AANA and APRN Coalition Partners Urge Medicare Agency to Remove Supervision
In response to the Centers for Medicare & Medicaid Services' (CMS) request for additional feedback regarding elimination of specific Medicare regulations that require more stringent supervision than existing state scope of practice laws, or that limit health professionals from practicing at the top of their license, the AANA and APRN organizations urged the removal of costly and unnecessary physician supervision requirements for APRNs.
The coalition letter signed by 11 APRN organizations and the AANA stated, "We recommend that CMS eliminate unnecessary requirements for physician supervision of APRNs as described below. Given the growing population of persons in the United States requiring healthcare, particularly among Medicare-eligible populations, physician supervision requirements stand in the way of deploying the vast APRN workforce. Unnecessary requirements for physician supervision, such as facility Conditions of Participation that require physician supervision of CRNA anesthesia services...contribute to duplication and waste in the healthcare delivery system. There is no evidence that supervision requirements contribute to higher quality, lower cost, greater value, or access to healthcare. APRNs must hold their own license in each state; therefore, their practice is regulated and does not require additional supervision. On the contrary, ample evidence points to the value provided by APRNs."
Mental Health vs. Mental Illness
Mental Health America says it best, “Not everyone experiences mental illness—but everyone has mental health. Instead of focusing only on people who have already reached a point of crisis, we try to help people understand their mental health needs as early as possible.” Visit www.aana.com/mentalwellbeing to see resources on PTSD, burnout, stress, suicide, and more.
AANA Foundation – Call for Review Committee Members; Respond by January 31, 2020
The Foundation is currently looking for CRNAs to serve on the Research and Scholarship Committees. The Research Committee reviews applications for research grants, fellowships and poster sessions. The Scholarship Committee reviews student scholarship applications. The Board of Trustees makes funding decisions based on the recommendations of these committees. If you are interested, please submit a statement of interest along with your CV to firstname.lastname@example.org by January 31, 2020.
A New Mobile Journal App Coming Soon – February 2020
Stay current with the latest CRNA research and industry news using the new AANA Journal mobile app! You’ll get the same great AANA Journal content, quickly and conveniently across your mobile devices.
AANA members will be able to download the app for free from Google Play, Apple App Store, or the Amazon App Store.
- Listen to Articles - All articles will include narrated audio.
- Watch Videos - Video resources can be viewed in the app.
- Easily navigate - View external resources and pages online directly from the app.
Nomination Deadline for AANA Award for State Government Relations Advocacy is Feb. 15
State Associations: Submit your entry for the Excellence in State Government Relations Advocacy Award, to be presented at the AANA Mid-Year Assembly in April 2020. This annual award is not tied to a specific “victory” in the state legislative or regulatory arena, but is given based on the quality of the state association effort.
Examples of state association efforts include successful lobby days, legislative/regulatory efforts, or increased member participation in grassroots or other efforts. For more information and to submit your state’s application by Feb. 15, 2020, visit the AANA website.
MHAUS Seeks Feedback to Develop Upcoming Anesthesia Machine Preparation Webinar
In February 2020, MHAUS will provide a webinar on options to clean anesthesia machines for MH-susceptible patients and answer specific questions attendees may have on this topic. To ensure the information given will meet attendees' needs, they are soliciting information through a short survey. Please provide feedback to help MHAUS develop a solid and insightful webinar for all.
Gain Inspiration: State Leadership Workshop – Newport Beach, California
When: March 7-8, 2020
Location: Hyatt Regency Newport Beach
Join us in Newport Beach, Calif., for a day-and-a-half workshop that will inspire leaders to:
- Conduct an effective crucial conversation and how to influence change for positive outcomes.
- Describe the applied skills in emotional intelligence and how this relates to your role as a state leader.
- Develop strategies for improving association board governance.
Do You Know an Outstanding CRNA? Nominate Your Colleague for an AANA Recognition Award!
Nomination Deadline: March 15, 2020.
Do you work with an outstanding program director, didactic instructor, or clinical instructor? Do you know someone who has spent a lifetime advancing the practice of nurse anesthesia as a practitioner, educator, clinician, or advocate? Consider nominating your colleague for one of the national AANA recognition awards.
Visit Recognition Awards for details on the:
Nomination deadline is March 15, 2020.
