BEHIND THE MASK: DRIFITING OFF TO SLEEP; PATIENT COMFORT KEY TO NURSE ANESTHETISTS' JOB

The nurse anesthetist's day usually begins with a routine of changing into scrubs, checking the surgery board to see what has been scheduled and scanning patient files before meeting them and heading into surgery.

That simple routine can change into a job full of challenges by day's end. Certified Registered Nurse Anesthetists make sure a patient sleeps comfortably during surgery and awakens quickly. They administer about 65 percent of the anesthesia for surgical procedures in the United States.

"Sometimes people say we are one of the best kept secrets in health care," said Suzanne Dufek, a nurse anesthetist who works at Southeast Missouri Hospital.

In Southeast Missouri, nurse anesthetists work at hospitals, outpatient clinics, dentist offices and eye clinics to administer anesthesia for surgeries.

Many work in conjunction with anesthesiologists, doctors trained in anesthesia care, which is the case at both Southeast Missouri Hospital and St. Francis Medical Center in Cape Girardeau.

In many rural areas, the nurse anesthetist is often the sole provider of anesthesia care.

The American Association of Nurse Anesthetists has declared this week to be "National Nurse Anesthetists Week" to recognize the 27,000 nurse anesthetists who work in the United States.

Worry about nurse shortage

With a national nursing shortage, Dufek worries that there could also be a lack of nurse anesthetists in the near future.

"I hate to think what that crunch could be like," she said. But nurse anesthetists are in such demand, she gets job offers through the mail almost daily.

However, the number of anesthesiologists in the area seems to be stable, said Dr. Jeff Steele, who practices at St. Francis Medical Center where the eight nurse anesthetists work alongside eight anesthesiologists.

Nurse anesthetists must be trained as registered nurses, have a bachelor's degree in a related field and have at least a year of critical care nursing before entering a nurse anesthesia program.

There are more than 90 nurse anesthetist schools in the country, and nearly all require training on at least 450 cases or 1,000 hours.

Anesthesiologists receive four years of medical school training and four years of residency with specialized training in anesthesia. Some programs offer similar courses for both nurse anesthetists and anesthesiology residents, Steele said.

It isn't difficult for nurse anesthetists to get that training because there are so many procedures that require some type of anesthesia.

"I did 1,000 cases myself," Dufek said of her training.

You do the gamut'

The variety of work is what makes the job exciting.

"You do the gamut of cases." Dufek said. "It could be a 3-year-old with a hernia or a 100-year-old in for cataract surgery."

In some areas of the country there is animosity between anesthesiologists and nurse anesthetists but not in Cape Girardeau, Dufek said.

"We give good anesthesia," she said. Patients can be assured that the medications are better and machines help CRNAs monitor conditions to "give vigilant watch over what's happening."

Certified registered nurse anesthetists work in tandem with doctors who perform the surgeries. Dufek has to know what type of procedure is being done so she knows what sorts of medicines to give a patient.

At St. Francis Medical Center, there is a team approach to anesthesia. Nurse anesthetists perform anesthesia under a physician's direction. For more difficult or specialized cases, a physician provides the care from beginning to end, said Steele, who has been an anesthesiologist at St. Francis for 10 years.

Steele trained at Bethesda Naval Hospital with both nurse anesthetists and anesthesiologists. "When they left the nursing program they were leaving with the same level of training as the junior residents," he said, except that nurse anesthetists didn't have the medical school background of the doctors.

In a recent case where laser surgery was possible, Dufek had to take extra precautions with breathing tubes. The tube had to be wrapped in special flame-resistant tape in case a stray spark from the laser would touch it and cause the oxygen to combust.

"Once you know a patient's history and what plans the doctor has for the surgery then you will know what type of medication to administer," Dufek said.

The work is different every day. One day she might work on the obstetrics floor helping with deliveries, another could be in surgery where she'll see only ear, nose and throat cases.

Reducing stress

Nurse anesthetists work for a week at a time in the cardiovascular unit at Southeast Hospital. Heart cases are more difficult and time-consuming, Dufek said.

"You want to make them as nonstressful as possible," she said of the heart surgeries.

Anesthesiologists at St. Francis Medical Center handle all heart surgeries and any cases that require specialized skills.

What drugs are prescribed differ with each surgery, patient history and allergies. In nearly every case, Dufek will give the patient something that puts him to sleep, keep him unaware and a muscle relaxant to keep his body still during the surgery.

"It's difficult to put your trust in someone," she said, and that's exactly what patients do when they get anesthesia. "They fear losing control and want to know what's happening to their bodies."

It's often easier with children, who get to choose a mask flavored with bubble gum, cherry or strawberry smells. Dufek asks the child to play a game to see how many times they can blow into the mask -- all the while she's administering the anesthesia -- and they don't get scared.

The elderly are more trusting and just "want you to do what's best," she said.

Throughout a surgery, Dufek wears a precordial stethoscope in her ear that lets her listen to the patient's heart and breathing rhythms. She gives the patient fluids with an IV drip and watches a monitor to check the heart rate. Sometimes she puts a patient on a ventilator, a machine that breathes for them and other times she regulates the breathing by squeezing a bag.

"You don't want the patient to suffer," she said. For a surgery involving the vocal cords, she had to make sure that the patient's airway wasn't blocked or didn't swell so much she couldn't breathe.

"But I needed to keep her in a fairly deep sleep because there are so many nerve endings in the throat area," Dufek said.

"It's my job to make sure they don't hurt."