Nurse Anesthesia

1398 Pages·2017·85.86 MB·English

by  John J. Nagelhout

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p p p TH EDITION
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N U R S E
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A N E S T H E S I A
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JOHN J. NAGELHOUT, PhD, CRNA, FAAN
Director, School of Anesthesia
Kaiser Permanente/California State University Fullerton
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e Southern California Permaneente Medical Group e
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o Pasadena, Californiao o
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m SAmSS ELISHA, EdD, CRNA m
s : / / t . s : / / tA.ssistant Director, School of Anesthesia s : / / t .
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h t t h t t Kaiser Permanente/California State Univershity tFtullerton
Southern California Permanente Medical Group
Pasadena, California
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o 3251 Riverport Lane o o
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e St. Louis, Missouri 63043 e e
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p NURSE ANESTHESIA, SIXTH EDITIOpN ISBN: 978-0-323-44392-0 p
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Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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o This book and the individual contributions contained in it are protected under copyrighto by the Publisher (other o
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Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they shsould be mindful of their own safety and the safety of others, including parties for whom theys s
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have a perofessional responsibility. e e
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o With respect to any drug or pharmaceutical products identified, readers are advised to choeck the most o
o current information provided (i) on procedures featured or (ii) by the manufacturer of oeach product to be o
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e administered, to verify the recommended dose or formula, the method and deuration of administration, and e
e / contraindications. It is the responsibility of practitioners, relying on teheir /own experience and knowledge of e /
m their patients, to make diagnoses, to determine dosages and thme best treatment for each individual patient, m
s : / / t . andT ot ot htaek feu lallels ta pepxtreonptr ioaft et hsaef elatyw ,p nreecitahuetrio tnhses. Pu:bli/sh/er tno.r the authors, contributors, or editors, assume any s : / / t .
p liability for any injury and/or damage top persons or property as a matter of products liability, negligence or p
h t t otherwise, or from any use or hopetrattion of any methods, products, instructions, or ideas contained in the h t t
material herein.
Previous editions copyrighted 2014, 2010, 2005, 2001, and 1997.
Library of Congrsess Cataloging-in-Publication Data s s
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Nameks: Nagelhout, John J., editor. | Elisha, Sass, editor. k k
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o Title: Nurse anesthesia / [edited by] John J. Nagelhout, Sass Elisha. o o
b Other titles: Nurse anesthesia (Nagelhout) b b
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e / Description: Sixth edition. | St. Louis, Missouri : Elsevier, [2018] | Incluedes/ bibliographical references and index. e /
m Identifiers: LCCN 2016032301 | ISBN 9780323443920 (hardcmover : alk. paper) m
s : / / t . SCulabsjseicfitcs:a t|i oMn:E LSHCC: A RnDes8th2e |s iNa |L AMn eWsthOe t2ic0s0 | |N DsuDrseC: A 6/n1e7/s.t9ht/e6t.i–sdtsc 2| 3N LuCrse rse’ cIonrsdtr uavcatiiolanble at https://lccn.loc. s : / / t .
p gov/2016032301 p p
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Executive Content Strategists: Tamara A. Myers and Kellie White
Content Development Manager: Lisa Newton
Senior Content Desvelopment Specialist: Laura Selkirk s s
Publishinge Servrices Manager: Jeff Patterson e r e r
Projeckt Manager: Lisa A. P. Bushey k k
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o Design Direction: Brian Salisbury o o
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m Preface m m
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Nurse anesthesia education and clinical practice continues to evolve at figures, and boxes. Effective anesthesia must be viewed as part of a
a rapid pace. Our professional degree has moved to the doctoral level, therapeutic continuum of care. For this reason, we have been especially
and the requisite knowledge needed to provide safe patient care is sensitive to include the latest medical and surgical information available
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increeasinr g exponentially. Due to the complexity of modern surgical from the sepeciralties that impact our practice. Integrating new technol- e r
kprocedures, ensuring the highest-quality outcomes requires the need ogy aknd knowledge in the basic sciences into clinical practice has k
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o for lifelong learning. Anesthesia practice has expanded beyond the o allowed nurse anesthetists to continue to evolve as leaders in providing o
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e traditional surgical settings to include interventional procedurese, pain safe and comprehensive care. We have included additional new chapterse
e / management, and non-operating room anesthetics. Thee ob/jective of on a wide variety of topics, including patient-centered care; ceultu/ral
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this new edition is to integrate the vast amount of current knowledge competence and nurse anesthesia practice; additional drugs of interest,
p s : / / t . to hTeelcph gnuoildoeg icclainl iicnanl opvraatcitoinces. thpat asllo:w /th/ist te.xtbook to be used in iflnucildu dthinerga panyt; ibblioootidc sa,n pds ybclhooiadtr cico mdrpuognps,e natns tdh ae:nrat/piey/m; aetntie.csst;h geosiaal -mdiarnecatgeed-
h t t traditional, as well as vahriouts etlectronic formats, are now commonplace. ment for patients with cardiahc dtevtices; anesthesia for robotic surgery;
We approach the sixth edition of Nurse Anesthesia with a clear intent anesthesia for transplant surgery and organ procurement; and chronic
to bridge these platforms while remaining true to our educational pain: physiology and management. The chapter dedicated to research
objectives. Since the conception of the first edition of this text more in nurse anesthesia has been reconceptualized to focus on the integra-
than two decades ago, we continue to be guided by our original vision tion of evidence-based research into practice.
to fill the need for scientifically-based, clinically-oriented work on Producing an educational resource of this size and complexity
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whiech arnesthesia practitioners and learners can rely to deliver excellent would note be rpossible without the tireless efforts of our authors and a e r
kpatient care. broad karray of experts. We would like to express our sincere gratitude k
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o Our intent is to harness the vast knowledge that nurse anesthetists o to Retta Smith, who assisted in the production and editing of this o
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e bring to clinical practice and provide a comprehensive, evidencee-based textbook, and Clinton Lee for designing graphics. We proudly carrye
e / resource for continuous learning. We are tremendously gerat/ified that over from the previous editions hundreds of anatomic figures thaet w/ere
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this textbook has become the seminal work for our specialty. This book specially hand drawn for this text by the renowned medical illustrator,
p s : / / t . ifso rin mclueddeicda la mlibornagr itehs e tLhirboruagryh ooupf tC tohsneg rU:esn/s’ist /eedsts eSn.ttaitael sn uanrsdin ign t enxatbtiooonkasl Wat iElllisaemvi eEr. wLoheoc hweol.r Wk eti rweoleuslsdly l itkoe ptor poedxupcrsees st: hoiu/s r t/gerxtattb.iotuodke. tTho tihs eb sotoaffk
h t t digital resource databahses tsutch as Elsevier’s ClinicalKey for Nursing. would not exist without theirh knotwtledge, expertise, and enthusiasm. A
We reach an international audience of nurses and nurse anesthetists special thank you to Tamara Meyers, Executive Content Strategist;
and are always pleased when we hear of the positive impact we are Laura Selkirk, Senior Content Development Specialist; and Lisa
having on anesthesia practice worldwide. Bushey, Project Manager.