- Agatha Hodgins Award for Outstanding Accomplishment,
- Helen Lamb Outstanding Educator Award,
- Alice Magaw Outstanding Clinical Anesthesia Practitioner Award,
- Ira P. Gunn Award for Outstanding Professional Advocacy,
- Clinical Instructor of the Year Award,
- Didactic Instructor of the Year Award, and
- Program Director of the Year Award.
NewsMaker: CRNA Jana Bailey Works to Protect Patients from Addiction
According to Wave3 News (Louisville, Ky.), Jana Bailey, CRNA, APRN, is the founder of the Opioid Stewardship Initiative. Its goal is "to educate, show alternatives and give people a mixture called Dispose Rx that lets them dissolve their prescription drugs immediately after they are no longer needed. Combined with water, Dispose Rx turns harmful drugs into a gooey substance that you won't and can't use. The initiative also works to prevent overuse of opioids and keep them away from vulnerable people, allowing nurses and doctors to make an impact outside the operating room." Learn more.
NewsMaker: CRNA Mary Anne Krogh Appointed to Brookings Health System Board of Trustees
Mary Anne Krogh, PhD, MS, CRNA, APRN, FAAN, was recently appointed to Brookings Health System's Board of Trustees. She is currently the dean of the College of Nursing at South Dakota State University (SDSU),
“I am interested in developing important relationships in the community to work on critical health care issues such as access to primary care and behavioral health care services for the communities we serve,” said Krogh. “We need a robust health system for the Brookings area.” Learn more.
AANA Meetings: Refresh Your Knowledge and Make New Connections
Come Meet Your Future
Earn Class A CE credits, build your support network, and meet AANA leaders. To view all upcoming live events, visit AANA.com/Meetings
Call for Abstracts: Share Your Story at 2020 Leadership Summit
AANA members are invited to submit an abstract for the new Leadership Summit mini-session series, “Leadership in Action.” This is an excellent opportunity to be recognized as a thought leader and to share your experience with hundreds of engaged CRNA leaders in various levels of leadership. If selected, speakers will receive free registration (travel and hotel accommodations not included) to the 2020 AANA Leadership Summit at the Fort Lauderdale Marriott Harbor Beach Resort & Spa on November 13-15, 2020.
The deadline to submit your abstract(s) for consideration is Friday, February 28. Visit our information page to learn more about submission guidelines, the selection process, and topic suggestions.
Mid-Year Assembly 2020: Advocate for Your Profession on Capitol Hill
When: April 18-22, 2020
Location: Renaissance Washington D.C. Downtown, Washington, D.C.
The Mid-Year Assembly is the most important nurse anesthesia advocacy meeting. Join us on Capitol Hill as we gather, rally, and impress the importance of nurse anesthesia on our legislators.
Ultrasound-Guided Peripheral Nerve Block Workshop
When: March 28-29, 2020
Location: AANA National Headquarters, Park Ridge, Ill.
Earn 12 Class A CE credits and refresh your knowledge of ultrasound-guided peripheral nerve block techniques. This weekend workshop features expert lectures, hands-on instruction, and group discussions of representative clinical cases. Register now for advance registration rates.
Get Details or Register
Save the Date! Spinal Epidural with Obstetric Essentials Workshop
When: April 30-May 2, 2020
Location: AANA National Headquarters, Park Ridge, Ill.
Earn 23.50 Class A CE credits with 4.25 Pharmacology/Therapeutics credits with expert lectures and hands-on instruction. Topics include: normal and abnormal physiology of pregnancy, pharmacology, analgesia/anesthesia techniques, clinical applications of spinal and epidural anesthesia procedures, and introduction to the application of ultrasound using live models.
CRNACareers.com - The New Year is Here! What Will 2020 Bring for Your Career?
Maybe you need a change of scenery or a new challenge. 2020 is here with new opportunities and goals to keep your career stimulated, and jobs for which you are uniquely qualified. Find the new you on CRNACareers.com!
- Search and apply to locum tenens or permanent positions at industry-leading facilities.
- Upload your resume anonymously and allow employers to contact you.
- Set up job alerts to receive notifications on new openings.
- Access free career resources to assist with resume and interview preparation.
