麻醉护理专业历史

分享智慧

共同成长

Full text

‍Abstract

Despite the fact that anesthesia was discovered in the United States, we believe that both physicians and nurses are largely unaware of many aspects of the development of the nurse anesthetist profession. A shortage of suitable anesthetists and the reluctance of physicians to provide anesthetics in the second half of the 19th century encouraged nurses to take on this role.

We trace the origins of the nurse anesthetist profession and provide biographical information about its pioneers, including Catherine Lawrence, Sister Mary Bernard Sheridan, Alice Magaw, Agatha Cobourg Hodgins, and Helen Lamb. We comment on the role of the nuns and the effect of the support and encouragement of senior surgeons on the development of the specialty. We note the major effect of World Wars I and II on the training and recruitment of nurse anesthetists. We provide information on difficulties faced by nurse anesthetists and how these were overcome. Next, we examine how members of the profession organized, developed training programs, and formalized credentialing and licensing procedures. We conclude by examining the current state of nurse anesthesia practice in the United States.

1. Introduction

Although nurses have administered anesthesia for more than a century, many health care providers, including certified registered nurse anesthetists (CRNAs), are not aware of the history of the profession of nurse anesthesia [1].

2. Early years

Before the first public demonstration of successful ether anesthesia by William T.G. Morton on October 16, 1846, at Massachusetts General Hospital, surgery was by no means an everyday occurrence [2], [3]. Pain associated with surgery and the high rate of complications dissuaded patients and surgeons from most forms of elective surgery. The discovery of anesthesia might have been expected to result in an immediate increase in the number and complexity of surgical operations, but this did not occur [4]. Although the germ theory of disease was known, the concept of antisepsis had not been extended to surgical operations [5]. Postoperative infections were the rule rather than the exception, and early surgeons believed that pus in the wound was a sign of satisfactory healing [6], [7], [8]. Antibiotics were not introduced into medical practice until the Second World War [9], and opposition to the use of anesthetics to dull pain associated with surgery was actually opposed by medical practitioners, lay persons, and the clergy [10], [11]. Therefore, for a variety of reasons, anesthesia remained unpopular and unrefined for nearly 50 years after its discovery. Anesthesia was considered dangerous due to high mortality associated with the aspiration of gastric contents, asphyxiation due to respiratory obstruction, or unrecognized events such as low blood pressure or cardiac arrhythmias, in the absence of clinical monitoring [12]. Anesthesia training programs did not exist in the late 19th century, and the job of administering anesthetics was often assigned to medical students, house officers, nurses, or orderlies, none of whom received formal instruction in anesthetic procedures [13], [14].

3. A shortage of trained personnel

As surgical techniques improved and the demand for anesthesia increased, surgeons believed anesthesia to be a “mixed blessing” because patients were aware of the existence of pain-free surgery, but anesthesia was associated with high mortality, and there was a shortage of qualified anesthetists [1], [15], [16], [17]. Thus, the job fell to anyone who was willing and available: mostly medical students and less senior physicians. However, most physicians were not interested in a position they considered to be subordinate and were more eager to learn the skills and techniques of the surgeon. Surgeons, on the other hand, were eager to find well-educated and intelligent professionals to fill the role of anesthetist. Unable to convince enough other physicians to undertake the administration of anesthesia, surgeons turned to graduate nurses to fill this role [2], [17], [18], [19]. Although surgeons had identified nurses as likely candidates for “occasional anesthetist,” many issues continued to plague medicine at this time, including lack of cleanliness and asepsis.

4. Advent of nursing as a profession

The transformation of nursing into a profession required changes in the way society viewed women. However, Thatcher in her 1953 History of Anesthesia, With Emphasis on the Nurse Specialist, recognized the important contributions of women to the field: “To women and to the discovery of ‘germs’ must go the credit for the greatest contributions to the relief of human suffering during the years between 1860 and 1900” [17]. The birth of feminism and their changing status post–Industrial Revolution led women to seek higher education. Nursing experiences in the Crimean War (1853-1856) and the Civil War (1861-1865) allowed women to challenge male dominance in hospitals and “demand improvements in hospital housekeeping and the care of the sick” [17].

Nursing as a religious calling was never stigmatized, but women practicing nursing outside religious orders were viewed as socially and morally corrupt. After experiences in the wars, educated women began a campaign to train others in the field of nursing, thus opening up a new vocation for women.

Perhaps the most famous of all nurses and the woman considered the founder of modern nursing, Florence Nightingale (1820-1910) grew up in a prominent family in Victorian England. She surprised her family by choosing such a career (or perhaps a career at all), and during the Crimean War (1853-1856), she was given credit for advancing nursing by emphasizing cleanliness, hygiene, and ventilation. She established the first nursing school at St Thomas' Hospital in London and is also remembered as a great social reformer, statistician, and writer [2], [20].

However, even after training programs were established, nurses continued to face challenges in the male-dominated medical system until there was a strong demand for their services, created by the discovery of germs. Once the germ theory of disease was understood and the importance of preventing infection accepted, a “new” nurse emerged. Her function was no longer limited to providing comfort, food, and housekeeping but now also required knowledge and application of science. As science expanded the role of the physician by improving our understanding of disease and how to surgically treat illness, the nurse's role also broadened. Nurses assumed duties once limited to physicians; in the operating room, this included administering anesthesia.

