Below is the text of a graduation address I gave a few years ago at the Kaiser Permanente School of Nurse Anesthesia in Pasadena, California. I came across it the other day and I thought that it might be worth sharing with all of those of you who are recent graduates, as well as those of you who taught those graduates. I have always felt that we who have the honor of training the next generation must always strive to inspire the best that that generation has to offer. I hope you enjoy.
I come to celebrate your graduation day with you. Congratulations! Graduations have by tradition needed someone to pontificate, in order to sanctify the moment for posterity. I take this opportunity to pass on some words of wisdom culled from many years of experience as a “gas passer”.
You are about to embark on a grand adventure.
On October 16th, 1846,D r William Morton, a dentist, used ether to painlessly remove a facial tumor from a patient in the OR of Massachusetts General Hospital in Boston under the watchful eyes of the Harvard medical school class. No longer was surgery expected to be a tortuous affair for an awake patient screaming in pain. The world forever changed that day. But it changed in part because the world was ready for it to change. Prior to the 19th century, man’s history was more involved with inflicting pain than relieving it. By the mid 19th century, man had spent almost half a century developing humanitarian reforms and protections – and had begun to seek relief from pain in earnest. Pain was no longer viewed as unavoidable, as something to be endured stoically, as something accepted as divine punishment for sins.
Chemistry had advanced to the stage where compounds could be synthesized. Scientific curiosity for the sole purpose of discovery was now politically correct. And physicians were beginning to make accurate observations and apply them to comparing different treatments. They began to question what they were doing rather than accept all that they had been taught as the ultimate truth.
And in this atmosphere, ether, a commonly known treatment for asthma, COPD and typhoid – and a major recreational drug among health care providers – was recognized as a potential panacea for surgical suffering. What it took was a flexibility of thinking, a person who was willing to open his mind and see the world and its various parts in a different way.
You are now entering a profession where such flexibility of thinking can change the practice of anesthesia both locally and perhaps globally. And you are doing so at a time of considerable societal change.
What would I want you to know as you start your anesthesia careers?
Whitten Truism #1″:
You will always be a student of anesthesia.
Medicine in general and anesthesia in particular continue to change at astounding speed. On my first day of medical school, we were told that within 10 years 50% of what they were about to teach us would be proven wrong. On the other hand, we would only remember 25% of what they were about to teach us. And if we were really lucky, we would remember our 25% from the 50% that was still correct.
Your chosen profession will require you to continue to study for the rest of your lives. This is exciting because you will see all wonder of changes and advances When I started anesthesia in 1980 we were still sometimes using the old bullet type of EKG oscilloscopes where you could see 2 -3 beats in dim succession on a 3 inch screen before the beams wept past again. Monitoring consisted of manual blood pressure cuffs and precordial stethoscopes. The automatic blood pressure cuff and the oximeter were not invented. You had to arrive first in order to claim one of the two portable ventilators and then you had to prove your patient was sickest in order to keep it. Otherwise you just manually ventilated the patient for hours. Our agents were halothane, ethrane and penthrane. Pavulon was the newest muscle relaxant on the block. In 10 years propofol, desforane and sevoforane may well be obsolete.
Truism # 2: Never accept anything you do as the only way.
You must continuously question why you do what you do. Sometimes by doing this you’ll discover that a commonly held belief is just plain wrong. More often it will simply make you a better anesthetist – one who is able to come up with plans B, C and D when plan A fails at 3 a.m. and your patient’s safety is in jeopardy.
Truism #3: Don’t forget that there’s a patient under all those monitors.
There were advantages to growing up in anesthesia without all the alarms and automatization. I developed an internal clock, which made me feel anxious if I didn’t see a new blood pressure within 5 minutes. I could time my anesthetics and judge the depth of anesthesia based on the way the heart tones sounded and on the pattern of respiration. The newest agents and machines are forgiving and will allow you the luxury of giving anesthesia technically and efficiently, without thinking. You could allow yourself to become dependent on the alarms to alert you to problems.
And once the alarms sound you could trouble shoot the alarms without once looking at your patient.”… I expect more of you than this.
As a veteran of many third world trips where the lights and power fail regularly and unexpectedly and where surgery has to continue anyway, I can guarantee you that you are and will always be the most important monitor in the room. Use the new agents and alarms intelligently to enhance patient safety and to improve speed and efficiency. You need to control them. Don’t rely on them to succeed.
Truism #4: Teachers must teach their students to think for themselves.
You will be the teachers of the next generation of anesthetists. Teaching is one of the world’s greatest challenges. You must learn to give your students knowledge and skill while at all times maintaining the safety of your patient. This is not an easy task. You will soon learn why your instructors frequently stood by you with their hands clasped behind their backs. This posture keeps them from grabbing whatever potential “weapon” if destruction the student is holding at the time.
You have to let students develop the ability to think and act on their own. As my teachers used to say, you have to let the students learn to play with the alligators while you’re still around to pull them out of the swamp. You need to teach them to question. They need to know why, not just how.
Truism #5: The most expensive drug or “toy” is not always the next best thing to sliced bread.