We are especially grateful to all of our new and returning authors We would also like to acknowledge the contributions of Karen
who bring a wealth of expertise and experience to their respective areas. Plaus, PhD, CRNA, FAAN, as the coeditor of the first five editions of
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Thee marjority of clinical anesthesia continues to be provided by nurse this text. Der. Pr laus has devoted her career to educating nurse anesthe- e r
kanesthetists, and this textbook is a testament to the leadership we bring tists aknd advancing our specialty. Her decades-long achievements on k
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o to academic and clinical nursing. Each chapter has been extensively o the national and international level continue to be instrumental in o
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e reviewed and revised to contain the most salient information avaeilable. making nurse anesthesia a vital specialty for delivering high-qualitye
e / The newest concepts, techniques, and areas of controversy ein a/nesthesia healthcare. e /
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are discussed in detail. This is the first edition to contain full color, John J. Nagelhout
s : / / t . which greatly enhances the readabilisty :of/ th/e thu.ndreds of new tables, s : / / t . Sass Elisha
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m Acknowledgments m m
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We would like to thank the following authors for their contributions to the first through fifth editions of this textbook.
John G. Aker Wayne E. Ellis Jeffrey F. Kopecky Brian P. Radesic
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Roy Alisoglur Ronda L. Erway Michael J. Kremer r Janet Rojo r
e e e
Stevek L. Alves Ladan Eshkevari Gail LaPointek Susanna Sands k
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o Anne E. Aprile Michael D. Fallacaro Jeannoe B. Learman Elaine Sartain-Spivak o
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e Charles R. Barton Nadine A. Fallacaro e Kim Litwack James Scarsella e
e / Victoria Base-Smith Margaret Faut-Callaham e / Julie Ann Lowery Allan Schwartz e /
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Collen M. Beauchamp Michael A. Fiedler Russell R. Lynn Lisa A. Sebastian
s : / / t . DAnodnraelwd BRe.l lBiegner CDaarvmisde nN: F. /oFro/dr-ttFle.ifel JDaneneti sMe Maraornteiny-Sheridan EJelffizraebye Pth. SMerowsnitni :Se/ib/ertt .
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h t t Danny R. Bowman h t t Jan L. Frandsen John Maye Bherrty tShaw
Michael Boytim Donna J. Funke Maura S. McAuliffe Jeffrey A. Sinkovich
Baher Boctor Vance G. Gainer, Jr. John P. McDonough Brent Sommer
Charlene Brouillette Paul Gregg Gambrell Linda Saber McIntosh Julie A. Stone
Rick Brown Silas N. Glisson Ann Misterovich Kathy Swender
Joseph Burkard Ira P. Gunn Michael P. Mitton Lisa J. Thiemann
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Joanne M. Crafarelli Richard E. Haas Ralph O. Morgan, Jr.r Kimberly J. Thompson r
e e e
Terrik M. Cahoon Stanley M. Hall Diane Monizk Michael Troop k
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o Troy Calabrese C. Wayne Hamm Betho Ann Movinsky Patricia Tuttle o
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e Cynthia Cappello Walter R. Hand, Jr. e Julie A. Rigoni Neville Charles A. Vacchiano e
e / Marge Chick Celestine Harrigan e / Anne Kiyomi Nishinaga Ronald L. Van Nest e /
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Anthony Chipas Shelly Harthrong-Lethiot Howard J. Normile Edward Waters
s : / / t . GThaerrye sDa .L C. lCaruklpepper BDeornns aHdei:ltlte/ H/etnr.ichs MR. icLheaee Ol Pl.s oOn’Donnell JWohannd Wa eOis.b Wrosidlso:n/ / t .
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h t t Nicholas Curdt h t t Frederick C. Hill, Fr. Lisa Osborne Ahdrete tN. Williams
Matthew D’Angelo Holly E. Holman Sandra Maree Ouellette John R. Williams
Angela Darsey Betty J. Horton Sherry Owens Lori Ann Winner
Diane Bleak Dayton Maria Iacopelli Tim Palmer Hilary V. Wong
George G. DeVane Donna M. Jasinki Carla M. Percy E. Laura Wright
Joanne Donnelly Joseph Anthony Joyce DeAnna Powell
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Lyle Dormanr Jeanne M. Kachnij John C. Preston r r
e e e
Melykdia J. Edge Kenneth M. Kirsner Richard S. Pukrdham k
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UNIT I Professional Issues
1
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m Nurse Anesthesia:m A History of Challenge m
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h t t BRUCE E. KOCH h t t h t t
It is fitting to open a text on nurse anesthesia with a history chapter.