5. Pioneer nurse anesthetists

Catherine S. Lawrence (1820-1904) (Fig. 1) has been identified as the first nurse to administer anesthesia, which occurred during the Civil War, 1861 to 1865 [21]. It was during the Battle of Bull Run of 1863 that she administered chloroform to wounded soldiers who needed emergency operations in the battlefield [17], [21]. Nevertheless, it still took several years for nurses to step forward and formally answer the call to provide anesthesia. Reasons for this delay included lack of training, the nonemergency nature of civilian surgical practice after the war was over, and the paucity of role models and sponsors. However, the wartime concept of nurses providing anesthesia care gradually took root as surgeons trained and encouraged nurses to take on this important role. Surgeons who had been searching for a vigilant anesthesia provider began supporting nurses as ideally suited for the role. Thatcher, also in her History of Anesthesia, With Emphasis on the Nurse Specialist, stated nurses were ideal for the role as they would “…be satisfied with a subordinate role that the work required, make anesthesia their one absorbing interest, not look on the situation of anesthetist as one that put them in a position to watch and learn from the surgeon's technique, accept comparatively low pay and, have a natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation the surgeon demanded” [17]. Thus, the profession of nurse anesthetist was born.

6. Early American hospitals and nurse anesthetists

Pennsylvania Hospital in Philadelphia was the first general hospital in the United States, and founding father Benjamin Franklin (1706-1790) played a major role in establishing it in 1751 [22]. The next hospital to be founded was the New York Hospital in 1791 [23], and the third US hospital was Massachusetts General Hospital in 1811 [24], [25].

During the 19th century, most medical care was provided in the home by members of the patient's family. Conditions in institutions that preceded hospitals were unhygienic, and mortality was extremely high. Thus, these early hospitals primarily catered to the needs of the poor and the indigent [2], [26], [27].

Catholic nuns played an important role in the training of nurses and also in anesthesia [28]. The earliest recorded nurse to specialize in anesthesia was Sister Mary Bernard Sheridan (1860-1924) (Fig. 2). Sister Bernard took over anesthesia duties in 1877 at St Vincent's Hospital in Erie, Pennsylvania. Her influence spread throughout the Midwest, and many other Catholic nuns who were also nurses began training to administer anesthesia. Nuns of the Third Order of the Hospital Sisters of St Francis from Muenster, Germany, established a community in Springfield, Illinois, and on June 22, 1879, they founded St John's Hospital. At St John's, the administration of chloroform and ether was taught to the nurses by surgeons, and many of the Franciscan Sisters were assigned as anesthetists throughout the Midwest. Nurse anesthesia became “undoubtedly a prevailing practice in many Catholic hospitals” [2], [17]. In 1883, Minnesota was devastated by a tornado. Mother Alfred Moes and the Sisters of Saint Francis proposed building a hospital to aid the sick and injured in Southern Minnesota. However, they stipulated that William W. Mayo (1819-1911) and his sons work at the hospital. The Mayos agreed, and in 1889, St Mary's Hospital opened with 27 beds [29]. Although Catholic nuns seemed to be the most influential force in teaching nurses to administer anesthesia in the late 1800s, it was William W. Mayo who should be credited for promoting the popularity of nurse anesthesia practice [30]. Mayo and his sons William J. Mayo (1861-1939) and Charles H. Mayo (1865-1939) were well known for their surgical skills. Surgeons traveled from across the country to their clinic in Minnesota to observe operations and learn their surgical techniques. However, the visiting surgeons were also impressed with the skillful and capable nurses administering anesthesia at the head of the operating table [29], [30].

One of the most impressive and well-known nurse anesthesia pioneers was Alice Magaw (1860-1928) (Fig. 5), who came to St Mary's Hospital in Rochester, Minnesota, in 1893. She was trained by the Graham sisters, Edith (1871-1943) and Dinah (1860-1947), and began working as a nurse anesthetist for Charles H. Mayo, who bestowed on her the title of “Mother of Anesthesia” due to her natural aptitude and mastery of safe administration of open-drop ether [2], [17], [31]. In addition to being skilled, Magaw documented and evaluated all her anesthesia procedures, culminating with a landmark article in nurse-anesthesia history [32]. An even larger work (A Review of Over Fourteen Thousand Surgical Anesthesias) was published in 1906, reporting huge number of open-drop ether anesthetics, incredibly without a single fatality [1], [33]. In this work, Magaw outlined her technique for administering anesthesia. She reported assessing each patient preoperatively to determine that patient's needs and surgical requirements, stressing the “accustomed” relationship between surgeon and anesthetist. She wrote, “One must be quick to notice the temperament” of the patient and determine how to approach the administration of the anesthetic. She stressed the need to gain the confidence of the patient and to prepare the patient “for each stage of the anesthesia with an explanation of just how the anesthetic is expected to affect him.” Magaw also promoted individualizing the anesthetic plan: “It is a mistake to think that the same elevation of the head will do for all patients” and stated that the secret to the open-drop method was not to rush anesthetic but to “talk [the patient] to sleep,” recommending adjustment of the anesthesia plan to meet the patient's needs. “The dose required for each individual patient cannot be estimated so as to be of any value, as it depends largely on the temperament of the patient, pathological condition present, time consumed in anaesthetizing, and operating” [33]. Before Magaw's refinement of the open-drop method, Thatcher describes patients often requiring artificial respiration, physical restraint, or even resuscitation due to anesthesia errors by untrained anesthetists. Magaw's work highlighted the benefits of the trained anesthetist, allowing great advances in the practice of medicine. As the reputation and success of the Mayo Clinic spread, so did the renown of the Mayo Clinic nurse anesthetists. Thatcher documents testimonials from across the United States and England of the gratitude and praise directed to the Doctors Mayo and Magaw for the advances made in the delivery of anesthesia, and many surgeons and hospitals sent their nurses to the Mayo Clinic to be trained by Alice Magaw.

