Chapter 1
Nurse Anesthesia
A History of Challenge
People have known since the late eighteenth century that inhaling nitrous oxide or diethyl ether could produce euphoria. The English scientists Joseph Priestley and Humphrey Davy experimented on themselves and even partied with these substances. Davy famously speculated that nitrous oxide “may probably be used with advantage during surgical operations.”1
At the same time, American medical students used ether and nitrous oxide recreationally. But almost 40 years would pass before they attempted to use these agents as adjuncts to surgery. Crawford Long, a Georgia physician, used diethyl ether for the removal of a small cyst in 1842. Unfortunately, he did not report his findings. At least two other men, the Massachusetts physician Charles Jackson and the Connecticut dentist Horace Wells, experimented with ether or nitrous oxide. Finally, on October 16, 1846, the Boston area dentist William T.G. Morton conclusively demonstrated the use of ether for surgical anesthesia in an operating room (now memorialized as the “Ether Dome”) at Massachusetts General Hospital. So important was the event that the surgeon John Collins Warren, who had witnessed many prior failed attempts, reportedly exclaimed, “Gentlemen, this is no humbug.” Another eminent surgeon who had been in attendance stated, “I have seen something today that will go around the world.”2 From their vantage point, optimism seemed justified; however, another half century would pass before the promise of painless surgery would be substantially fulfilled.
From the outset, Morton’s discovery caused problems. People realized its value, and some wanted a piece of the action. Morton attempted to disguise ether so he could profit from it. He named the substance Letheon and applied for a patent. Long, Jackson, and Wells all claimed credit for Morton’s discovery. The four men battled for years. The physician and writer Oliver Wendell Holmes, Sr. (father of the Supreme Court Justice) wrote to Morton, “Everybody wants to have a hand in a great discovery…All I want to do is give you a hint or two as to names.” Rather than Letheon, Holmes suggested “anaesthesia from the Greek for insensible.” But it seems Holmes too wanted something for himself. The term anaesthesia, according to historian Julie Fenster, “had been in use before to denote parts of the body benumbed but not paralyzed.” She added that, “Holmes only borrowed the word for the new state of being, though he has received credit for coining it.”3 As Robert Dripps dryly noted, “anesthesia was placed under a cloud.”4
Nineteenth century anesthesia was problematic in other more important ways. Related infections and the careless administration of anesthesia vexed surgeons, plagued patients, and delayed progress in the field of anesthesia for decades. They led the historian Ira Gunn to term this era “the period of the failed promise.”5
The Problem of the Occasional Anesthetists
In the nineteenth century, physicians expanded surgery as a medical specialty, but not anesthesia, although there were calls for them to do so.6 James Gather, the pioneer physician anesthetist, gave one explanation for this medical disinterest: “So intense had been the interest in surgery that anesthetics had been used only as a means to an end, and this fully explained the attitude of the profession on this subject in America at the present time.” But money was also an issue. One physician commentator S. Simon doubted whether a physician “taking the work up as a specialty could make a living at it alone; and especially is this true in the smaller cities.”7 Indeed, the historian Marianne Bankert agreed: “Apart from the few physicians who had a genuine intellectual interest in anesthesia, it would also take years for the economics of anesthesia to make it an attractive area for their colleagues—if at first, only as a supplemental source of income.”8 The Philadelphia surgeon J.M. Baldy thought anesthesia unworthy of a physician’s intellect: “Every physician obtains his medical education with the idea of practicing medicine, and it is only dire necessity which will compel him to give up such a future for the narrow one of anesthesia. Every physician who for a few years of his early and least busy life devotes a part of his time to anesthesia does so with the distinct idea of observing and learning surgery, with the result that he is shortly paying more attention to the technic [sic] of the operation than he is to the anesthetic, and within a year or so he is demanding an assistantship from the surgeon as a reward for his faithful service in what he considers a subordinate position and which he has all along filled under mental protest and only as a means to an end.”9 As a result, anesthesia remained a medical stepsister to surgery until well into the twentieth century.