Learn more today!
CRNA: Banner Health, Nebraska
Come Home to the clean air quality of life in rural Nebraska!
Nebraska isn't for everyone, but if you enjoy unique adventures, beautiful scenery, calm pace of life, and a solid compensation package, this opportunity is just right for YOU!
Banner Health is one of the largest non-profit healthcare systems in the country with 28 hospitals, six long term care centers and an array of other services, including family clinics, home care services and home medical equipment, in six Western states.
We have an excellent opportunity for a dynamic CRNA to join our highly trained team!
- CRNA-only practice model.
- Responsible for performing general, regional, and monitored anesthesia services including Ultrasound-guided block, and OB.
- Experience preferred.
- One week on, one week off, one week call.
Ogallala Community Hospital (OCH) is an 18-bed critical access hospital committed to meeting the health care needs of western Nebraska and was one of four Banner Health facilities named HealthStrong™ Top 100 Critical Access Hospitals scoring best among critical access hospitals on the iVantage Health Analytics’ Hospital Strength Index™. The Hospital Strength Index is a comprehensive rating of critical access hospitals, and results recognize the Top 100 Critical Access Hospitals that provide a safety net to communities across rural America. Service area 15,653.
Banner Health offers a competitive salary and recruitment incentives along with an industry leading benefits package that provides security for you and your family:
- Comprehensive medical, dental, vision and pharmacy plans.
- Paid time-off plans.
- Eligible for benefits coverage within 30 days.
- Financial savings resources.
- Career advancement and optimal work/life balance.
- Employee Discounts.
CRNA: Atlantic Anesthesia Inc., Virginia
At Atlantic Anesthesia Inc., our supportive care team environment encourages and challenges CRNAs in both clinical and management related team efforts. We are a very stable large Group employing 40 Physicians and 100 CRNAs. As a team member, you’ll gain unrivaled experience working alongside our 100% Board-certified anesthesiologists and other professionals. You’ll also gain valuable exposure to a wide range of clinical cases.
Atlantic Anesthesia, Inc. provides anesthesia services to three hospitals and four ambulatory surgery centers in Norfolk and Virginia Beach: Sentara Norfolk General Hospital (569 beds) Sentara Leigh Hospital (250 beds) Sentara Virginia Beach General Hospital (274 beds) and Virginia Beach Ambulatory Surgery Center.
Experience Opportunities: The total case load among all facilities averages 60,000 procedures per year and 6,000 deliveries per year. We provide anesthesia services for a large variety of surgical procedures, with a case mixture that includes general, trauma, bariatric, ENT, orthopedic, vascular, neurosurgery, ophthalmology, obstetric, and others.
Requirements: Thirty percent of cases in our practice are performed on an outpatient basis. CRNAs work 8hr, 10hr, or 12hr shifts and rotate among facilities. 7 p.m.-7 a.m. in-house night shifts are predominantly covered by a small subset of “night” anesthetists. “Day” CRNAs are scheduled an average of 2 nights per year and 2 weekends per year. There is a financial incentive for CRNAs working the hours from 5 p.m. to 7 a.m. and weekends. Moonlighting opportunities are available. Any CRNAs taking a 12hr in-house night shift will have the following day off. This plan allows CRNAs to work a condensed schedule or work overtime if desired. CRNAs are not required to work overtime unless they choose to do so. The average work week is 36-40 hours. Learn more.
Certified Registered Nurse Anesthetist: Memorial Medical Center, Wisconsin
Full Time opening for CRNA. Practice includes bread+butter cases, general, ortho, ENT, dental, healthy peds, OB and endo. Experience with spinals, labor epidurals, and ultrasound-guided regional anesthesia preferred. Administers anesthesia to patients of all ages in the operating room, delivery room, and in other patient care areas according to hospital policies and procedures.
Reports to anesthesiologist. Salaried 80 hours/2 weeks with call 1:5. Excellent benefits and generous PTO.
Enjoy the best of our 4 season recreation area on the south shore of Lake Superior.
Experience with spinals, labor epidurals, and ultrasound-guided regional anesthesia preferred. Must have excellent customer service skills and the ability to work independently. Must be a graduate of a program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs. A current Wisconsin RN license is required, along with a current certification issued by the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA). Must possess current BCLS, ACLS, and PALS certifications. Advanced pharmacology knowledge, interpersonal skills, and effective verbal and written English communication are required. Learn more.