The sustainability and historical longevity of the practice of nurse anesthesia can be attributed to excellent working relationships between nurse anesthetists and surgeons. Impressed by the provision of superior anesthesia by nurses at St Mary's, following the example of the Mayo Clinic, prominent Cleveland surgeon George Washington Crile (1864-1943) recruited Agatha Cobourg Hodgins (1877-1945) (Fig. 3) as his personal anesthetist in 1908 [2], [17], [34]. Later in the 19th century, other prominent surgeons also employed personal anesthetists for their practice. Chest surgeon Evarts Ambrose Graham (1883-1957) from Barnes Hospital in St Louis recruited Helen Lamb (1899-1979) (Fig. 4) to administer anesthesia for his thoracic cases. Not only did she provide anesthesia for the first successful pneumonectomy, she also authored a chapter on anesthesia for Graham's textbook. Pioneering heart surgeon Claude Schaeffer Beck (1894-1971) from University Hospital of Cleveland employed Gertrude L. Fife (1902-1980) as his personal anesthetist. Nurse anesthetist Olive Louise Berger (1898-1981) was at the head of the table when Alfred Blalock (1899-1964) performed the pioneering Blalock-Taussig procedure for “blue babies” at Johns Hopkins Hospital in 1944. She remained his personal nurse anesthetist for many years and instructed others in anesthesia techniques.

7. Initial challenges

The first challenge to the nurse's right to administer anesthesia came in 1911 from Francis Hoeffer McMechan (1879-1939), a native Cincinnati physician, who felt that the field of anesthesia should belong solely to physicians. McMechen challenged the practice of nurse anesthesia with the Ohio Medical Board [35], which along with Ohio State Attorney General ruled in 1916 that only a registered physician could administer anesthesia. Surgeons at the Lakeside Hospital in Cleveland, such as Crile, initially obeyed the ruling. However, in 1917, Crile and his supporters successfully lobbied the Ohio legislature to create an exemption within the Medical Practice Act for nurses who were educated appropriately to administer anesthesia under the supervision of a physician [2], [36]. Therefore, the Lakeside Hospital School of Nurse Anesthesia was able to reopen in 1917.

The second challenge for nurse anesthetists in the practice of anesthesia occurred in 1917 in Kentucky. The Louisville Society of Anesthetists suggested to the Kentucky Attorney General that only people who had medical knowledge and training should administer an anesthetic, which the Attorney General supported. Thus, expulsion from the Society was threatened if nurse anesthetists were used; this threat was extended to hospitals that used nurse anesthetists. Louis Frank (1867-1941), a Louisville surgeon, and his anesthetist, Margaret Hatfield (circa 1889-1964), filed suit against the Kentucky Medical Society and won at the appellate level [1], [37]. However, perhaps the most noteworthy challenge occurred in 1934, when nurse anesthetist Dagmar Nelson (1892-1958) was charged by a physician, William Vane Chalmer-Francis (1876-1950), with practicing medicine and violating California Medical Practice by administering anesthesia without a license. The case went all the way to California Supreme court, but Nelson was given favorable ruling at each level of the case [38]. The Dagmar Nelson case was won via precedents set by early nurse anesthetists. Blumenreich (1984) identifies 2 lines of reasoning along which the California Supreme Court ruled that Nelson was not engaged in the illegal practice of medicine [39]. First, the Court reasoned that Nelson's practice of anesthesia was in “accordance with the uniform practice in operating rooms” not only in Los Angeles but also throughout the country including the Mayo Clinic, where Nelson had trained and “where…one hundred thousand surgical operations had been performed” with anesthetic administered by nurses [17]. Second, the Court reasoned that nurse anesthetists were following physician orders. Thatcher's reasoning was as follows: “most anesthetics are drugs and admittedly drugs have always been applied and administered without question by nurses pursuant to medical direction” [17]. Although there were barriers to the progress of nurse anesthesia, the strong and productive relationships between surgeons and anesthetists remained a key factor in the continued evolution of the nurse anesthetist profession.