The Problem of the Occasional Anesthetists
Nurses were the first professional anesthetists in the United States; the
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vaste marjority of anesthetics provided in this country are administered In the 19teh cerntury, physicians developed surgery, but not anesthesia, e r
kby nurses. And nurses have contributed to progress in clinical anesthe- as a mkedical specialty, although there were calls for them to do so.6 k
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o sia, patient safety, and the science, education, and public policies sup- o James Gather, the pioneer physician anesthetist, gave one explanation o
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e porting anesthesia. By teaching what nurse anesthetists in the paset have for this medical disinterest: “So intense had been the interest in surgerye
e / accomplished, oftentimes against great odds and with fewe o/r none of that anesthetics had been used only as a means to an end, and theis fu/lly
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the resources available to us today, we fix in the pupil’s mind the fact explained the attitude of the profession on this subject in America at
p s : / / t . thatP eaonpesleth heasviae iksn ao wprna cstiniccee otfh enp ulartsei ns1g8.t:h /ce/nttur.y that inhaling nitrous tmheen ptaretoser,n St .t iSmime.o” nB, udto umbotnede yw wheatsh aelrsp oa apnhs yissis:cuiea/.n / O“tntake. inphg ytshicei awno rcko mup-
h t t oxide or diethyl ethehr ptrotduces euphoria. The English scientists as a specialty could make a livhingt att it alone; and especially is this true
Joseph Priestley and Humphrey Davy experimented on themselves and in the smaller cities.”7 The historian Marianne Bankert agreed: “Apart
even partied with these substances. Davy famously speculated that from the few physicians who had a genuine intellectual interest in
nitrous oxide “may probably be used with advantage during surgical anesthesia, it would also take years for the economics of anesthesia to
operations.”1 make it an attractive area for their colleagues—if at first, only as a
At the same time, American medical students used ether and nitrous supplemental source of income.”8 The Philadelphia surgeon J. M. Baldy
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oxidee rrecreationally. But almost 40 years would pass before they thought aneesthr esia unworthy of a physician’s intellect: “Every physician e r
kattempted to use these agents as adjuncts to surgery. Crawford Long, obtainks his medical education with the idea of practicing medicine, and k
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o a Georgia physician, used diethyl ether for the removal of a small cyst o it is only dire necessity which will compel him to give up such a future o
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e in 1842, but he did not report his findings. At least two othere men, for the narrow one of anesthesia.” Anesthesia remained a medical step-e
e / the Massachusetts physician Charles Jackson and the eCo/nnecticut sister to surgery until well into the 20th century.9 e /
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dentist Horace Wells, experimented with ether or nitrous oxide. Four The work of anesthesia was relegated to others: “Students, nurses,
p s : / / t . ydeeanrtsi satf tWer iLllioanmg ’sT u.Gse. oMf eotrhtoern, opcno nOcslcutso:ibvee/lry / 1d6te, m.18o4n6st,r athteed B tohset ouns ea reoaf ndieawnlsy wgrearde ucaatleledd p uhpysoinci atnos ,b sep eetchiaerliisztespr si.n” 1o0s t“hA:enr /efiset/hldetss,i .aa ncdo uelvde nb ec uasntoy--
h t t ether for surgical anesthhesita itn an operating room (now memorialized body’s business,” wrote Virginhia tThtatcher.11
as the “Ether Dome”) at Massachusetts General Hospital. So important Lack of attention led to a degradation of knowledge and technique:
was the event that the surgeon John Collins Warren, who had witnessed “Within a few months (of the discovery) at the Massachusetts General
many prior failed attempts, reportedly exclaimed, “Gentlemen, this is Hospital, Morton’s inhaling apparatus (which had worked well) was
no humbug.” Another eminent surgeon who had been in attendance abandoned in favor of a small bell-shaped sponge, which was saturated
stated, “I have seen something today that will go around the world.”2 with ether and applied directly over the nose and the mouth of the
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Frome threir vantage point, optimism seemed justified; however, another patient.”11e Nort surprisingly, ether pneumonia resulted. Some surgeons e r
khalf century would pass before the promise of painless surgery would therefokre turned to chloroform, which had been discovered to have k
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o be substantially fulfilled. o anesthetic properties by James Simpson in England in 1847. “But, very o
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e From the outset, Morton’s discovery caused problems. Peoplee real- soon, a death occurred from chloroform, then another and another ine
e / ized its monetary and historic value, and wanted a piece oef th/e action. quick succession. This led to its more careful and restricted use bey so/me
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Morton attempted to disguise ether so he could profit from it. He surgeons, to its total abandonment by others, but in 1855, the general
p s : / / t . nanamd eWd etlhlse saullb sctlaanimcee dL ecthreedoint afnoprd Mapsoprli:teodn/ ’fs/o rd tias c.poavteernyt.. LThone gf,o Juarc kmsoenn, mcitaesds oofn es uprhgeyosincsi aann wd hpoh,y isnic i1a8n5s 9s,t iwll rpcooten:t si“nIun:e ds/o mi/tse t ucs.aes…es ”D12r .Th Ma.t chhaedr
h t t battled for years. The phhysitcitan and writer Oliver Wendell Holmes, Sr. seen chloroform administeredh byt ytoung gentlemen rather in a careless
(father of the Supreme Court Justice) wrote to Morton: “Everybody manner….In fact, he believed that most of the fatal cases can be traced
wants to have a hand in a great discovery…. All I want to do is give to a careless administration of the remedy.”13
you a hint or two as to names.” Holmes suggested “anesthesia from the Careless anesthesia persisted for decades. A cogent example was
Greek for insensible.” But it seems Holmes too wanted something for recorded in 1894 by Harvey Cushing, the founder of neurosurgery.
himself. The term anesthesia, according to historian Julie Fenster, “had Almost fifty years after the discovery of anesthesia, Cushing was a
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beene in ruse before to denote parts of the body benumbed but not para- student ate Harrvard Medical School: e r
klyzed.” She added that, “Holmes only borrowed the word for the new k k
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o state of being, though he has received credit for coining it.”3 As Robert o My first giving of an anaesthetic was when, a third-year student, I o
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e Dripps dryly noted, “anesthesia was placed under a cloud.”4 e was called down from the seats and sent in a little side room with a e
e / Nineteenth century anesthesia was problematic in eoth/er more patient and an orderly and told to put the patient to sleep. I kneew/
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important ways. The related infections and careless anesthetists vexed nothing about the patient whatsoever, merely that a nurse came in
p s : / / t . sthuergsieao fnosr, dpelcaagdueesd. Thpateiye nletds, tahned hp idsetolasryiaend: Ip/raro/ Ggtruens.sn itno ttherem fi ethldis oefr aa “ntehse- aconudl dg auvned tehre thpae toierndte raly ’hs ydpioredcetrimonisc, iapnnjedc tisino nv:.i eI/w p /roofct tehe.de erde paesa bteedst I
h t t period of the failed prohmiste.”t5 urgent calls for the patient hfromt tthe amphitheatre it seemed to be an
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2 UNIT I • Professional Issues
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intermeinarble time for the old man, who kept gagging, to go to sleep. who were activee inr the building and staffing of St. John’s Hospital in e r
Wke finally wheeled him in. I can vividly recall just how he looked Springfieldk, Illinois, were particularly successful in preparing hospital k
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o and the feel of his bedraggled whiskers. The operation was started and Sisoters as nurse anesthetists and sending them out to other Midwestern o
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e at this juncture there was a sudden great gush of fluid from the e hospitals. Having been prepared by another community of the Sisters e
e / patient’s mouth, most of which was inhaled, and he died. I stoeod / of St. Francis (Syracuse, New York), Sister Mary Erhard went to Hawaeii /
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aside, burning with chagrin and remorse. No one paid the slightest in 1886, where she administered anesthesia and performed other
p s : / / t . aptetrefnectti oanm taoz meme,e natl,t hIo uwgahs Ito sludp ipt owsepads In hostahdi: nkgi/ lale/td a ttlhl,.e tphaatti eIn ht.a dT o my nursing duties on the island of Maui for appprosxim:at/ely/ 4t2. years.