CRNA II: Novant Health, North Carolina
Novant Health is seeking a CRNA to grow and develop within a professional setting. Team members utilize skills obtained through additional training, education and/or experience in the provision of anesthesia care to patients who present with complex and unique anesthetic requirements. Come join a remarkable team where quality care meets quality service, in every dimension, every time.
Let Novant Health be the destination for your professional growth.
This position is located at our Center City Charlotte Orthopedic Hospital Location.
The schedule is a combination of 10- and 12-hour shifts, one day off per week. This position will cover 7 OR orthopedic suites and also cover a 7 OR outpatient surgery center (peds urology, peds general, outpatient ortho, GYN, robotic hysterectomies).
Highlights: No OB, No out of department, both facilities on the same floor located just down the hall from each other. Beeper call approximately 3 times per month. MDs currently do spinals/blocks. Weekend on-call cases urgent emergent only.
AANA dues paid, Current Reviews CE provided, paid education time, great benefits and retirement matching, surgical services bonus plan
$15,000 Sign-on Bonus for experienced CRNAs and $10,000 for new grads. Relocation assistance provided!
- Education: Bachelor's degree required. BSN required. Graduate from both an accredited school of nursing and school of nurse anesthesia. Listed on the National Board of Certification and Recertification for Nurse Anesthetists as a Certified Registered Nurse Anesthetist and recognized by the state of practice as an Advanced Practitioner. Must maintain CRNA certification as required.
- Experience: Previous experience is not necessary. Four to six week orientation period (working with preceptor) is required. Orientation period will depend on previous experience and clinical skills.
- Licensure/Certification/Registration: Current RN licensure in appropriate state required. BLS, ACLS, and PALS required. CRNA by NBCRNA required.
- Additional skills required: Must have extensive knowledge of current anesthetic agents, techniques, drugs and equipment. Has knowledge and skills necessary to modify the anesthetic care suitable to patient age. Must have considerable ability to make independent decisions, sometimes under stress, and to maintain a professional demeanor with patients, coworkers and physicians.
CRNA at Private Practice: iOBX, North Carolina
Our physicians specialize in Orthopedic Stem Cell procedures. We do all treatments in house at our state-of-the-art facility in Ballantyne. The CRNA would be responsible for administering conscious sedation anesthesia to patients during our treatments. They also would be responsible for stocking the crash cart, maintaining their on-site inventory and performing a pre-procedural assessment the day of the treatment. Shifts may vary depending on the complexity of the case but in general will be 9 a.m.-5 p.m. Our Center is open Monday – Friday, but you would need to be available for the occasional Saturday case. Our average patient is of good health, however we need someone who is comfortable handling the occasional complex patient.
- Medical, Vision and Dental Insurance.
- Great hours (typically an 8-hour day and Mon-Fri).
- PTO for all major holidays.
- Relocation assistance provided.
- $10,000 sign-on bonus.
- Bonus based on performance in addition to competitive salary.
- AANA and state licensure fees paid for by company.
- Frequent catered meals and team building events.
- No on call.
- Malpractice paid for by company.
- Supportive clinical team consisting of PA-Cs, Clinical Assistants and Radiology Technicians.
- License to practice as a Registered Nurse in the state of North Carolina required.
- BLS, ACLS, and PALS required.
- CRNA by NBCRNA required.
CRNA: Beverly Hills Physicians, California
Beverly Hills Physicians, outpatient plastic surgery group in Southern California, CRNA immediate hire. Salary at 160 to 180k depending on experience plus a sign-on bonus plus benefits. No weekends, no on call. 30 to 40 hours per week. Four Surgery Center locations. Travel necessary to locations in Thousand Oaks, Encino, Beverly Hills and Rancho Cucamonga. Learn more.
CRNA: VCU Health System, Virginia
Seeking an Anesthetist to provide anesthesia services at VCU Medical Center for all age groups.
Licensure, Certification or Registration & Education/Experience Requirements:
- Current RN license in Virginia.
- Current license to practice in specialty area (Certified Registered Nurse Anesthetist-CRNA) in Virginia.