8. Early training programs and the effects of World Wars I and II

As the popularity of nurse anesthesia grew, so did the demand and need for formalized training. The first 4 such programs were started between 1909 and 1914 [17]: St Vincent's Hospital in Portland, Oregon 1909 (Agnes McGee), St John's Hospital in Springfield, Illinois 1912 (Mother Magdalene Wiedlocher), The New York Post Graduate Hospital in New York City 1912 (Minnie Lister), and Long Island College Hospital Brooklyn, New York 1914 (Louise McMurray). Another well-known early program was Lakeside Hospital School of Nurse Anesthesia, established in 1915 by Agatha Hodgins and George W. Crile. The first graduating class consisted of 6 physicians, 2 dentists, and 11 nurses [17].

As the profession continued to evolve, educational requirements slowly became more stringent, and it was difficult to meet the need for anesthetists during WWI. The Army and Navy sent their nurses to the Mayo Clinic and Pennsylvania Hospital for a 6-week course. Agatha Hodgins traveled to France with Crile in 1914 to conduct research and teach anesthesia to nurses and physicians. Reputation and contributions by nurse anesthetists in WWI prompted an increased need and period of growth [17], [40].

In addition to working closely with George W. Crile, Agatha Hodgins also founded the National Association of Nurse Anesthetists (NANA) on June 17, 1931, in Cleveland, OH, after her request to form a specialty section for anesthesia was denied by the American Nurses Association [17]. Helen Lamb (1899-1979) was a prominent nurse educator who founded and was director of the School of Anesthesia at Barnes Hospital in St Louis [17]. She codeveloped the von Foregger gas machine with Richard von Foregger (1872-1960). Later in her career, she established the curriculum and minimum standards for schools of nurse anesthesia and was American Association of Nurse Anesthetists (AANA) president 1940 to 1942 [41], [42]. Prominent CRNA Alice Maude Hunt (1880-1956) was appointed Assistant Professor of Anesthesia in the Department of Surgery in 1930 at Yale University. In 1949, she became the first nurse anesthetist to publish a textbook of anesthesia [43].

Despite the rapid growth of the nurse anesthetist profession following the Great War, WWII again precipitated a shortage of anesthetists. A recruitment campaign was begun, but this was quickly followed by concern about the emergence of “ill advised and unjustified schools” [2], [17]. Helen Lamb in turn stressed the importance of maintaining educational standards even in times of shortages. By the end of WWII, the military had trained more than 2000 nurses to provide anesthesia using a program patterned by the NANA [2], [3]. The quality of nurse anesthesia education was again upgraded following WWII, and although university affiliation was advised, most programs were still hospital based. In 1933, the NANA established an Education Committee to develop educational standards, and by 1952, formal accreditation standards were in place [44].

9. Professional organization

Nurse anesthetists formed a professional organization to further their professional development, training, interests, and political strength. The NANA spearheaded the establishment of anesthesia educational standards in 1935 [2], [17]. In 1939, its name was changed to the American Association of Nurse Anesthetists (AANA) [2], [17]. The credentialing of trained nurse anesthetists and adoption of the title “certified registered nurse anesthetist” occurred in 1956 [45]. In the mid-1970s, the AANA established, through bylaws changes, independent councils to manage accreditation, certification, and recertification [46].

The Council on Accreditation of Nurse Anesthesia Educational Programs has been recognized by the United States Department of Education as the accrediting agency for nurse anesthesia educational programs since 1975 [44]. The Council on Certification of Nurse Anesthetists and the Council on Recertification of Nurse Anesthetists were together incorporated in 2007 as the National Board of Certification and Recertification of Nurse Anesthetists [44].

Advancing quality education to ensure that nurse anesthetists are prepared to deliver safe, quality care has been a basic tenet of the AANA since its founding. Over the years, the AANA has promoted development of educational standards to keep pace with the evolving needs of society for high-quality anesthesia care. In 1998, nurse anesthesia education moved from hospital based programs to university based graduate education; in 2022, the doctoral degree will be fully implemented [44].

10. Current status

Nurse anesthesia training programs have evolved with time, from humble beginnings credited to Catholic nuns, informal training and support by prominent surgeons, to the formal training and certification programs in existence today. Currently, there are 116 accredited programs in the United States [47]; in fiscal year 2014, the National Board of Certification and Recertification of Nurse Anesthetists reported 2445 first-time candidates for the National Certification Examination [48].

Requirements for admission include graduation from accredited nursing program, a valid nursing license, a bachelor's degree in nursing or equivalent degree, and critical care nursing experience of at least 1 year. The training programs are 24 to 36 months in length, and students administer an average of 850 anesthetics during training [49]. Upon graduation, students are required to pass a National Certification Examination and maintain Continued Professional Certification. In addition, starting August 2016, CRNAs will be required to participate in a newly established recertification program to maintain educational standards and ensure that today's nurse anesthetists continue to deliver safe and effective care—as they have for almost 150 years.