The work of anesthesia was relegated to others. “Students, nurses, newly graduated physicians, specialists in other fields, and even custodians were called upon to be etherizers.”10 “Anesthesia could be anybody’s business,” wrote Virginia Thatcher.11
Lack of attention led to a degradation of knowledge and technique. “Within a few months (of the discovery) at the Massachusetts General Hospital, Morton’s inhaling apparatus (which had worked well) was abandoned in favor of a small bell-shaped sponge, which was saturated with ether and applied directly over the nose and the mouth of the patient.”12 Not surprisingly, ether pneumonia resulted. Some surgeons therefore turned to chloroform, which had been discovered by James Simpson in England to have anesthetic properties. “But, very soon, a death occurred from chloroform, then another and another in quick succession. This led to its more careful and restricted use by some surgeons, to its total abandonment by others, but in 1855, the general mass of surgeons and physicians still continued its use…”13 Thatcher cited one physician who, in 1859, wrote, “In some cases Dr. M. had seen chloroform administered by young gentlemen rather in a careless manner…In fact, he believed that most of the fatal cases can be traced to a careless administration of the remedy.”14
Careless anesthesia persisted for decades. A cogent example was recorded in 1894 by Harvey Cushing, the founder of neurosurgery.∗ Almost fifty years after the discovery of anesthesia Cushing was a student at Harvard Medical School:
My first giving of an anaesthetic was when, a third-year student, I was called down from the seats and sent in a little side room with a patient and an orderly and told to put the patient to sleep. I knew nothing about the patient whatsoever, merely that a nurse came in and gave the patient a hypodermic injection. I proceeded as best I could under the orderly’s directions, and in view of the repeated urgent calls for the patient from the amphitheatre it seemed to be an interminable time for the old man, who kept gagging, to go to sleep. We finally wheeled him in. I can vividly recall just how he looked and the feel of his bedraggled whiskers. The operation was started and at this juncture there was a sudden great gush of fluid from the patient’s mouth, most of which was inhaled, and he died. I stood aside, burning with chagrin and remorse. No one paid the slightest attention to me, although I supposed I had killed the patient. To my perfect amazement, I was told it was nothing at all, that I had nothing to do with the man’s death, that he had a strangulated hernia and had been vomiting all night anyway, and that sort of thing happened frequently and I had better forget about and go on with the medical school. I went on with the medical school, but I have never forgotten about it.i
Surgeons began to appreciate the need for professional anesthetists. The need as Thatcher defined it was for anesthetists who would “(1) be satisfied with the subordinate role that the work required, (2) make anesthesia their one absorbing interest, (3) not look on the situation of anesthetist as one that put them in a position to watch and learn from the surgeon’s technic [sic], (4) accept the comparatively low pay, and (5) have the natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation that the surgeon demanded.” Some surgeons, particularly in the Midwest, “accepted in this capacity a class of persons for whom they had learned to have deserved respect and from whom they had obtained commendable assistance and service—the Catholic hospital Sister.”15 And so as a result of medical disinterest, poor delivery of anesthesia in general, and an overwhelming need, nurses were asked to give anesthesia.
Historical Antecedents of the Nurse as Anesthetist
The Civil War provided the first opportunity for nurses to assume the duties of anesthetist. Evidence is found in three different accounts. Mrs. Harris from Baltimore, Maryland, took chloroform and stimulants to the Battle of Gettysburg. Harris “penetrated as near as possible to the scene of the conflict, ministering as much as in her power to the stream of wounded that filled the cars…”16 It is not known whether Mrs. Harris was a nurse. A second report connects a nurse with administering chloroform. “Private Budlinger of the 76th Ohio Unit, after breathing it for a few minutes without any apparent effect, more chloroform was added and reapplied by a nurse in attendance.”17
But the most convincing example was written by a nurse. Catherine S. Lawrence, a native of Skaneateles, New York, wrote a 175-page autobiography in which she recorded administering anesthesia as a Union Army nurse. Lawrence described her duties at a hospital outside Washington, D.C., during and after the Second Battle of Bull Run (1863). She administered medications, resuscitated with restoratives like ginger, tied sutures around arteries, and administered chloroform. “I rejoice that the time has arrived that our American nurses are being trained for positions so important. A skillful nurse is as important as a skillful physician.”18–21
The early use of nurses as anesthetists was mostly an American phenomenon. However, a 1911 article revealed that “(In) the European hospitals female as well as male nurses…were taught how to give anaesthetics [sic] in the …(Franco-Prussian War of 1870-1871). Only the nurses gave anaesthesia in the ambulatory hospitals on the field.”22