h t t nothing to do with the mahn’s tdetath, that he had a strangulated The St. Mary’s Experience h t t
hernia and had been vomiting all night anyway, and that sort of In the summer of 1883, a very destructive tornado swept through
thing happened frequently and I had better forget about and go on Rochester, Minnesota. In its wake, wrote Helen Clapsattle, the tornado
with the medical school. I went on with the medical school, but I “left an idea in the mind of the mother superior of the Sisters of St.
have never forgotten about it. Francis.” During rescue efforts, Mother Alfred paid a visit to Dr. W.W.
Mayo and asked: “Did he not think it would be well to build a hospital
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Not surperisinrgly, surgeons began to appreciate the need for professional in Rochester?”e Dr.r Mayo thought the town too small to support a e r
anestkhetists. The need, as Thatcher defined it, was for anesthetists who hospital, bukt “Mother Alfred had made up her mind. Quietly she over- k
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o would “(1) be satisfied with the subordinate role that the work required, ruoled the Old Doctor’s objections and said that if he would promise to o
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e (2) make anesthesia their one absorbing interest, (3) not look on thee take charge of a hospital, the sisters would finance it.” St. Mary’s Hos- e
e / situation of anesthetist as one that put them in a position to waetch/ and pital was built and opened, and although hospitals ranked low in thee /
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learn from the surgeon’s technic [sic], (4) accept the comparatively low public’s mind, the venture was a huge success. By 1904, it had expanded
p s : / / t . phaigyh, alnevde l( 5o)f hskaivlel itnh ep rnoavtiudrianl ga pthtiet uspdmeo aosnthd : ainn/tees/ltlhitgees.niac ea ntdo rdeelvaexlaotpio na taws itchee iMn aoyrod eCr ltion ick.e eThp eu Mp wayioths (dWemillainamd, Sanrp.d, W hsailsl ie:anm/d uJ/rr.e,t da n.udn tCilh taordleasy)
h t t that the surgeon demandehd.” tStome surgeons, particularly in the won international acclaim for theihr sutrgtery.
Midwest, “accepted in this capacity a class of persons for whom they But how did the Mayos handle the administration of anesthesia?
had learned to have deserved respect and from whom they had obtained Like many surgeons, they were aware of its dangers, but unlike their
commendable assistance and service—the Catholic hospital Sister.”11 colleagues on the East Coast, they were quick to embrace the open
And so as a result of medical disinterest, poor delivery of anesthesia drop method of ether when it was brought to the United States from
in general, and an overwhelming need, nurses were asked to give Germany. They also differed from East Coast physicians in one other
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anesthesiea. r respect: “In emeplorying a permanent full-time anesthetist, and that a e r
k nurse, the Mk ayos were unusual if not unique. In other hospitals anes- k
Hoistorical Antecedents of the Nurse as Anesthetist o o
o theotizing was one of the duties of the interns.” o
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e The Civil War provided the first opportunity for nurses to assume thee Why would they give the job to nurses? The Mayos had given the e
e / duties of anesthetist. Evidence is found in three different accounets. M/ rs. job to a nurse “in the first place through necessity; they had no internes. /
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Harris from Baltimore, Maryland, took chloroform and stimulants to And when the interns came, the brothers decided that a nurse was
p s : / / t . tshceen Be aotft lteh oe fc oGnefltticyts,b murign.i sHtearrinrigs a“ps emnpuetcrhas taesd :i na /sh ne/re atpro .awse pr otoss itbhlee sttore tahme bonet tietr, swuhiteerde atso tthhee itnastker bne cwaauss en sahtue rwalalys mmpoorree lsiiknet:elyr e/tsot/e kdte ein.p hwehr amt itnhde
h t t of wounded that filled the hcarts…t”14 It is not known whether Mrs. surgeon was doing.”20 h t t
Harris was a nurse. A second report connects a nurse with administer- Nurses won the Mayos’ admiration by improving anesthesia care.
ing chloroform: “Private Budlinger of the 76th Ohio Unit, after breath- Alice Magaw could discuss “a hundred and one details as to signs of
ing it for a few minutes without any apparent effect, more chloroform sufficient anesthesia and ways of recognizing and preventing impending
was added and reapplied by a nurse in attendance.”15 disaster.” Magaw, along with her pupil Florence Henderson, refined
But the most convincing example was written by a nurse. Catherine and advocated the dripping of ether. Ether anesthesia required vigilance
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S. Lawreence,r a native of Skaneateles, New York, wrote a 175-page and careful atteentiorn to detail and to the psychological care of patients e r
autobkiography in which she recorded administering anesthesia as a to minimizke the agitation that often led to disasters like the one previ- k
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o Union Army nurse. Lawrence described her duties at a hospital outside ouosly described by Harvey Cushing. o
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e Washington, D.C., during and after the Second Battle of Bull Ruen Florence Henderson described how this was done: “A modified e
e / (1863). She administered medications, resuscitated with resteora/tives Esmarch inhaler, which is covered with two layers of stockinet, eis /
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like ginger, tied sutures around arteries, and administered chloroform. used…. With the mask held about an inch from the face the ether is
p s : / / t . “trIa rinejeodi cfeo rt hpaot stihtieo ntism soe himasp aorrrtiavnedt. tAhp astk iollsufur lA: nm/uer/sreic tiasn .a ns uimrspeso ratraen bt eaisn ga dnraotuprpaeldly uthproonu gith, tshloew nlyo saet. fiThrsetn, atnhde mthaes kpp aitsi esgnrta :dius/ aals/lyk etldo. wtoer ebdr,e aatnhde
h t t skillful physician.”16-18 h t t the rapidity of the dropping increahsedt, ctare being taken not to give the
The early use of nurses as anesthetists was mostly an American ether fast enough to cause a sensation of smothering or suffocation. As
phenomenon. However, a 1911 article revealed that “(In) the Euro- soon as the jaw relaxes the head is turned to one side, because the
pean hospitals female as well as male nurses…were taught how to patient usually breathes more easily with the head in this position.”