11. Summary

In the United States, after initial work by pioneers who played a key role in the discovery of the anesthetic properties of nitrous oxide and ether, relatively little is known about the qualifications, or lack thereof, of anesthetists. In this article, we provide detailed historical information about nurses who learned the techniques of safe delivery of anesthetics and took over the ill-defined job of the anesthetist. We discuss how military conflicts precipitated sudden demands for anesthetists and how short-term training programs were established to meet this demand. Nurses accepted the challenge, most likely because safe administration of anesthesia was not believed by physicians to be sufficiently challenging to require a full-time commitment. Most pioneer nurse anesthetists had the strong support of senior surgeons, who saw the value of a reliable and adequate supply of safe anesthetists. Formal training programs for nurse anesthetists began in 1909 in Portland, Oregon [17], and one of the first residency programs for physicians was created in Madison, Wisconsin, in 1927 [50]. Nurse anesthetists and physician anesthesiologists currently operate in near-equal numbers, providing more than 40 million anesthetics annually in the civilian and military setting throughout the United States [51].

‍  

全文翻译（仅供参考）

 1.介绍

尽管护士实施麻醉已经有一个多世纪的历史，许多医疗保健提供者，包括注册麻醉护士(CRNAs)，并不知道麻醉护士的职业历史[1]。

2. 早期

1846年10月16日，威廉·t·g·莫顿在马萨诸塞总医院首次成功地公开演示乙醚麻醉，在此之前，手术绝不是每天都发生的事情。与手术相关的疼痛和高并发症率劝阻患者和外科医生放弃大多数形式的选择性手术。麻醉的发现可能会使外科手术的数量和复杂性立即增加，但这并没有发生。虽然疾病的微生物理论已经为人所知，但消毒的概念还没有扩展到外科手术。术后感染是常见的而不是例外，早期的外科医生认为伤口脓液是愈合满意的标志[6]，[7]，[8]。抗生素直到第二次世界大战才被引入医疗实践中，而反对使用麻醉剂来缓解手术带来的钝痛，实际上是医务从业人员、外行和神职人员反对的。因此，由于种种原因，麻醉在被发现后的近50年里一直不受欢迎，也没有得到完善。麻醉被认为是危险的，因为在没有临床监测[12]的情况下，与胃内容物的吸入、呼吸阻塞导致的窒息或未被识别的事件如低血压或心律失常相关的高死亡率。在19世纪后期，麻醉培训项目还不存在，给药的工作通常分配给医学生、住院部官员、护士或护工，这些人都没有接受过正式的麻醉操作指导。

3.训练有素的人员短缺

随着手术技术的提高和对麻醉需求的增加，外科医生认为麻醉是一件“喜忧参半”的事情，因为患者知道存在无痛手术，但麻醉与高死亡率相关，且缺乏合格的麻醉师[1]，[15]，[16]，[17]。因此，这份工作就落在了任何愿意而且有空的人身上:大多数是医科学生和资历较浅的医生。然而，大多数医生对他们认为是从属的职位不感兴趣，他们更渴望学习外科医生的技能和技术。另一方面，外科医生渴望找到受过良好教育和聪明的专业人士来填补麻醉师的角色。由于无法说服足够多的其他医生承担麻醉的管理，外科医生转向毕业的护士来填补这个角色[2]，[17]，[18]，[19]。尽管外科医生已经确定护士是“偶尔麻醉师”的可能人选，但许多问题仍然困扰着当时的医学，包括缺乏清洁和无菌。

4. 护理作为一种职业的出现

护理转变为一种职业需要改变社会看待女性的方式。然而,撒切尔夫人在她1953年的历史麻醉,强调护理专家,认识到女性领域的重要贡献:“妇女和发现的“细菌”必须的功劳最大的贡献减轻人类的痛苦在年1860年和1900年之间”[17]。女性主义的诞生和后工业革命时期女性地位的变化促使女性寻求更高的教育。克里米亚战争(1853-1856年)和内战(1861-1865年)的护理经验使女性能够挑战男性在医院的主导地位，并“要求改善医院的家务和对病人的照顾”。

作为一种宗教职业的护理从来没有被污名化，但在宗教之外从事护理工作的女性被认为是社会和道德败坏的。在经历了战争之后，受过教育的妇女开始了在护理领域培训其他人的运动，从而为妇女开辟了一个新的职业。

弗洛伦斯·南丁格尔(Florence Nightingale, 1820-1910)可能是所有护士中最著名的，被认为是现代护理学的创始人，她在维多利亚时代的英国一个显赫的家庭长大。她选择这样的职业(或者干脆就选择这样的职业)让她的家人感到惊讶，在克里米亚战争(1853-1856)期间，她强调清洁、卫生和通风，推动了护理事业的发展。她在伦敦的圣托马斯医院建立了第一所护理学校，她也是一位伟大的社会改革家、统计学家和作家。

然而，即使在培训项目建立之后，护士仍然面临着男性主导的医疗体系的挑战，直到发现细菌，对她们的服务产生了强烈的需求。一旦了解了疾病的微生物理论和预防感染的重要性，“新”护士就出现了。她的功能不再局限于提供舒适、食物和家务，现在还需要知识和应用科学。随着科学通过提高我们对疾病和如何手术治疗疾病的理解，扩大了内科医生的作用，护士的作用也随之扩大。护士承担了以前仅限于医生的职责;在手术室里，这包括给病人麻醉。