The St. Mary’s Experience
Why would they give the job to nurses? “The Mayos had given the job to a nurse “in the first place through necessity; they had no interns. And when the interns came, the brothers decided that a nurse was better suited to the task because she was more likely to keep her mind on it, whereas the intern was naturally more interested in what the surgeon was doing.”23
And it was successful. Nancy Harris and Joan Hunziker-Dean, who investigated Florence Henderson’s life, concluded that “through a delicate balance of interpersonal skills and technical expertise, (Henderson) was able to essentially eliminate the excitement phase of ether anesthesia and consistently used a fraction of the usual ether dose. She demonstrated to all who observed that the administration of ether anesthesia could be elevated to an art form.”24
Magaw and Henderson made anesthesia safe. Magaw accounted delivery of over 14,000 anesthetics “without an accident, the need for artificial respiration or the occurrence of pneumonia or any serious results.”25 Included were anesthetics for abdominal, intraperitoneal gynecologic, urologic, orthopedic, ophthalmic, head and neck, and integument operations. Some were even conducted in the prone position.26
Thatcher wrote that it was Alice Magaw who “brought to the profession of nurse anesthetist as well as to the Mayo Clinic no little fame at a time when poor anesthesia was the major worry of most surgeons.” Charles Mayo was so impressed by Magaw that he named her “The Mother of Anesthesia.”27 Surgeons who visited from Minneapolis, Iowa, Baltimore, Chicago, and England “sent selected nurses to Rochester to observe Alice Magaw and other nurse anesthetists at St. Mary’s Hospital at their work.”27
Magaw and Henderson introduced better teaching methods too. Early anesthesia education has been described by A.J. Wright as “on the spot training of any person available…” At Mayo sometimes the “nurses stayed for 2 or 3 months and learned to give ether under supervision.”27
The Lakeside Experience
Hodgins’ primary interest was in education. Like St. Mary’s Hospital, Lakeside Hospital was the recipient of many requests for anesthetist training from both physicians and nurses. According to Thatcher, “Visiting surgeons eager to emulate the Lakeside methods, customarily bought a gas machine (the Ohio Monovalve) and then sent a nurse to Cleveland to find out how it worked.”28 Hodgins recalled, “The number of applicants increased so rapidly that we felt some stabilizing of work necessary and the matter of a postgraduate school in anesthesia presented itself.” In 1915, Hodgins opened a school at Lakeside Hospital. The Lake School was not the first formal postgraduate anesthesia educational program. That honor belongs to St. Vincent’s Hospital in Portland, Oregon. But the Lakeside School is the only program for which original records still exist. There were admission requirements, the course included both clinical and didactic components, tuition was charged, and a diploma was granted. “The department of anesthesia encompassed the school, both being under the charge of Agatha Hodgins as chief anesthetist. She, in turn, worked under the jurisdiction of the superintendent of the hospital and the chief surgeon. For the supervision of the students she had 1 or 2 assistants until 1922 when the number was increased to 3.”29 The evolution of nurse anesthesia education into a more formalized, scientifically based discipline can thus be seen.
Although records do not exist, 54 similar programs were said have to existed at major hospitals in Chicago, Illinois; Worcester, Massachusetts; Milwaukee, Wisconsin; New Orleans, Louisiana; Baltimore, Maryland; Ann Arbor, Michigan; St. Louis, Missouri; Detroit, Michigan; Poughkeepsie, New York; Tacoma, Washington; and Minneapolis, Minnesota.30
The Proliferation of Nurse Anesthetists
Prior to World War I, anesthesia grew more sophisticated. Nitrous oxide was reintroduced, and with it came the first anesthesia machines. Surgeons and hospitals sought nurse anesthetists who were capable of using the machines. The first recognition of the value of formalized education also occurred at this time. Four postgraduate programs were developed: at St. Vincent’s Hospital in Portland, Oregon (1909);31 at St. John’s Hospital in Springfield, Illinois (1912); at New York Postgraduate Hospital in New York City (1912); and at Long Island College Hospital, Brooklyn, New York (1914).32 Other nurse anesthesia programs were developed as a part of the undergraduate nursing curriculum as a specialty option. Isabel Adams Hampton Robb, a pioneer nursing leader and the first superintendent of the Johns Hopkins School of Nursing, which had opened in 1889, had in 1893 published a nursing textbook titled Nursing: Its Principles and Practices for Hospital and Private Use; this textbook included a chapter titled “The Administration of Anaesthetics.” By 1917, as a result of the “superior quality of anesthesia performed by nurse anesthetists,33 they were given the responsibility for surgical anesthesia at Johns Hopkins Hospital in Baltimore, where a training program was established under the direction of Ms. Olive Berger.
