Mark J. Lema, M.D., Ph.D.

T he Russians are our allies; Iraq held free elections; there is a cease-fire in the Middle East; and the American Association of Nurse Anesthetists (AANA) and ASA are moving toward respectful interactions. Anything is possible in the 21st century. Before we celebrate the end of threatening situations, however, be mindful that events can revert to their metastable interactions if taken for granted or not continuously respected. Consider the strained relations with North Korea, Iran, France and Germany as examples of the effects of “back burner” diplomacy.

I have had the privilege to serve as one of your negotiators since last August in the high-profile and somewhat controversial (for both societies’ members) AANA-ASA discussions. As an outspoken supporter of physician supervision and a critic of AANA policy in the past when I served as NEWSLETTER editor, I am sure that AANA officers had been suspect of my presence. In fact, at the Association of periOperatve Registered Nurses (AORN) summit last June, then-AANA president Tom McKibban, CRNA, upon meeting me for the first time, checked my head and back for horns and a spaded tail.

In reality the two societies are finding that they have more in common as health care practices continue to uncontrollably evolve, or more likely unravel, according to intense market competition and technological advances. I believe that the “Lobby Wars” of the past forced us to engage in a death grip with the nurse anesthetists, fighting for control of the vast kingdom of anesthesiology. Ironically, as both groups were preoccupied with advancing their practice strategies, their backs were to their boundaries. Nonanesthesia providers then surreptitiously gained control of anesthesiology domains like Visigoths invading the fringes of the Roman Empire.

The safe practice of anesthesiology is both the practice of medicine and the practice of nursing. Only an anesthesia professional is qualified to provide safe general anesthesia. Recently both groups jointly supported the principle that propofol is a potent general anesthetic agent and needs to be treated as such. Propofol frankly belongs in operating rooms, sometimes in intensive care units, rarely in emergency rooms, but never in the endoscopy suite unless carried in by an anesthesia professional who knows the complete effects of the drug and can adequately resuscitate when necessary.

ASA and AANA must eventually resolve the philosophical differences in practice arrangements between doctors and nurses licensed to practice anesthesia. Our training as doctors and their training as nurse anesthetists are markedly different and ultimately need to be addressed in scope-of-practice issues. On the other hand, the science of anesthesia delivery is jointly shared by both specialties. By example, propofol has the same side effect profile regardless of who pushes the plunger — responding to adverse effects, however, will differ according to the intensity and duration of training in understanding the medical principles.

While the two specialties continue to negotiate in Chicago, being mindful that scope-of-practice battles are intensifying in key states, every anesthesiologist and nurse anesthetist must look outward to the boundaries of our respective practices. The Visigoths continue to advance in the guise of conscious sedation nurses, intensivists, pediatricians and endoscopists seeking to expand their anesthetic roles. They seek to do what we worked hard to master, not knowing their limitations, not appreciating the unforeseen dangers, not knowing what they do not know when it comes to the art of anesthesia.



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