give anaesthetics [sic] in the… (Franco-Prussian War of 1870–71). This was quite a contrast to the “crude” methods of most early anes-
Only the nurses gave anaesthesia in the ambulatory hospitals on the thetizers, and it was successful. Nancy Harris and Joan Hunziker-Dean,
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field.”19 e r who investigateed Frlorence Henderson’s life, concluded that “through a e r
k delicate balkance of interpersonal skills and technical expertise, (Hen- k
Tohe First Civilian Nurses to Practice Anesthesia o o
o deorson) was able to essentially eliminate the excitement phase of ether o
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e Civilian nurses began to practice anesthesia at the behest of surgeones anesthesia and consistently used a fraction of the usual ether dose. She e
e / during the 1870s in the Midwest. Sister Mary Bernard founeded/ the demonstrated to all who observed that the administration of etheer /
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Sisters of St. Joseph of Wichita, Kansas, and in 1877 entered St. Vin- anesthesia could be elevated to an art form.”21
p s : / / t . cshene tt’so oHko sopvietra lt hine Eanriees,t hPeesnian sdyulvtaiensi aop ft ot htsera hi:no s/apsi /taa tln. u.Thrseis. Apr aycetairc el awtears, MaMgawag aawcc oaunndt eHd ednedleivrseoryn oimf porvoevre d1 4t,h0e0p 0s aafnesteys t:hoe/f tia/cns te“stw.hietshioa uct araen.
h t t repeated by surgeons throughhoutt tthe Midwest. The Franciscan Sisters, accident, the need for artificial hrestpitration or the occurrence of
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CHAPTER 1 • Nurse Anesthesia: A History of Challenge 3
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pneeumornia or any serious results.”22-26 Included were anesthetics for under thee charrge of Agatha Hodgins as chief anesthetist. She, in turn, e r
kabdominal, intraperitoneal gynecologic, urologic, orthopedic, ophthal- workekd under the jurisdiction of the superintendent of the hospital and k
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o mic, head and neck, and integument operations. Some were even o the chief surgeon. For the supervision of the students she had 1 or 2 o
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e conducted with the patient in the prone position.23 e assistants until 1922 when the number was increased to 3.”11 The evolu-e
e / Thatcher wrote that it was Alice Magaw who “brought teo th/e profes- tion of nurse anesthesia education into a more formalized, scienteifica/lly
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sion of nurse anesthetist as well as to the Mayo Clinic no little fame at based discipline can thus be seen.
p s : / / t . aC htiamrlee sw Mheany op owoars asnoe sitmhepsrieas swedaps btyhs eM m:aag/jaowr/ wtthoa.rtr yh oe f nmamosetd s uhregre o“Thns.”e proAmlpthteodu gthhe reesctaobrdliss hmdoe nnt ootf 5e4xi sstim, pitlhaer spLroa:kgre/asmi/dest aHt. mosapjoitra lh oSscphitoaolsl
h t t Mother of Anesthesia.”h Surtgetons who visited from Minneapolis, Iowa, in Chicago, Illinois; Worcestehr, Mtatssachusetts; Milwaukee, Wisconsin;
Baltimore, Chicago, and England “sent selected nurses to Rochester to New Orleans, Louisiana; Baltimore, Maryland; Ann Arbor, Michigan;
observe Alice Magaw and other nurse anesthetists at St. Mary’s Hospital St. Louis, Missouri; Detroit, Michigan; Poughkeepsie, New York;
at their work.”11 Tacoma, Washington; and Minneapolis, Minnesota.24
Magaw and Henderson introduced better teaching methods too.
The Proliferation of Nurse Anesthetists
Early anesthesia education has been described by A.J. Wright as “on
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the esport training of any person available.” At Mayo, sometimes the Prior to Weorrld War I, the administration of anesthesia grew more e r
k“nurses stayed for 2 or 3 months and learned to give ether under sophiskticated. Nitrous oxide was reintroduced, and with it came the k
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o supervision.”27 o first anesthesia machines capable of pressurizing, regulating, and deliv- o
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e e ering a gas. Surgeons and hospitals sought nurse anesthetists who weree
e / The Lakeside Experience e / capable of using the machines. The first recognition of the vaelue/ of
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A second “Mecca” of nurse anesthesia developed in Cleveland, Ohio. formalized education also occurred at this time. Four postgraduate
p s : / / t . lIann 1d9 0to0 , wAograkt haat HLoadkgesinidse ( FHigo. s1pp.i1ta),ls .a DC:ra./ nGa/deitoarng. en uCrsrei,l ew cehnot steo hCelre vteo- p(1r9og0r9a)m;25s awte Sret .d Jeovhenlo’sp Hedo: sapti Statl. Vini nScpernpint’sg fiHseolds:p, iI/tlalil/n inot iPs. o(r1t9la1n2d),; Oatr eNgeown
h t t become his anesthetist hin 1t9t08, and as such she became perhaps even York Postgraduate Hospital ihn Ntetw York City (1912); and at Long
more renowned than Alice Magaw. Together with Crile, Hodgins pio- Island College Hospital, Brooklyn, New York (1914).11 Other nurse
neered the use of nitrous oxide/oxygen anesthesia, introduced it in anesthesia programs were developed as a part of the undergraduate
World War I, and opened and led a prominent school for nurse anes- nursing curriculum as a specialty option. Isabel Adams Hampton Robb,
thetists that endured the first major challenge from physician anesthe- a leading pioneer in nursing and the first superintendent of the Johns
tists. In 1931, Hodgins alone founded the American Association of Hopkins School of Nursing, which opened in 1889, had, in 1893,
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Nurese Arnesthetists (AANA). published ea nurrsing textbook titled Nursing: Its Principles and Practices e r
k Hodgins’ primary interest was in education. Like the St. Mary’s for Hokspital and Private Use; this textbook included a chapter titled k
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e ent of many requests for anesthetist training from both physicianes and “superior quality of anesthesia performed by nurse anesthetists,”24 theye
e / nurses. According to Thatcher, “Visiting surgeons eager toe em/ulate the were given the responsibility for surgical anesthesia at Johns Heopk/ins
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Lakeside methods, customarily bought a gas machine (the Ohio Mono- Hospital in Baltimore, where a training program was established under
p s : / / t . vHaolvdeg) ianns dr etchaelnle dse, n“tTh a en unrusme tboe rCp olefv aesplapnl:idc a/tno/ tfis ntind.c oreuats ehdo wso i tr awpoidrklye dth.”a1t1 the Bduirte scuticocne sos fb Mreds. rOesilsivtaen Bcee.r gTher.atchper wsrote: t/ha/t, t“Th. e rapid growth
h t t we felt some stabilizingh oft wtork necessary and the matter of a post- of postgraduate schools of anhesthtestia in which nurses were trained, as
graduate school in anesthesia presented itself.” In 1915, Hodgins well as the increasing enthusiasm for the trained nurse anesthetists
opened a school at Lakeside Hospital. The Lakeside School was not the during World War I, did not escape the attention of physician special-
first formal postgraduate anesthesia educational program; that honor ists in anesthesia, and during the 1920s resentment against the nurse
belongs to St. Vincent’s Hospital in Portland, Oregon. But the Lakeside anesthetist culminated in attempts to legislate her out of existence.”11