But success bred resistance. Thatcher wrote that, “The rapid growth of postgraduate schools of anesthesia in which nurses were trained, as well as the increasing enthusiasm for the trained nurse anesthetists during World War I, did not escape the attention of physician specialists in anesthesia, and during the 1920s resentment against the nurse anesthetist culminated in attempts to legislate her out of existence.”34
The Great War, a Small Battlefield
When America entered the war, the Army Nurse Corps numbered 233 regular nurses; it would grow to 3524 nurses by 1918. The number of nurse anesthetists is unknown because at the time nurse anesthetists formed part of the general nursing staff.35 However, nurse anesthetists were credited with introducing nitrous oxide/oxygen, and teaching its administration to the English and French.36 As a result of the superior performance of nurse anesthetists, both the Army and the Navy sent nurses for anesthesia training for the first time.
Several outstanding World War I–era nurse anesthetists have been remembered because they wrote of their work. Nurse anesthetists spent countless hours etherizing wounded soldiers as they arrived in “ceaseless streams for days at a time after battles,” wrote Mary J. Roche-Stevenson. “Work at a casualty clearing station came in great waves after major battles, with intervals between of very little to do.…Barrages of gun fire would rock the sector for days, then convoys of wounded would begin to arrive by ambulance. Night and day this ceaseless stream kept coming on.… The seriously wounded, especially the ones in severe shock, were taken to a special ward, given blood transfusions and other treatments in preparation for surgery later. From the receiving tent, the wounded were brought to the surgery, put on the operating tables stretcher and all given an anesthetic, operated upon, picked up on their stretcher, and loaded on hospital trains for evacuation to base hospitals.”37 Terri Harsch,38 who described the works of Roche-Stevenson and others such as Sophie Gran Winton, reported that 272 nurses were killed during the war.
In a paper about Miss Nell Bryant, who was the sole nurse anesthetist for Base Hospital Number 26 from the Mayo Clinic39 we learn that chloroform and ether were in use, the physiology of shock was poorly understood, oxygen and nitrous oxide were given without controlled ventilation, and venipuncture involved a surgical cutdown.
Anne Penland was a nurse anesthetist with the Presbyterian Hospital of New York unit, Base Hospital Number 2. She had the honor of being the first U.S. nurse anesthetist to go officially to the British front, where she so won the confidence of British medical officers that the British decided to train their own nurses in anesthesia, ultimately relieving more than 100 physicians for medical and surgical work. Several hospitals were selected for this training of British nurses, including the American Base Hospital Number 2, with Penland as the instructor.40
Commenting in the Bulletin of the American College of Surgeons, Frank Bunts wrote, “The (First) World War demonstrated beyond any question the value of the nurse anesthetist.”41 George Crile speculated that “if the Great War had gone on another year, the British army would have adopted the nurse anesthetists right in the middle of the war.”42 Looking back after World War II, Lt. Colonel Katherine Balz, Deputy Chief of the Army Nurse Corps, credited nurse anesthetists for the fact that 92% of “battle wounded who reached Army hospitals alive were saved.”43
Anesthesia: Medicine, Nursing, Dentistry, or What?