- Current CRNA certification by the National Board of Certification and Recertification for Nurse Anesthetists.
At VCU Health System, our most important assets are not bricks and mortar; they are our team members … all 13,000+ of them. Our workforce is diverse, dedicated and talented. Our team members continue to earn local, regional and national awards and accolades, which is an indicator that they are happy and feel supported working here. And our culture of STAR Service focuses on our common purpose – “Our Caring Service Begins With Me.” – in the provision of the highest level of customer service, which encourages diversity and inclusion.
- Academic health care experience.
- One (1) year within the specialty practice area.
If you have been looking to take your career to the next level, we have been looking for you. We offer more than 400 work/life benefits including competitive pay, generous benefits, flexible work options, prepaid tuition, on-site child and elder care and much, much more. Learn more.
Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.
1-1-8 One-Step Sevoflurane Wash-In Scheme for Low-Flow Anesthesia: Simple, Rapid, and Predictable Induction
To improve on shortfalls in existing sevoflurane wash-in schemes for low-flow anesthesia (LFA), researchers developed a 1-1-8 design that can be used with N2O or Air. The team, working out of Khon Kaen University in Thailand, set out to identify the time needed with both to reach each level of alveolar concentration of sevoflurane (FAS) between 1 and 3.5 percent. They assembled a study population of 199 adults requiring general anesthesia with endotracheal intubation and controlled ventilation. The one-step wash-in phase was initiated after induction and intubation, using fresh gas flow of O2:N2O plus sevoflurane for 102 patients and O2:Air plus sevoflurane for 97. Rising patterns of FAS and inspired concentration of sevoflurane (FIS) were comparable between the two interventions, with similar time needed to achieve an FAS of 1, 1.5, 2, 2.5, 3, 4, and 5 percent. Patients in both groups also experienced an early acceleration in heart rate and blood pressure, which subsided as FAS increased. The experiment showcased many benefits of the 1-1-8 wash-in scheme for sevoflurane LFA, including simplicity, target coverage, speed, safety, cost-effectiveness, and flexibility to use N2O or Air.
From "1-1-8 One-Step Sevoflurane Wash-In Scheme for Low-Flow Anesthesia: Simple, Rapid, and Predictable Induction"
BMC Anesthesiology (01/24/20) Vol. 20, No. 23 Tribuddharat, Sirirat; Sathikarnmanee, Thepakorn; Vattanasiriporn, Naruemon; et al.
New Study Sheds Light on PCA Pump Documentation Inaccuracy
Patient-controlled analgesia (PCA) pumps are often used after surgery, in ICU, and in other settings to alleviate pain and manage consumption of narcotic medications, but new findings suggest potential harms. Researchers at the University of California, Irvine Medical Center (UCIMC) conducted a retrospective review of PCA documentation entered into patient electronic medical records (EMRs) during January and February 2019. One or more documentation error was found in 87 percent of the cases. The next leg of the study involved an analysis of 19 PCA pumps, with investigators comparing real-time data from the pump computer with the information contained in the EMR. They found that patients received nearly 21 percent more opioid medication than what their records indicated. The pattern on consistent errors, missing information, and erroneously listed pump dosages could have significant implications, warns Ryan Nguyen, a fourth-year UCIMC medical student who worked on the study. "Doctors write out prescriptions based on the EMR," he explains. "Without accurate documentation, the patient may head home with a prescription that compromises effective pain management. The patient won't have optimal pain control." The research underscores the need to arm nurses with tools to automate I.V. communication, including the PCA pump, Nguyen and his co-authors conclude.
From "New Study Sheds Light on PCA Pump Documentation Inaccuracy"
Pain Medicine News (01/23/20) Davidson, Jordan
Advantages of the Combination of Conscious Sedation Epidural Anesthesia Under Fluoroscopy Guidance in Lumbar Spine Surgery
Spinal surgery is becoming more common as people live longer, but having the procedure under general anesthesia can be dangerous for older patients and those with comorbidities. Researchers in Korea hypothesized that fluoroscopy-guided epidural anesthesia plus conscious sedation might be a safer approach for at-risk populations. To investigate, they retrospectively reviewed medical records for 111 patients who underwent this protocol for lumbar surgery from February to September 2018. The technique proved to be both effective and safe, with all patients registering decreases in postoperative pain regardless of their American Society of Anesthesiology (ASA) physical class or their age. Patients aged 70 and older did, however, take longer to recover postoperatively than their younger counterparts. Recovery time also was prolonged in patients who received greater volumes of epidural anesthesia, which were associated with a higher rate of epidural spread.