5. 先锋麻醉护士

Catherine S. Lawrence(1820-1904)(图1)被认为是第一个实施麻醉的护士，这发生在1861年到1865年的南北战争期间。在1863年的布尔溪战役中她给在战场上需要紧急行动的伤员注射了氯仿[17][21]。尽管如此，护士们还是花了好几年的时间才挺身而出，正式响应提供麻醉的号召。造成这种延误的原因包括缺乏训练，战后平民外科实践的非紧急性质，以及缺乏榜样和赞助者。然而，随着外科医生培训和鼓励护士承担这一重要角色，护士提供麻醉护理的战时观念逐渐扎根。一直在寻找警惕的麻醉师的外科医生开始支持护士，认为他们最适合这个角色。撒切尔也在她的《麻醉史》中强调护士专家，她说护士是这个角色的理想人选，因为他们“……满足于工作所需要的从属角色，使麻醉成为他们唯一的兴趣，看起来形势麻醉师,把它们放在一个位置观看和学习外科医生的技术,接受较低工资,有一种天然的能力和智力发展高水平的技能提供平滑的麻醉和放松外科医生要求”[17]。于是，麻醉护士这个职业就诞生了。

6. 早期美国医院和麻醉护士

位于费城的宾夕法尼亚医院是美国第一家综合医院，开国元勋本杰明·富兰克林(1706-1790)在1751年建立它起了重要作用。下一家成立的医院是1791年成立的纽约医院，第三家美国医院是1811年成立的马萨诸塞州总医院。

在19世纪，大多数医疗护理是由病人的家庭成员在家中提供的。在医院之前的机构条件不卫生，死亡率极高。因此，这些早期医院主要是为了满足穷人和穷人的需要。

天主教修女在护士培训和[28]麻醉培训中发挥了重要作用。有记录的最早专攻麻醉的护士是修女玛丽·伯纳德·谢里丹(1860-1924)(图2)。修女伯纳德于1877年在宾夕法尼亚州伊利的圣文森特医院接管麻醉职责。她的影响传遍了整个中西部，许多其他天主教修女也开始接受管理麻醉的培训，她们也是护士。来自德国明斯特的圣弗朗西斯医院修女第三团修女在伊利诺斯州的斯普林菲尔德建立了一个社区。1879年6月22日，她们成立了圣约翰医院。在圣约翰医院，外科医生教护士使用氯仿和乙醚，许多圣方济会修女被指派在整个中西部担任麻醉师。护士麻醉“无疑成为许多天主教医院的普遍做法”[2]，[17]。1883年，明尼苏达州被龙卷风摧毁。阿尔弗雷德·莫斯嬷嬷和圣弗朗西斯修女提议在明尼苏达州南部建一所医院，以帮助病人和伤员。然而，他们规定威廉·w·梅奥(1819-1911)和他的儿子在医院工作。梅奥夫妇同意了，于是在1889年，圣玛丽医院开业了，当时有27个床位。尽管在19世纪晚期，天主教修女似乎是教导护士实施麻醉的最具影响力的力量，但推动护士麻醉实践[30]普及的应该是威廉·w·梅奥(William W. Mayo)。梅奥和他的儿子威廉·j·梅奥(1861-1939)和查尔斯·h·梅奥(1865-1939)因他们的外科技术而闻名。外科医生从全国各地来到他们在明尼苏达州的诊所，观察手术并学习他们的外科技术。然而，来访的外科医生也对熟练和有能力的护士在手术台上实施麻醉的[29]，[30]印象深刻。

最令人印象深刻和最著名的麻醉护士先驱之一是爱丽丝·玛高(1860-1928)(图5)，她于1893年来到明尼苏达州罗切斯特的圣玛丽医院。她由格雷厄姆姐妹伊迪丝(Edith, 1871-1943)和黛娜(Dinah, 1860-1947)训练，开始为查尔斯·h·梅奥(Charles H. Mayo)担任麻醉护士，由于她的天赋和对开滴乙醚[2]，[17]，[31]安全用药的掌握，梅奥授予她“麻醉母亲”的称号。除了熟练之外，Magaw记录和评估了她所有的麻醉过程，并在护士麻醉史[32]上发表了一篇具有里程碑意义的文章。1906年发表了一篇更大的文章(《超过14,000外科麻醉药评论》)，报道了大量开滴式乙醚麻醉剂，令人难以置信的没有一个死亡病例[1]，[33]。在这项工作中，Magaw概述了她的麻醉管理技术。她报告说，术前评估每个病人，以确定病人的需要和手术要求，强调外科医生和麻醉师之间的“习惯”关系。她写道，“必须迅速注意到病人的性情”，并决定如何给药。她强调需要获得病人的信心，并让病人“为麻醉的每个阶段做好准备，并解释麻醉将如何影响他。”Magaw也促进了个性化麻醉计划:“这是错误的认为相同高度的头部会为所有的病人”,说的秘密开放式点滴方法不是冲麻醉而是”(病人)睡觉,“推荐麻醉计划的调整以满足病人的需求。不能估计每个病人所需的剂量以使其具有任何价值，因为它在很大程度上取决于病人的脾性、目前的病理状况、麻醉和手术所花费的时间。在Magaw改进开滴法之前，Thatcher描述了由于未经训练的麻醉师的麻醉错误，病人经常需要人工呼吸，身体约束，甚至复苏。Magaw的工作强调了训练有素的麻醉师的好处，使医学实践取得了巨大进步。随着梅奥诊所的声誉和成功的传播，梅奥诊所的麻醉护士的声誉也随之提高。撒切尔记录了美国和英国各地对梅奥医生和玛考医生在麻醉生产方面取得的进展表示感谢和赞扬的感谢信，许多外科医生和医院把他们的护士送到梅奥诊所接受爱丽丝·玛考的培训。