School is the only program for which original records still exist. There
s The Great Wars, a Small Battlefield s
weree adrmission requirements, the course included both clinical and e r e r
kdidactic components, tuition was charged, and a diploma was granted. Nursek anesthetists played a very large role during World War I. Their k
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e e involved militarily, and lasted until the armistice in 1918. e
e / e / When America entered the war, the Army Nurse Corps numebe/red
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233 regular nurses; it would grow to 3524 nurses by 1918. The number
p s : / / t . p s : / / t . otifm neu rnseusr swe haon aecsttuhaeltliyst ps rafocrtimceedd apnaerstt hpoesfi ast hise : ugn/eknn/eortwaln .,n buerscianugs e satat ffth.2e7
h t t h t t However, nurse anesthetists hwerte tcredited with introducing nitrous
oxide/oxygen and teaching its administration to the English and the
French.28 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
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e r remembereed brecause they wrote of their work. Nurse anesthetists spent e r
k countlkess hours etherizing wounded soldiers as they arrived in “ceaseless k
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o o streams for days at a time after battles,” wrote Mary J. Roche-Stevenson. o
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e e “Work at a casualty clearing station came in great waves after majore
e / e / battles, with intervals between of very little to do.… Barrages eof g/un
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fire would rock the sector for days, then convoys of wounded would
p s : / / t . FAIAGNUARE, r1e.i1n trAogdautchead H(woditghi nos,t haenr peAdmucesraitco:arn / ann/du rtsfeo u.anndeisnthg etpirsetss)id tehnet uosf et hoef bcoemginin tgo oanrr.i…ve bThy aem sebruiolaunsclye . wNoiguhntd aepndd, edssapye :cthia/ilsl y/c ettahsee. leosns esst reinam s ekveepret
h t t nitrous oxide for battlefiehld sturtgery during World War I in Europe. shock, were taken to a specialh wartd,t given blood transfusions and other
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4 UNIT I • Professional Issues
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treatmenets inr preparation for surgery later. From the receiving tent, the passed a resoluteion rproclaiming that only physicians should administer e r
wounkded were brought to the surgery, put on the operating tables anesthesia. kThe attorney general concurred, and the Kentucky State k
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o stretcher and all, given an anesthetic, operated upon, picked up on their Moedical Association followed with a resolution stating that it was o
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e stretcher, and loaded on hospital trains for evacuation to base hospei- unethical for a physician to use a nonphysician anesthetist or to use a e
e / tals.”29 Terri Harsch,27 who described the works of Roche-Steeven/son hospital that permitted nurses to administer anesthesia. These evenets /
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and others such as Sophie Gran Winton, reported that 272 nurses were prompted the surgeon Louis Frank and his nurse anesthetist Margaret
p s : / / t . killeInd ad upraipnegr tahbeo wuta rM. iss Nell Bryantp, whso w:a/s t/het so.le nurse anesthe- Hthaet fiKeelndt utoc kays kS ttahtee sMtaeted ibcoala rAds soofc hiaetaioltnh. tThop jeoyi nsl otsht:e imn/ ti/hne ta l o.suwiet ra cgoauinrstt,
h t t tist from the Mayo Clinic sthatiotnetd at Base Hospital Number 26,30 we but on appeal, they won. In 1917,h Judtgte Hurt of the Kentucky Court
learn that chloroform and ether were in use, the physiology of shock of Appeals not only confirmed the right of nurses to administer anes-
was poorly understood, oxygen and nitrous oxide were given without thesia, he also enunciated clearly that state licensure was meant to
controlled ventilation, and venipuncture involved a surgical cutdown. protect consumers, not professionals.
Anne Penland was a nurse anesthetist with the Presbyterian Hospital These two cases showed physicians that they could not rely on the
of New York unit at Base Hospital Number 2. She had the honor of courts to end nurse anesthesia. But still, they were not deterred. Physi-
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being thee firsrt US nurse anesthetist to go officially to the British front, cian anesthetistes inr California brought suit against Dagmar Nelson, a e r
wherke she so won the confidence of British medical officers that the nurse anestkhetist. The Chalmers-Francis v. Nelson case was decided in k
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o British decided to train their own nurses in anesthesia, ultimately reliev- favoor of Dagmar Nelson at each level of the California civil court o
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e ing more than 100 physicians for medical and surgical work. Severael system. The California Supreme Court ruled again that the functioning e
e / hospitals were selected for this training of British nurses, includeing/ the of the nurse anesthetist under the supervision of and in the direct prees- /
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American Base Hospital Number 2, with Penland as the instructor.8 ence of the surgeon or the surgeon’s assistants was the common practice
p s : / / t . FranCko mBumnetns twinrog tein: “tThhee B(Fuilrlestti)n W oof rptlhde W Asamr e:drei/cma/no ntCsto.rlaletegde obfe ySounrdge oannsy, iann do ptereraattiinngg rwoiothmins; tthhee rmefoearen,i nthge o nfu trhsee amneepdstihcaeslt ipstr: awc/taisc/ en toatc .td.3ia6,g37nosing
h t t question the value of the nuhrse tantesthetist.”31 George Crile speculated At the time, nurse anesthetists whelctomted and embraced the concept
that “if the Great War had gone on another year, the British army would of physician supervision. Gene Blumenreich, who has written exten-
have adopted the nurse anesthetists right in the middle of the war.”32 sively on the legal history of anesthesia, noted that “A number of states
Looking back after World War II, Lt. Colonel Katherine Balz, Deputy adopted statutes recognizing the practice of nurse anesthetists. Typi-
Chief of the Army Nurse Corps, credited nurse anesthetists for the fact cally, these statutes followed the formulation in Frank v. South and
that 92% of “battle wounded who reached Army hospitals alive were provided that nurse anesthetists were to work under the ‘supervision’
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saved.”33e r or ‘direction’ oef a rphysician.” However, the statutes did not define e r
k supervisionk. “It is clear that the legislation was not attempting to create k
Aonesthesia: Medicine, Nursing, Dentistry, or What? o o
o neow duties and responsibilities but merely to describe what was already o
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e Although few physicians chose to specialize in anesthesia before Worled occurring practice…to explain why nurse anesthetists were not practic- e
e / War II, one who did, Francis Hoeffer McMechan—a Cinecin/nati ing medicine.”38 Decades later, however, supervision would be miscone- /
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native—began a crusade around 1911 to claim the field solely for strued by anesthesiologists and turned into a battleground.