Although few physicians chose to specialize in anesthesia before World War II, one who did, Francis Hoeffer McMechan—a Cincinnati native—began a crusade to claim the field solely for physicians around 1911. McMechan had become disabled shortly after entering the field of medicine and did not practice. He and his wife undertook his mission through writing, publishing, and speaking. McMechan’s first target was the high profile Lakeside School and its famous surgeon George Crile. He alleged that anesthesia was the practice of medicine, and he petitioned the Ohio Medical Board to take action. McMechan considered Ohio a “pivotal state in the national fight for the preservation of the status of the anesthetist as a medical specialist.”44
But to protect nurse anesthetists, Crile took an additional step. In 1919, together with supporting physicians, he “introduced a bill into the (Ohio) legislature to legalize the administration of anesthetics by nurses.”45 An amendment to the legislation stated that nothing in the bill “shall be construed to apply to or prohibit in any way the administration of an anesthetic by a registered nurse under the direction of and in the immediate presence of (emphasis added) a licensed physician,” provided that such a nurse had taken a prescribed course in anesthesia at a hospital in good standing.46 Physician supervision, first mentioned here, would recur many times over.
These two cases showed physicians they could not rely on the courts to end nurse anesthesia. But still they were not deterred. A California case (1933 through 1936) in which Dagmar Nelson, a nurse anesthetist, was charged with the practice of medicine has been considered as the defining test case of whether nurse anesthetists are practicing medicine or nursing when they administer anesthesia. This case was decided in favor of Dagmar Nelson at each level of the California civil court system. The California Supreme Court ruled again that the functioning of the nurse anesthetist under the supervision and in the direct presence of the surgeon or the surgeon’s assistants was the common practice in operating rooms; therefore the nurse anesthetist was not diagnosing and treating within the meaning of the medical practice act.47,48
At the time, nurse anesthetists welcomed and embraced supervision. Gene Blumenreich, who has written extensively on the legal history of anesthesia, noted that “A number of states adopted statutes recognizing the practice of nurse anesthetists. Typically, these statutes followed the formulation in Frank v. South and provided that nurse anesthetists were to work under the ‘supervision’ or ‘direction’ of a physician.” But, the statutes did not define supervision. “It is clear that the legislation was not attempting to create new duties and responsibilities but merely to describe what was already going on in practice…to explain why nurse anesthetists were not practicing medicine.”49 Decades later, however, supervision would become a battleground.
Organization: “We Who are Most Interested”
In 1926 Agatha Hodgins called together a small group of Lakeside Hospital alumnae to form a national organization. Hodgins had been an educator since World War I, and she must have sought strength in numbers to address problems related to education. One hundred thirty-three names were submitted and tentative bylaws were drawn up. But, as Ruth Satterfield recalled, “much of what she (Hodgins) said fell on deaf ears.”50 The association failed to thrive. As Thatcher has noted, “It is only when common problems become too big for individual solutions that the average professional person becomes conscious of the protection that can be found in organization.” The national organization of nurse anesthetists would only come to life after several problems coalesced in 1931.
Physician opposition to nurse anesthetists was one factor in this development. For example, California nurse anesthetists organized in 1929 after the Board of Medical Examiners alleged that Adeline Curtis was practicing medicine illegally. Curtis, a natural public speaker, went on the road with this refrain: “…we can get nowhere without an organization. We’re in the minority of course but we must organize.”51 California held its first meeting February 3, 1930.52 Other states followed suit, and by the end of the 1930s, 23 had established organizations.
Hodgins in 1935 noted that “the strongest objection of physicians during this period was against those nurse anesthetists who were working on a fee for service basis.”53 Hanchett,54 who examined the Chalmers-Francis v. Nelson case (1933), concluded that plaintiff California physicians were motivated by economic factors. And Thatcher observed that “Miss Hodgins’ concept (of an organization) might never have been sparked into action, and organizations of nurse anesthetists might have stayed at the local level if the collapse of the nation’s economy had not revived the physician anesthetist’s interest in protecting his income by eliminating competition from nurses…”55
But it was the poor state of anesthesia education that most motivated Agatha Hodgins. In 1931 she wrote to Adeline Curtis who was embroiled in the California dispute: “My chief interest is in education.”56 And with the previous factors compounding each other, Agatha tried again.
