists is on
  duty, they may be assigned to duties other than
  those of anesthetist.

203
Chapter 5 - WWII

• From the U.S. Navy, Rear Admiral Ross McIntire,
  Surgeon General, provided the following
  statement
• under existing Navy regulations there is no
  provision whereby nurses may be appointed in the
  Nurse Corps of the Navy or Naval Reserve for duty
  limited to the administration of anesthetics

204
Chapter 5 - WWII

• The AANA made the following recommendation to its
  members
• with the critical need before us for supplying
  more well trained nurse anesthetists to service
  the acute shortage which exists in civilian
  hospitals throughout the United States, the AANA
  is reluctant to urge the individuals of this
  highly trained

205
Chapter 5 - WWII

• AANA statement continued
• group to forsake their specialized and badly
  needed service in these civilian hospitals, for
  possible general nursing service in the military
  forces, under the regulations as they now exist.

206
Chapter 5 - WWII

• March 1942 AANA President Helen Lamb wrote to the
  heads of both the Army and Navy Nurse corps,
  urging that nurse anesthetist be assigned to
  anesthesia service and given an appropriate rank.
• Because of the critical need for nurse
  anesthetists for the war effort, the Army agreed.
  The Navy Nurse Corps refused.

207
Chapter 5 - WWII

• The nurse anesthetists would have to wait until
  the end of WWII for such recognition.
• In August 1947, LTC Katherine Baltz, Education
  Consultant to the ANC, published in the Journal
  of the AANA an essay title, The Value of Special
  Training In Anesthesia For the Army Nurse.

208
Chapter 5 - WWII

• LTC Katherine Baltz admitted mismanagement for
  nurse anesthetists in the Army Nurse Corps during
  WWII.

209
Chapter 5 - The Diversity of Anesthesia Tng. in
the Military

• The AANAs additional concern that its
  educational programs and plans not be compromised
  was well-founded.
• The demand for nurse anesthetists in both the
  military and civilian spheres were so great that
  the AANA could not contain the growth of
  emergency-training programs.

210
Chapter 5 - WWII

• The Army had programs which were little more
  than on-the-job training programs, some as short
  as three months.

211
Chapter 5A High Type of Service

• Nurse anesthetists received citations for
  meritorious service in both the Army and Navy
  during WWII.
• Army nurse anesthetists served in front line
  hospitals in the Army as the war progressed.
• - (Major M. Jernigan)

212
Chapter 5 - WWII

• The AANAs wartime pursuit of educational goals.
• In May 1942 the AANA published an 8 page
  recruiting brochure (written by Gertrude Fyfe)
  title, Anesthesia A Career for the Graduate
  Nurse. in it she presented the AANAs position
  in the face of the wartime emergency. The need
  for nurses

213
Chapter 5 - WWII

• cont. Anesthetists both in civilian and Army
  hospitals is becoming increasingly urgent. In
  order to meet the situation, many schools of
  anesthesia have increased the student bodythe
  AANA has been opposed to lowering the standards
  by allowing students to be graduated with less
  clinical experience than necessary to prepare her

214
Chapter 5 - WWII

• cont. properly for working in active surgical
  clinics. The Association has therefore
  encouraged the establishment of schools in
  hospitals equipped to offer training in this
  field.
• During this same time (1942) was the call for a
  qualifying examination.

215
Military CRNAs 100 Year History

• http//www.aana.com/bookstore/videos/Army_wmf/AANA
  100c.wmv

Click link above to launch Windows Media Player
Video
216
Chapter 6

• Everything is Under Control

217
Chapter 6

• AANA President Lucy Richards reflected in 1947
• When the war came to an end, we all hoped that
  many of our problems would quickly disappear.
  The end of the war has brought forth not only a
  hangover of many of our old problems, but many
  new ones.

218
Chapter 6

• With the growth of the AANA an Executive
  Director was appointed in 1948.
• Miss Florence A. McQuillen, who had been a staff
  anesthetist and instructor of anesthesia at the
  Mayo Clinic.
• No single assoc. leader before or after Miss
  McQuillen would exercise comparable control over
  all facets of its business.

219
Chapter 6An