p s : / / t . pfihelyds iocfia mnse.d MicicnMe,e acnhadn d hida dn obte cpormaceti cdpei.s aHbslee da:n sdh/ oh/ritslt yw .aiffete ur nednetretroinogk thhies Organization: “We Who Are Most Inpteresste:d/”/ t .
h t t mission through writing, puhblisthitng, and speaking. McMechan’s first In 1926, Agatha Hodgins called htogetthter a small group of Lakeside
target was the high profile Lakeside School and its famous surgeon Hospital alumnae to form a national organization. Hodgins had been
George Crile. He alleged that anesthesia was the practice of medicine, an educator since World War I, and she sought strength in numbers to
and he petitioned the Ohio Medical Board to take action. McMechan address problems related to education. One hundred thirty-three names
considered Ohio a “pivotal state in the national fight for the preserva- were submitted, and tentative bylaws were drawn up. But according to
tion of the status of the anesthetist as a medical specialist.”34 Ruth Satterfield, who was an eminent Certified Registered Nurse Anes-
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The beoardr acted. In a letter to Crile in 1916, the board claimed that thetists (CRNAe) edrucator and the first nurse appointed as Consultant e r
no okne other than a registered physician was permitted to administer to the Armky Surgeon General, “much of what she (Hodgins) said fell k
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o anesthesia. Essentially, the board ordered Lakeside Hospital’s School of ono deaf ears.”39 The association failed to thrive. The national organiza- o
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e Nursing to cease its anesthesia program or lose its accreditation. Noet tion of nurse anesthetists would only come to life after several problems e
e / wanting to be responsible for the loss of the school’s accreditatioen, C/rile coalesced in 1931. e /
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obeyed the order, pending the outcome of a hearing conducted in Physician opposition to nurse anesthetists was one such factor in
p s : / / t . 1w9a1s 7o.n Alyt fothlleo whienagri nthge, lCeardil eo ft omoakn tyh oepf pthoessi tmio:anjo/ trh /calttin Li.cask iens itdhee Hcoousnptitray.l tinh i1s 9d2e9ve aloftpemr tehnet .B Fooarr dex oafm Mpleed, iCcaall iEfoxranmiai nnpeurrs saesl laen:gees/dt ht/ehtatist t.ns uorrsgea nanizeesd-
h t t Crile managed to persuade thhe tbotard of medicine to lift its order, and thetist Adeline Curtis was practicinhg mtedticine illegally. Curtis, a natural
he was able to reinstitute his nurse anesthesia educational program and public speaker, went on the road with this refrain: “…we can get
his use of nurse anesthetists. nowhere without an organization. We’re in the minority of course but
But to protect nurse anesthetists, Crile took an additional step. In we must organize.”40 California held its first meeting February 3,
1919, together with supporting physicians, he “introduced a bill into 1930.41 Other states followed suit, and by the end of the 1930s, 23
the (Ohio) legislature to legalize the administration of anesthetics by had established organizations.
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nurses.”4,e11 Arn amendment to the legislation stated that nothing in the Economics ebrourght nurse anesthetists together as well. This era of e r
bill “kshall be construed to apply to or prohibit in any way the admin- organizatiokn occurred during the Great Depression, and Hodgins k
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o istration of an anesthetic by a registered nurse under the direction of and nooted in 1935 that “the strongest objection of physicians during this o
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e in the immediate presence of (emphasis added) a licensed physician,e” period was against those nurse anesthetists who were working on a fee e
e / provided that such a nurse had taken a prescribed course in aneesth/esia for service basis.”42 Hanchett,43 who examined the Chalmers-Francis ev. /
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at a hospital in good standing.35 Physician supervision of nurse anes- Nelson case (1933), concluded that plaintiff California physicians were
p s : / / t . thetAis tsse wcoonudld artetceumr pmt atnoy lteigmiselsa toev enrpu.rses an:es/th/esita .out of existence mHootdigviantes’d c obnyc eepcot n(oofm ainc ofargcatonrisz.a tAionnd) mThigaphtct hneserv eo:rb hs/earv/vee tdb e.tehna ts p“aMrkeisds
h t t occurred in 1916. The Louhisvitllet (Kentucky) Society of Anesthetists into action, and organizations of nhurste tanesthetists might have stayed
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CHAPTER 1 • Nurse Anesthesia: A History of Challenge 5
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at thee lorcal level if the collapse of the nation’s economy had not revived from undeer trhe wing of surgery, and “the nurses were summarily e r
kthe physician anesthetist’s interest in protecting his income by eliminat- rejectekd.”47 k
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o ing competition from nurses…”11 o So, instead, with the guidance and support of the American Hos- o
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e But it was the poor state of anesthesia education that moste moti- pital Association, Gertrude Fife and Helen Lamb planned the firste
e / vated Agatha Hodgins. In 1931, she wrote the followineg to/ Adeline meeting, which was held in Milwaukee in 1933. They also creafte/d a
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Curtis, who was embroiled in the California dispute: “My chief interest highly centralized organization to efficiently address the association’s
p s : / / t . eisa cinh eodtuhcear,t iAonga.”t4h4 aA tnride dw iatgha itnh.e pfactosrs :no/te/d ptre.viously compounding cboenrscheirpn ss.o Th thaattc hthere rleis twedo utlhdo sbee cao ncrceepdrnitsa:b s“le(1 :s)h /bouw/iilndtgin .gat utph et hMe imlweamu--
h t t The National Associhatiotnt of Nurse Anesthetists (NANA) was born kee meeting; (2) arranging a hprotgrtam; (3) getting a constitution and
on June 17, 1931. Its name would be changed to the American Associa- the bylaws revised; and (4) launching the association’s educational
tion of Nurse Anesthetists in 1933. The first meeting was held in a program.”
