Merel H. Harmel

A Practice of Anesthesia

It is well-established that nurse anesthetists practice nursing. Anesthesia administration has been a proper nursing function both in practice and in law for more than 100 years. Courts have long recognized the administration of anesthesia by nurses as a proper nursing function. In Frank v South, 194 S.W. 375 (Ky. 1917), the court ruled that a nurse giving anesthesia was not engaged in the practice of medicine within the meaning of the statute forbidding the unauthorized practice of medicine. Although Frank v South is many years old, its finding that nurse anesthetists do not practice medicine is still relevant because it has never been overturned or contradicted by another court. In Montana Society of Anesthesiologists v. Montana Board of Nursing, 339 Mont. 472, 171 P.3d 704 (2007), the Supreme Court of Montana reaffirmed this legal principle, recognizing that anesthesia is a specialty within the field of nursing and that nurse anesthetists practice nursing. 1

AN ANESTHESIOLOGIST LOOKS AT MONITORING

T h e monitoring of t h e phys io log ic func t ion of p a t i e n t s h a s a l o n g h is tory da t ing from t h e t i m e t h e f i r s t phys i c i an f e l t a p u l s e and followed i t s late a n d rhythm or o b s e r v e d resp i ra tory ac t iv i ty , record ing t h e r e s p e c t i v e r a t e s of each . T h e a n e s t h e s i o l o g i s t , from t h e t i m e of John Snow, h a s u s e d s imple monitoring: coun t ing and record ing p u l s e and resp i ra tory rate. Soon a f t e r Riva-Rocci in t roduced sphygmomanometry, Harvey Cush ing , t h e eminen t neurosurgeon, app l i ed t h i s m e a n s of measur ing blood p r e s s u r e to p a t i e n t s undergoing a n e s t h e s i a a n d opera t ion . Until t h e p r e s e n t t h e s e s i m p l e me thods and the information they y i e lded s e e m e d su f f i c i en t , but t h e t echno log ica l deve lopmen t s i n e l e c t r o n i c s and t h e s c i e n c e of phys io log ic measurement h a s brought 3 d e g r e e o f s o p h i s t i c a t i o n to monitoting t h a t is forcing, a l b e i t s lowly , s ign i f i can t c h a n g e s in approach and concept . Monitoring, i n c o n t r a s t to its u s e i n i n v e s t i g a t i v e app l i ca t ions , is ultimately d i r ec t ed toward provid ing t h e m e a n s for moment-tomoment obse rva t ion of a pa t ien t ’s s t a t u s so tha t untoward c h a n g e s from wha t is cons ide red normal function i n t h e c l in i ca l milieu c a n b e eva lua ted , t r ea t ed and t h e t rea tment appra ised . While monitoring f requent ly is in i t i a t ed i n t h e ope ra t ing room and its u s e f u l n e s s i n t h i s l oca t ion is undeniable , t h e despe ra t e ly ill pa t i en t , medica l o r su rg ica l , may b e followed to grea t advan tage with appropr ia te monit o l ing d e v i c e s at all times. W e a r e now a b l e to d i sp lay and record pu l se , blood p res su re , blood flow, c a r d i a c output, resp i ra t ion , pCO,, p H , t h e e l ec t r i ca l ac t iv i ty of h e a i t and brain, temperature, a n d sk in r e s i s t ance . From t h i s mul t i tude of phys io log ic pa rame te r s w e mus t select t h o s e t h a t h a v e r e l e v a n c e for t h e problem at hand and t h a t l end t h e m s e l v e s t echn ica l ly to t h e c l i n i c a l s i t ua t ion within t h e ope ra t ing t h e a t e r o r t h e c l i n i c a l i nves t iga t ion laboratoty. W e may with r e l a t ive e a s e , even at t h e p t e s e n t , accompl ish our o b j e c t i v e s in t h e ope ta t ing thea te r , but i n recovery and i n t e n s i v e c a r e a r e a s t h e numbe r of p a t i e n t s and t h e d i f f i cu l t i e s a s s o c i a t e d with mul t ip le and s imul t aneous d i sp lay from a number of p a t i e n t s p r e s e n t s a problem i n log i s t i c s . Even though most monitoring in medic ine h a s been des igned around equipment t h a t t r ansmi t s d i rec t ly with w i r e s to d i sp l ay or l eco rd ing appa ta tus , t h e a d v e n t of s p a c e t rave l and t h e phys io log ic

Introduction to Anesthesia. The Principles of Safe Practice

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Long‐Term Ventilator Treatment for Patients With Respiratory Failure After Major Abdominal Surgery

Since September 1964, more than one hundred surgical patients have received prolonged ventilator treatment in the Kings County Hospital Center. Our attention has been particularly directed to the application of this therapy in patients who had major abdominal surgery. This represents 60 per cent of the patients whom we treated by prolonged artificial ventilation. We have been impressed, as have others, with the extraordinarily high mortality in this group (1, 2, 3). Accordingly, we have examined our clinical experiences, in an effort to analyse the clinico-pathologic features involved in these patients.

INCOMPATIBLE BLOOD TRANSFUSIONS DURING OPERATION

RECOGNITION of haemolytic transfusion reactions in conscious patients is usually not difficult. Shortly after the onset of an incompatible blood transfusion, the conscious patient generally develops a variety of symptoms (Wiener, 1943), such as a sensation of fullness in the head, generalized tingling, precordial oppression and sudden sharp pain in the lumbar region. He becomes anxious, restless and dyspnoeic. His face is suffused and the neck veins are distended. Nausea and vomiting are not uncommon. These initial signs and symptoms may be followed by circulatory collapse, marked by hypotension, a rapid feeble pulse, and cold clammy skin; more rarely, pilo-erection and cyanosis appear. About an hour later, the patient commonly has a shaking chill and an elevation in temperature. Occasionally, chills and fever alone or in combination are the presenting signs of haemolytic reaction, the initial symptoms being unrecognized or absent. A haemorrhagic tendency can develop during or immediately after transfusion, and blood may ooze from the transfusion site, from the gums, uterus (in postpartum patients), or from any incised tissue. The appearance of this clinical complex makes recognition of haemolytic transfusion reactions in the conscious patient relatively simple.