The National Association of Nurse Anesthetists (NANA) was born on June 17, 1931. Its name would be changed to the American Association of Nurse Anesthetists in 1933. The first meeting was held in a classroom at Lakeside Hospital and was attended by 40 anesthetists from 12 states.57
Right away, the new association set its sights on improving the quality of anesthesia by raising educational standards. The new president, in a letter to Marie Louis at the American Nurses Association wrote, “It is because of the increasing number of nurses interested in the particular work and growing realization of difficulties existing because of insufficient knowledge of, and proper emphasis on, the importance of education, that we who are most interested are taking the steps to insure our ability to define and help maintain the status of the educated nurse anesthetist.”58An education committee was formed. Chaired by Helen Lamb, the committee crafted “recommended” curriculum standards for schools and ratcheted them up in 1935 and again in 1936.
But the fledgling association was weak. With few members and little money, it could not hold its first national meeting for 3 years, much less advance an agenda of education reform. In that period, Agatha Hodgins sustained a heart attack and “for all practical purposes bowed out as administrative leader.” Gertrude Fife took over the day-to-day affairs. There grew the realization, attributed by Bankert to Helen Lamb and her Education Committee, that the problems were of such magnitude that an alliance with a more influential professional association would be required. But which one?
Forming an alliance with a major professional organization would likely prove problematic, as divergent interests collide and trust is tested to its limit. The small young NANA would have to fight to maintain independence, while at the same time obtain much needed support. According to historian Rosemary Stevens, the AANA “made overtures to the American Board of Anesthesiology (ABA) in 1938 which might have enabled the two movements to combine and the anesthesiologists to take on the responsibility of the nurses’ training.” But at the time, the ABA was struggling to emerge from under the wing of surgery, and “the nurses were summarily rejected.”59
Membership was to be a privilege, a mark of distinction. The bylaws required that an active member have graduated from an accredited school of nursing, have passed the required state board examination, and maintained an active license. Importantly, an applicant must “have engaged for not less than three years in the practice of the administration of anesthetic drugs prior to 1934, and must be so engaged at the time of making application for membership.”60 The founders meant business.
World War II and Nurse Anesthetists
Marianne Bankert quotes at length a letter Annie Mealor later wrote in which she described her experiences. Mealer recalled housing President Quezon and his family, dodging “Jap bombs,” and “giving anesthetics to one casualty after another” who “all needed help that only a nurse could give them.” In Japanese custody aboard a troop ship, and sick with dengue fever, Mealer wrote, “I threw my cape down on the deck to lie on it and prayed that the wind would blow the fumes of the stale fish in another direction. I looked around at the nurses in the various uniforms of coveralls and skirts. They had grown slender as reeds, but were smiling over some secret rumor about liberation—not realizing they had nearly three more years of hard work and starvation.”61
Wartime greatly expanded the need for anesthetists in both military and civilian hospitals. Lt. Col. Katherine Balz, the Education Consultant to the Army, estimated that “approximately 15,000,000 patients were admitted to Army hospitals during the war, and something had to be done to provide the anesthesia services needed for these patients’ care.” Rosemary Stevens reported that in 1942, nurse anesthetists outnumbered anesthesiologists by 17 to 1.62 By the end of World War II, the Army Nurse Corps had educated more than 2000 nurse anesthetists, most (though not all) of whom were given an abbreviated 4- to 6-month curriculum patterned after that required by the AANA.63 Lt. Col. Balz recalled a situation in which some volunteer nurses were placed into anesthesia service after only 90 days training! “At the end of that time, these volunteers were thrown into a situation in which 100 operations were being performed every 24 hours….there were not enough hours in the day to care for the patients and at the same time provide for formal instruction. In this hospital, over 5,000 anesthetics were given during a six months’ period, and not one death or complication occurred as a result of anesthesia.”64
The increased needs and the shortened training period posed “extraordinary complications” for the AANA. The quality of newly minted graduates had to somehow be addressed. To maintain standards, the AANA implemented a temporary “program of certification by exam and certification by waiver.”65 Accreditation of programs was postponed entirely. In 1943 the Annual Meeting was reduced to just 1 day; a quorum could not be met, so already elected officers remained on the board.
From her sick bed, Agatha Hodgins sent these words of encouragement: “The immense and vital part all branches of medical service will play in this continuing task can—because of its greatness—be now only dimly conceived. They will in very truth be a ‘green island’ in ‘the wide deep sea of misery’ now encompassing the earth.” These were among her last words. Hodgins passed away in 1945. Her gravesite is located on Martha’s Vineyard.66
As World War II drew to a close, the AANA’s plans for instituting a certification examination for civilian membership were at last realized. The first examination was given in June 1945. It was completed by “90 women in 39 hospitals in 28 states, plus one in the Territory of Hawaii.”67 It would be hard to conclude that their “high type of service” during the two world wars did not account for this accomplishment.