From "Advantages of the Combination of Conscious Sedation Epidural Anesthesia Under Fluoroscopy Guidance in Lumbar Spine Surgery"
Journal of Pain Research (01/20) Vol. 2020, No. 13, P. 211 Kang, Seung Youn; Kashlan, Osama Nezar; Singh, Ravindra; et al.
Impact of Timing of Pre-Procedural Opioids on Adverse Events in Procedural Sedation
Researchers wondered if the timing of opioid administration before painful procedures influences the rate of unfavorable sedation outcomes in children. To learn more, members of the Sedation Safety Study Group of Pediatric Emergency Research Canada performed a secondary analysis of a prospective cohort of 6,295 emergency department patients aged 18 years and younger. About 1,800 of the youngsters received pre-procedural opioids; and they were more likely to experience oxygen desaturation, vomiting, and positive pressure ventilation (PPV)—although the effect was not statistically significant with PPV. The risk for these adverse effects was greatest, according to the findings, for patients who took the opioids in the 30 minutes preceding sedation. Understanding this elevated risk can help clinicians prepare for sedation and the prospect of patient rescue, the study authors conclude.
From "Impact of Timing of Pre-Procedural Opioids on Adverse Events in Procedural Sedation"
Academic Emergency Medicine (01/01/20) Bhatt, Maala; Cheng, Wei; Roback, Mark G.; et al.
Development of a Risk Score to Predict Postoperative Delirium in Patients with Hip Fracture
A new risk score has demonstrated accuracy in identifying older adults who are more likely to experience post–hip fracture surgery delirium (PHFD). The nine-item screening tool is based on analysis of data from 8,871 patients aged 60 years or older, 30 percent of whom were assigned to a cohort formed for validation purposes. The other 70 percent made up the cohort that informed the risk score, and PHFD occurred in 1,816 of those 6,210 patients. Researchers applied stepwise multivariable logistic regression to single out the perioperative factors that predict PHFD: preoperative delirium, preoperative dementia, age, medical co-management, American Society of Anesthesiologists physical status III–V, functional dependence, smoking, systemic inflammatory response syndrome/sepsis/septic shock, and preoperative use of mobility aid. The predictive accuracy of the risk score, with a scope of 0 to 20 points, was upheld in the validation cohort.
From "Development of a Risk Score to Predict Postoperative Delirium in Patients with Hip Fracture"
Anesthesia & Analgesia (01/20) Vol. 130, No. 1, P. 79 Kim, Eun Mi; Li, Guohua; Kim, Minjae
Anesthetic Management of Pediatric Patients Diagnosed with X-linked Adrenoleukodystrophy
Researchers at the University of Minnesota examined the risk associated with anesthesia in children who have X-linked adrenoleukodystrophy, a demyelinating disease that typically affects males. They conducted a retrospective chart review of 38 diagnosed patients at the affiliated Masonic Children's Hospital who were exposed to anesthesia a collective 166 times between January 2014 and December 2016. Most of the encounters took place in the sedation unit and involved total intravenous anesthetic with spontaneous ventilation via natural airway. A number of anesthetic agents—including propofol, isoflurane, sevoflurane, ketamine, midazolam, and dexmedetomidine—were used effectively. There were few perioperative complications documented, and those that were noted were low in severity. Meanwhile, no anesthesia-related deaths were reported. The findings of the review indicate that children with X-linked adrenoleukodystrophy can tolerate procedures under anesthesia with little risk while under the care of skilled pediatric anesthesia providers.
From "Anesthetic Management of Pediatric Patients Diagnosed with X-linked Adrenoleukodystrophy"
Pediatric Anesthesia (12/19) Kloesel, Benjamin; Dua, Nupur; Eskuri, Ryan; et al.
News summaries © copyright 2020 SmithBucklin
Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed weekly to AANA members.
Anesthesia E-ssential is for informational purposes, and its contents should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.
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