classroom at Lakeside Hospital and was attended by 40 anesthetists Membership was to be a privilege, a mark of distinction. The bylaws
from 12 states.45 required that an active member have graduated from an accredited
Right away, the new association set its sights on improving the school of nursing, have passed the required state board examination,
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quaelity rof anesthesia by raising educational standards. The new presi- and mainteain ran active license. Importantly, an applicant must “have e r
kdent, in a letter to Marie Louis at the American Nurses Association, engagekd for not less than three years in the practice of the administra- k
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o wrote: “It is because of the increasing number of nurses interested in o tion of anesthetic drugs prior to 1934, and must be so engaged at the o
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e the particular work and growing realization of difficulties exeisting time of making application for membership.”48 e
e / because of insufficient knowledge of, and proper empheasis/ on, the As membership surpassed 2500, a survey of schools, using eon-/site
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importance of education, that we who are most interested are taking surveyors, evaluated courses being taught. An Anesthesia Records Com-
p s : / / t . tthhee estdeupcsa ttoed i nnsuurrsee oaunre satbhielittiyst .t”o4p 6d Aefinsn eed :uanc/adt i/hoentl pc. ommaminittatiene twhaes sftoartmuse odf. mcreitdteene twiaal s“ Mforemmebde rt oof ctrheea tAem a esrtiacnand aArpdssiozecdsia tai:noen/s toh/f eNttiuc. rrseec Aornde,s tahnedti stths”e
h t t Chaired by Helen Lamhb, tthet committee crafted “recommended” cur- was implemented. These strihdest sterved to show that the profession
riculum standards for schools and ratcheted them up in 1935 and again had left its infancy. Then World War II erupted and stalled further
in 1936. progress.
But the fledgling association was weak. With few members and little
World War II and Nurse Anesthetists
money, it could not hold its first national meeting for three years, much
less advance an agenda of education reform. In that period, Agatha When World War II began, nurse anesthetists once again distinguished
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Hodeginrs sustained a heart attack and “for all practical purposes bowed themselvees. Thr ey served at home and in all theaters of operations. e r
kout as administrative leader.” Gertrude Fife (Fig. 1.2) took over the Mildrekd Irene Clark, who was originally from North Carolina, joined k
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o day-to-day affairs. There grew the realization, attributed by Bankert to o the Army in 1938. Under Army auspices, she graduated from Jewish o
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e Helen Lamb and the Education Committee, that the problems weere of Hospital in Philadelphia, where Hilda Salomon was program director.e
e / such magnitude that an alliance with a more influentiale pro/fessional Clark was on assignment as a nurse anesthetist at the Schofield Bearra/cks
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association would be required. But which one? Hospital in Hawaii when Pearl Harbor was struck. Clark was among
p s : / / t . likeFlyo rpmroinveg parno ballleimanacteic w, aitsh d aiv emprgaejonsrt pi:nrot/efrees/sstitos nc.aolu oldrg caonlilzidatei oann dw toruulsdt ofotrh eprr enpuarrsien agn aedstdhietitoisntsa lo nnu arcstei vaen desutthye pwtishtos.s sCetl: aurp/k ec/doutmcap.tlieotnedal hperro gcararemers
h t t would be tested to its hlimitt. tThe small, young NANA would have to in 1967 as the Chief of the Ahrmyt Nturse Corps, the first nurse anesthe-
fight to maintain its independence, while at the same time obtain tist to hold this position.
much-needed support. According to historian Rosemary Stevens, the Annie Mealer, another notable Army nurse anesthetist, was sent
AANA “made overtures to the American Board of Anesthesiology from Walter Reed Army Medical Center to the Philippines in 1941.
(ABA) in 1938 which might have enabled the two movements to She served as chief nurse and chief nurse anesthetist of the hospital on
combine and the anesthesiologists to take on the responsibility of the Corregidor. For three years, Mealer was held as a prisoner of war.
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nursees’ rtraining.” But at the time, the ABA was struggling to emerge Among thee nrurse anesthetists imprisoned with her were Denny Wil- e r
k liams,k Doris Keho, and Phyllis Arnold Iacobucci. They and 62 other k
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o o Army nurses were imprisoned until February 3, 1945. o
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e e Marianne Bankert quotes at length a letter Annie Mealer later wrotee
e / e / in which she described her experiences. Mealer recalled housinge Pr/esi-
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dent Quezon and his family, dodging “Jap bombs,” and “giving anes-
p s : / / t . p s : / / t . tnhuertsiec sc otou lodn ge ivcae stuhaeltmy .”a fItenr Jaanpoatnheesre” cwpuhstoo sd“yal l:a bn/oeea/drdet da . htreolpo pth sahti po,n alyn da
h t t h t t sick with dengue fever, Mealehr wtrotte, “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
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e r starvatione.”8 r e r
k Wakrtime greatly expanded the need for anesthetists in both military k
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o o and civilian hospitals. Lt. Col. Katherine Balz, the Education Consul- o
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e e tant to the Army, estimated that “approximately 15,000,000 patientse
e / e / were admitted to Army hospitals during the war, and somethineg h/ad
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p s : / / t . vNFaIGAteNUd RAgE ri on1u .2p1 9Gw33he–rot3 r5ub udaeinl tdF itfahese atprnerdao sfHuerspeeslireo nfnr s.oL mFami: f1eb 9/ s3we/5rev–rte5ed 0.a ,m aason sndeg ce odtnhitdee dhp irtgehhseil dyA emnAtNo toAi-f tcooau rtben.e”u dmRobnoeesre etmod apraryno evSsittdheeve estihnoesl oargneipestsost rhtbeeysdi a 1 ts7hep arvtt oici sen1s .4n1:9e9 e/B4d2y/e, d tt nhfoue. rr setenh deas neo epfs taWhtieeotnirstltsds’
h t t Journal from 1933–50. h t t War II, the Army Nurse Corhps thatd educated more than 2000 nurse
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