Nationally, World War II was also associated with bringing about certain human rights advances. President Truman integrated the armed forces in 1948. And the first male nurse was commissioned in 1955, a step attributed to nurse anesthesia. The AANA admitted its first African-American member in 1944 and its first male member in 1947. The first two male nurses commissioned in the Army Nurse Corps were nurse anesthetists, Edward L.T. Lyon of New York and Frank Maziarski of Washington, who later became the sixtieth president of the AANA.68,69
A Short-Lived Peace for Nurse Anesthetists and the Nation
After the war the number of physicians in anesthesia greatly increased. In 1940 there were only 285 full-time anesthesiologists, 30.2% of whom were certified; in 1949 there were 1231, 38.3% of whom were certified.70 Ira Gunn attributed the increase to wartime medical experiences “alerting physicians to the potential of anesthesia as a specialty.71 Bankert listed as causes “the increased complexity of anesthetics, but also…a military structure that encouraged medical specialization and a GI Bill that supported medical residencies.”72 The country produced more physicians, and many were drawn into anesthesiology.
An “old problem” reappeared. For upon returning from military service, “medical (physician) anesthetists—many of them trained in the Armed Services—(in an effort) to establish themselves in a civilian economy, brought about a resurgence of activity against the nurse anesthetist.”73 One activity was to render “historically invisible” the contributions of nurses. For example, the centennial celebration of ether at the Massachusetts General Hospital made no mention of nurse anesthetists. (It would, in fact, be the impetus for Virginia Thatcher’s seminal history book.) Bankert listed other similar efforts: “a myth is launched of the early superiority of British anesthetists—a land, so the story goes, which was never so foolish as to allow nurses to administer anesthetics; the national association of physician-anesthetists backdates its founding (from 1936) to 1905; a new word (anesthesiologist) is coined in the 1930s to distinguish the work of physician-anesthetists from nurse-anesthetists; ‘historical’ studies are published with titles such as The Genesis of Contemporary Anesthesiology, as though nothing of significance occurred in the field until the 1920s, when physician-anesthesia began to be effectively organized…”74
Then anesthesiologists launched a public relations effort to denigrate nurse anesthetists. Bankert reported that in 1947, several “major articles” appeared in Look Magazine, Hospital Management, Reader’s Scope, and This Week. One excerpt railed, “Bad anesthesia causes more operating-room deaths than surgery. Now many hospitals have physician-anesthetists to protect you.” And fear was a part of this campaign: “Until the operating rooms of our hospitals are brought into line with the clear requirements of modern anesthesiology, hundreds of Americans will continue to die needlessly on operating tables, sacrificed to ignorance and incompetence.”75 It is not known what if any evidence was offered to support this opinion.
These efforts did not accomplish their goal. Surgeons, the public. and “often the anesthesiologist himself” were not dissuaded from trusting nurse anesthetists. However, they did “discourage many capable nurses from entering the field,” prompting the AANA to promote the profession and recruit nurses who had been frightened away.76 And soon thereafter, the first quality of care study in anesthesia took place. The results according to Gunn “shocked and dismayed many anesthesiologists.”
In 1954 Beecher and Todd published a prospective analysis of anesthesia outcomes collected between 1948 and 1952. Ten university hospitals contributed data for approximately 600,000 anesthetics. The nurse anesthetists’ death rate was one half that of anesthesiologists. Furthermore, there was no difference in physical status between groups of providers. However, that did not stop the authors from surmising (without evidence) that anesthesiologists were anesthetizing more complex surgical cases.77 Not surprisingly, more quality comparisons would be conducted in the coming decades.