护士麻醉实践的可持续性和历史寿命可归因于麻醉护士和外科医生之间的良好工作关系。克利夫兰著名外科医生George Washington Crile(1864-1943)在1908年聘请Agatha Cobourg Hodgins(1877-1945)(图3)作为他的个人麻醉师[2]，[17]，[34]。19世纪后期，其他著名的外科医生也雇佣了个人麻醉师。圣路易斯巴恩斯医院的胸外科医生Evarts Ambrose Graham(1883-1957)招募了Helen Lamb(1899-1979)(图4)为他的胸科病例实施麻醉。她不仅为第一例成功的肺切除术提供了麻醉，还为格雷厄姆的教科书撰写了一章关于麻醉的文章。来自克利夫兰大学医院的心脏外科先驱Claude Schaeffer Beck(1894-1971)聘请Gertrude L. Fife(1902-1980)作为他的私人麻醉师。1944年，阿尔弗雷德·巴洛克(1899-1964)在约翰·霍普金斯医院为“蓝色婴儿”实施了开创性的巴洛克-托西格手术，麻醉师护士奥利弗·路易丝·伯杰(1898-1981)坐在手术台上。多年来，她一直是他的私人麻醉护士，并指导其他人麻醉技术。

7. 最初的挑战

1911年，来自辛辛那提的医生Francis Hoeffer McMechan(1879-1939)对护士实施麻醉的权利提出了第一个挑战，他认为麻醉应该完全属于医生。McMechen通过俄亥俄州医疗委员会[35]对护士麻醉的做法提出了质疑，该委员会和俄亥俄州总检察长在1916年裁定，只有注册医生才能实施麻醉。克利夫兰湖滨医院(Lakeside Hospital)的外科医生，比如克雷尔(Crile)，最初服从了这项裁决。然而，在1917年，Crile和他的支持者成功地游说俄亥俄州立法机关在医疗实践法案中为那些受过适当教育的护士在医生的监督下实施麻醉创造了一个豁免。因此，湖滨医院麻醉护士学校得以在1917年重新开放。

麻醉护士面临的第二个挑战发生在1917年的肯塔基州。路易斯维尔麻醉师协会向肯塔基州总检察长建议，只有具备医学知识和培训的人才可以实施麻醉，这得到了总检察长的支持。因此，如果使用麻醉护士，就有可能被逐出协会;这种威胁扩大到使用麻醉护士的医院。路易斯维尔的外科医生路易斯·弗兰克(1867-1941)和他的麻醉师玛格丽特·哈特菲尔德(大约1889-1964)对肯塔基医学协会提起诉讼，并在上诉中胜诉。然而，也许最值得注意的挑战发生在1934年，当时麻醉护士达格玛·纳尔逊(1892-1958)被医生威廉·瓦恩·查尔默-弗朗西斯(1876-1950)指控从事医学工作，违反了加州医疗惯例，未经许可就施行麻醉。这个案子一直到加州最高法院，但尼尔森在案件的每一级都得到了有利的裁决[38]。达格玛·纳尔逊的案子是通过早期麻醉护士树立的先例赢得的。Blumenreich(1984)确定了两种推理方式，根据这两种方式，加州最高法院裁定纳尔逊没有从事非法行医[39]。首先，最高法院认为，尼尔森的麻醉实践“符合手术室的统一惯例”，不仅在洛杉矶，而且在全国范围内，包括梅奥诊所，尼尔森曾在这里接受过培训，“在这里……进行了10万例外科手术”，麻醉由护士[17]实施。第二，法院认为，麻醉护士是遵照医嘱行事的。撒切尔的理由如下:“大多数麻醉药是药物，不可否认，药物一直都是由护士毫无疑问地根据医疗指示使用和管理的”[17]。尽管护士麻醉的发展存在障碍，但外科医生和麻醉师之间牢固而富有成效的关系仍然是护士麻醉职业持续发展的关键因素。

8. 早期训练计划和一战和二战的影响

随着护士麻醉的普及，对正式培训的需求和需求也在增长。最早的4个这样的项目是在1909年到1914年间开始的1909年俄勒冈州波特兰市的圣文森特医院(Agnes McGee)， 1912年伊利诺伊州斯普林菲尔德的圣约翰医院(Mother Magdalene Wiedlocher)， 1912年纽约市的纽约研究生医院(Minnie Lister)， 1914年纽约布鲁克林长岛大学医院(Louise McMurray)。另一个著名的早期项目是湖滨医院麻醉护士学校，由阿加莎·哈金斯(Agatha Hodgins)和乔治·w·克里(George W. Crile)于1915年创建。第一个毕业班由6名医生，2名牙医和11名护士组成。

