Masters of sleep

“I love it, and now my mom and I talk shop all the time,” Marshall said. “Anyone who thinks this work is boring should shadow a nurse anesthetist.

“In the middle of an operation, it may look like we’re not doing anything, but we’re thinking and working all the time. Every time the patient’s blood pressure cycles, there’s a new decision to be made. I’ve got a whole tray full of drugs and must decide what to do as situations change. Every patient is unique.”

When she first became a CRNA Marshall craved action, so she worked at trauma hospitals in Charlotte and Atlanta.

“Working at Grady [Memorial Hospital], I felt like I had my finger on the pulse of the city,” she said. “I knew that what I saw on the news, I stood a good chance of seeing in the operating room.

“I worked with a team of anesthesiologists and CRNAs to deliver anesthesia for heart, burn, brain, general surgery, orthopedic and trauma patients.”

In urban hospitals, nurse anesthetists often work under the supervision of medically trained anesthesiologists. When anesthesia is administered by a CRNA, it’s recognized as the practice of nursing; when given by an anesthesiologist, it’s considered the practice of medicine.

All professionals administer anesthesia in the same manner, and numerous studies have shown no difference in the quality of care, according to the American Association of Nurse Anesthetists (AANA).

“I gained a lot of experience and confidence working in hospitals, so when the opportunity came along to be the sole anesthesia provider for a plastic surgeon, I took it,” said Marshall, who practices at North Atlanta Plastic and Reconstructive Surgery in Roswell. “I wanted to spread my wings and become independent.

“Now, when I talk with patients the night before surgery I can say I’ll see them tomorrow, knowing that I’ll be the one taking care of them.”

Nurse anesthetists have administered anesthesia to patients for 150 years, and the CRNA (certified registered nurse anesthetist) credential was established in 1956, according to the AANA. With a greater scope of practice than anesthesiologist assistants, CRNAs work in hospitals, surgery centers and doctors’ offices under the direction of physicians.

In most rural hospitals in the United States, nurse anesthetists are the primary providers of anesthesia. A May/June 2010 study in the Journal of Nursing Economics found that a CRNA acting as the sole anesthesia provider is the most cost-effective model of anesthesia delivery.

“Health care is under enormous pressure to function as efficiently as possible,” said Barry Cranfill, a partner with Sentry Anesthesia Management and president of the Georgia Association of Nurse Anesthetists (GANA). “Most people don’t realize that in 70 [percent] to 80 percent of cases, revenue doesn’t cover the cost of anesthesia. Most facilities have to supplement that cost.

“As anesthesia professionals, it’s our responsibility to maintain the highest quality of patient care and safety, while operating the most efficient model of care.”

Cranfill, CRNA, MHS, MBA, FAAPM, and his four partners provide anesthesia services to hospitals and surgery centers in Newnan, Columbus, Macon, Americus and smaller towns in between.

“To take a living patient to the point of unconsciousness, where he is dependent on you for every breath he takes, and then bring him back again to hug his family with no mishaps is a challenging job,” Cranfill said.

A former military pilot, emergency medical technician and critical-care nurse, Cranfill likes challenges.

He compares anesthesia delivery to flying. Like a pilot getting a plane off the ground and landing it, a CRNA plays a critical role at the beginning and end of surgery. Cranfill uses knowledge and skill to sedate patients and bring them back to recovery, but he doesn’t go into autopilot mode during surgery.

“You have to be prepared to handle any excitement that comes up; that takes eternal vigilance,” Cranfill said. “You’re constantly playing the ‘What if?’ game and going over scenarios in your head that you hope won’t happen.

“That’s a lot of responsibility and it’s stressful. Maintaining the quality of care and patient safety is job No. 1. The way we manage that stress is with proper preparation.”

CRNAs prepare through master’s-level classes and extensive clinical training. Protocols, procedures and quick intervention methods must become second nature.

More than 90 percent of CRNAs are members of their state and national associations and rely on them to keep abreast of practice and regulation changes, research and continuing education, Cranfill said. The GANA has about 1,100 members.

“I’m constantly going to meetings and learning [about] new drugs and methods to stay current,” said Leslie Jeter, who works at Ambulatory Anesthesia of Atlanta and has twice served as GANA president.

She discovered the profession during a career week in high school, which she spent in an operating room.

“I soon honed in on the CRNA, who seemed to be one of the key people when it came to making patient decisions,” said Jeter, CRNA, MS. “I went to nursing school with CRNA on my mind, and I’ve enjoyed the job for 20 years.”

Jeter believes her nursing skills and experience help her advocate for patients when they have no control over what’s happening.

“All of the wonderful monitoring equipment doesn’t help if you’re not paying attention to your patient,” she said. “It takes a minimum of two years in ICU nursing to gain those skills and confidence. You’ll be working with a high degree of autonomy, and you need those decision skills down beforehand.”

Jeter works at 10 or more outpatient surgery centers, including orthopedic, general surgery, gastric/intestinal and infertility centers. Working in that many settings makes it harder to know the facilities and surgeons’ preferences, but it’s also made her more flexible.

CRNAs have the option of working in whatever environment they choose, Jeter said.

“One of the biggest challenges in outpatient settings is that we’re doing surgeries that used to be done in hospitals,” she said. “Our patients are sicker, with more complications. Sometimes a surgery outcome isn’t what you anticipated or wanted, but a patient dying from anesthesia is rare.”

Anesthesia is nearly 50 times safer than it was in the early 1980s, according to a 1999 Institute of Medicine report.

“No two days are ever alike with my job, and I’m never bored,” Jeter said. “It’s immensely satisfying to take care of patients at this time in their lives, and a truly unique experience.”