In fact, as Gunn pointed out, nurse anesthetists at that time were second to no one. In 1948, for example, Olive Berger at Johns Hopkins reported 480 anesthetics for repair of cyanotic congenital heart disease, including tetralogy of Fallot.78 Betty Lank at Boston Children’s Hospital, pioneered the use of cyclopropane in pediatric anesthesia.79After the United States committed troops to South Korea, the National Women’s Press Club named the Army nurse as its Woman of the Year (1953). An Army nurse anesthetist, Lieutenant Mildred Rush from Massachusetts, was designated to accept the award on behalf of all Army nurses.
And it was the Korean War that ultimately led to the accreditation of all nurse anesthesia education programs. During the war itself, the AANA had begun accrediting programs, but it had little clout, and within each state the Veteran’s Administration had its own standards concerning ‘so-called’ accredited schools. To enforce proper standards, the AANA successfully appealed to the Department of Health, Education, and Welfare for recognition as the sole accrediting agency.80 Within a few years, civilian schools either brought themselves into compliance with AANA standards, or quietly closed.
Setting Education Standards and Developing an Approval Process
The foundation for the formal education of nurse anesthetists was embedded in the 1933 bylaws of the NANA (later renamed the American Association of Nurse Anesthetists [AANA]). The newly formed association was directed “to develop educational standards and technique(s) in the administration of anesthetic drugs,” as specified in Article II, Objectives.81 This objective revealed the vision of early nurse anesthesia leaders for a formal educational process that has grown and matured throughout the twentieth and early twenty-first centuries.
By 1934 the NANA’s Educational Committee had studied curricular outlines submitted to them by several schools of anesthesia as the basis for creating a standard curriculum that should be offered to all students. In addition to the detailed standard curricular outline, other guidelines for operating a school of anesthesia were developed, including the type of conducting institution, instructors, recordkeeping, and other activities.82 During the first decade of its existence, the Educational Committee worked on developing a list of schools of anesthesia and establishing an inspection process to evaluate whether the schools were offering the recommended standard curriculum. By 1939 a national survey of 106 hospitals and institutions had been completed that identified 39 courses of instruction located in 18 states of the United States. There was also a plan to have a representative of the NANA visit all schools for the purpose of collecting information, coordinating training methods, and promoting quality education. Helen Lamb’s work on developing the initial method for approving schools led to a formal accreditation process.82
Lamb, a former student of Agatha Hodgins, frequently addressed the value of a university education for nurse anesthetists. She was founder, then director, of the Barnes School of Anesthesia in St. Louis, Missouri, from 1929 to 1954.53 In 1989 the AANA established an annual award in Lamb’s name to honor outstanding educators.
With the advent of World War II, a shortage of anesthesia personnel became evident, and many hospitals began training anesthetists to meet their own needs. During the critical period, the professional organization encouraged the use of established schools of anesthesia that followed the association’s standard curriculum to train anesthetists, rather than the development of new schools that might use substandard methods of training.82
The publication of the 1945 Essentials of an Acceptable School of Anesthesiology for Graduate Registered Nurses containing information on the proper training of nurses was partially in response to the establishment of new schools with questionable quality during the manpower shortage in World War II. A standard curriculum was finally submitted to members of the board of trustees by the Educational Committee on July 11, 1945, for approval as part of the Essentials.82
The formal accreditation process for schools of nurse anesthesia was approved unanimously during the 17th Annual Meeting of the AANA in September 1950. Membership dues were also increased at that meeting to $20, with $5 of the assessment allocated for the accreditation program. The formal motion to approve the accreditation program included the rationale that the competency of past, present, and future graduate nurse anesthetists could be emphasized by having the schools of anesthesia inspected by qualified consultants, approved, and publicly endorsed. According to Helen Lamb, serving as chair of AANA’s Advisory to the Approval Committee, “Such accreditation would vouch for the fact that graduate nurse anesthetists, who now occupy or who in the future enter our field from our standard courses of training, are irreproachably equipped, educationally and clinically, to meet the professional requirements and responsibilities that are inherent in the practice of our specialty.”82
The New Age of Nurse Anesthesia: The 1960s
When the 1960s began, the AANA had evolved into a more fully fledged professional organization. It was under the influential leadership of its first full-time executive director, Florence McQuillen, who was hired in 1948. John Lundy, the chairman of anesthesiology at the Mayo Clinic, worked with McQuillen and referred to her as “the best-read person on the literature of anesthesia.” McQuillen exerted such a powerful influence at the AANA83
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