随着这一职业的不断发展，教育要求慢慢变得更加严格，在一战期间很难满足对麻醉师的需求。陆军和海军派遣他们的护士到梅奥诊所和宾夕法尼亚医院进行为期6周的培训。1914年，阿加莎·哈金斯和克雷尔一起前往法国进行研究，并向护士和医生传授麻醉知识。第一次世界大战中麻醉护士的声誉和贡献促使了需求的增加和生长周期的延长。

除了与George W. Crile密切合作外，阿加莎·哈金斯还于1931年6月17日在俄亥俄州克利夫兰成立了全国麻醉护士协会(NANA)，此前她提出的组建麻醉专业部门的要求被美国护士协会[17]拒绝。海伦·兰姆(1899-1979)是一位杰出的护理教育家，她在圣路易斯巴恩斯医院创办了麻醉学校并担任校长。她与理查德·冯·福格(1872-1960)共同开发了冯·福格气体机。在她职业生涯的后期，她建立了护士麻醉学校的课程和最低标准，并在1940年至1942年担任美国麻醉护士协会(AANA)主席[41]，[42]。著名CRNA Alice Maude Hunt(1880-1956)于1930年被耶鲁大学任命为外科麻醉助理教授。1949年，她成为第一个出版麻醉教科书[43]的麻醉护士。

尽管麻醉护士职业在第一次世界大战之后迅速发展，但第二次世界大战再次导致麻醉师短缺。一场招聘活动开始了，但很快就引起了人们对出现“不明智和不公正的学校”的担忧。海伦·兰姆反过来强调了即使在教育短缺的时候保持教育标准的重要性。到第二次世界大战结束时，军队已经培训了2000多名护士使用NANA[2]，[3]模式的程序提供麻醉。护士麻醉教育的质量在二战后再次提升，尽管建议大学附属，大多数项目仍然以医院为基础。1933年，NANA成立了一个教育委员会来制定教育标准，到1952年，正式的认证标准[44]已经就位。

9. 专业组织

麻醉护士组成了一个专业组织，以进一步提高他们的职业发展、培训、兴趣和政治实力。1935年，NANA率先建立了麻醉教育标准[2]，[17]。1939年更名为美国麻醉护士协会(AANA)[2]，[17]。经过培训的麻醉护士的资格认证和获得“注册麻醉护士”的称号发生在1956年[45]。在20世纪70年代中期，AANA通过修改章程建立了独立委员会来管理[46]的认证、认证和再认证。

护士麻醉教育项目认证委员会自1975年[44]被美国教育部认可为护士麻醉教育项目认证机构。麻醉师护士认证委员会和麻醉师护士再认证委员会于2007年合并为国家麻醉师护士认证和再认证委员会[44]。

推进优质教育，确保麻醉护士准备提供安全、高质量的护理，一直是美国麻醉师协会成立以来的基本宗旨。多年来，AANA推动了教育标准的发展，以跟上社会对高质量麻醉护理不断发展的需求。1998年，护士麻醉教育从以医院为基础的项目转变为以大学为基础的研究生教育;2022年，博士学位将全面实施[44]。

10. 当前的状态

护士麻醉培训项目随着时间的推移而发展，从卑微的天主教修女开始，由著名外科医生的非正式培训和支持，到今天存在的正式培训和认证项目。目前，在美国有116个认证项目[47];在2014财政年度，国家护士认证和再认证委员会报告了2445名第一次参加国家认证考试[48]的人。

入学要求包括毕业于认可的护理课程，有效的护理执照，护理学士学位或同等学位，至少一年的重症护理经验。训练计划为期24至36个月，学员在训练期间平均使用850种麻醉剂。毕业后，学生必须通过国家认证考试并持有继续职业认证。此外，从2016年8月开始，crna将被要求参加新建立的重新认证项目，以保持教育标准，并确保今天的麻醉护士继续提供安全有效的护理——正如他们近150年来所做的那样。

11. 总结

在美国，在发现一氧化二氮和乙醚的麻醉特性中发挥关键作用的先驱们进行了初步工作之后，对麻醉师的资格或缺乏资格的了解相对较少。在这篇文章中，我们提供了详细的历史信息，关于护士谁学会了安全交付麻醉药的技术，并接管了不明确的工作的麻醉师。我们讨论了军事冲突如何引发对麻醉师的突然需求，以及如何建立短期培训项目来满足这种需求。护士们接受了这一挑战，很可能是因为医生认为安全麻醉不够具有挑战性，不需要全职工作。大多数先锋麻醉护士都得到了资深外科医生的大力支持，他们看到了可靠和充足的安全麻醉师供应的价值。对麻醉护士的正式培训项目始于1909年俄勒冈州的波特兰市，而最早的住院医师培训项目之一于1927年在威斯康星州的麦迪逊市创立。目前，麻醉护士和内科麻醉师的数量几乎相等，每年在美国的民用和军事环境中提供超过4000万麻醉剂。

原文链接：

https://doi.org/10.1016/j.jclinane.2015.11.005

THE

END