You have the fortune of entering anesthesia at the beginning of the battle for managed care. The words cost-benefit will have great meaning in your lives and so they should. Until now, we haven’t had to think about medicine as a limited resource – one that needs to be triaged to a total patient population. We always thought that there was always more of whatever it was where that came from. No longer. Our society can no longer afford to think this way about medicine or about any of our resources- natural or otherwise.
I have been a volunteer on third world medical trips since 1984, travelling with Operation Smile and a few other plastic surgical teams doing free surgery for poor children and adults. I have visited Kenya, Colombia, Nicaragua, Mexico, Vietnam, Honduras, Thailand, and the Philippines. I have seen hospitals where there were 2 blood pressure cuffs for the entire hospital that needed to be shared among the sickest patients.
In the third world children die for the lack of the correct sized endotracheal tube. Third world children still suffer from polio, diptheria, and tetanus in addition to starvation and dysentery. The only anesthetic agents are halothane, curare, and rarely morphine. In some hospitals they still use open drop ether because its cheap, and readily available. You never see nitrous oxide because it’s too expensive. Some of their anesthesia machines are older than I am. Gloves, needles, syringes, and sometimes bandages and IV tubing are washed, re-sterilized and reused. They have no choice.
I have nothing but respect for practitioners in these hospitals because limited as they are, they put patients first and provide the best care they know how to with what they have.
Once you’ve practiced in a location like this, you realize the tremendous amount of senseless waste that our lives and our society are built upon. We take it for granted that this is the only way. Just like the time was right to invent anesthesia in the 19th century, the time is right now to change the way we practice medicine and indeed the way we live in 21th century society.
You will be the pioneers in coming up with good mechanisms for trialing new agents and new techniques and evaluating to see if they’re worth the added expense. Remember, not everything you read in a drug flyer or see on the internet is necessarily true in terms of true cost-benefit. We need to choose rationally and well.
Truism #6: The anesthesia care team approach is only as good as you make it.
You will be at the forefront of further developing the anesthetist/anesthesiologist team concept. This must be true partnership, with each one using the best of what the other part of the team has to offer in order to provide the best in anesthesia care. Two brains can and should be better than one. We are not competitors, we are partners.
Truism # 7: The surgeon is not the enemy.
No patient comes to the OR so that you can perform anesthesia. All come so that the surgeon can perform surgery to treat their disease process. The patient and the surgeon depend on you to allow that to happen safely and painlessly.
But you will find that there is a slight difference in mission that sometimes makes it seem as though the two professions are at odds. The surgeon’s mission is to perform surgery to treat the patient and he or she realizes that a small percentage of the patients will have a poor outcome or die as the result. The anesthesia provider’s mission is to keep all their patients alive and safe during surgery and in the immediate postoperative period – despite the fact that it sometimes appears that the surgeon is trying to kill them.
Your surgeon also cares deeply about the patient. You must develop good working relationships with your surgeons. Work as a team.
Truism # 8: Always strive for perfection but understand that perfection is ultimately unattainable.
You are entering one of the most responsible professions there is. You are the life support in the OR. You are the protector of someone who due to your ministrations is no longer capable of protecting themselves. You have an awesome responsibility and not one to be taken lightly.
You must strive for perfection in all that you do because imperfection can be devastating. But you must also realize that perfection, no matter how hard we strive for it, is unattainable.
In this age of technological wonders and near miraculous drugs, modern medicine has created the expectation of perfection. Technology seems so exact that error becomes almost unthinkable. We are never prepared for our mistakes and we don’t know how to cope with them when they occur. One of my favorite quotes is that good judgment comes from experience and that experience comes from bad judgment. Mistakes will make us grow if we forgive ourselves and let them.
It is also true that we can do everything perfectly, and the patient may still die or have a poor outcome. Medicine is not an exact science.
You cannot face these profound emotional hurdles alone. We all face them. We all feel them.
We can all help each other survive them.
Truism # 9 You are the hospital.
If you are rude so is the hospital. If you are cold and uncaring so is the hospital. Some people think that anesthesia providers never have meaningful patient contact because their patients are all asleep. Nothing could be further from the truth. Your patients are very often scared, powerless, and helpless. They may be in pain. They may feel isolated and alone. And you are the person being trusted with their safety.
You must also be their support. Speak at their level. Watch their eyes and body language to see if they understand you. Be a bit of a chameleon and mold your approach to how they respond to you. Should you be laid back and casual? Should you joke? Should you be very serious? Should you reach out and touch them in support?
Talk to them as they go to sleep. Hold their hand or touch their head or shoulder. Feeling consciousness drain away, perhaps for the feared last time, is frightening and the patient will feel terribly alone.
Your patient will tell between 10-20 people about their care. What will they remember about you?
Truism # 10 : Life is short, enjoy it.
None of us is guaranteed any more time than we’ve already had. At any moment we could be hit by the comet of the century, the traffic wreck of the week, or some unexpected medical disaster. How do you want to be remembered? Don’t we all want to be remembered as someone who was fun to work with; who was respected for our skill and knowledge; as someone who was loved by friends and family; as someone who made the world a better place to live? You won’t be remembered for any of those things unless you are also remembered as someone who really understood what it meant to live lift to the fullest.
With your career ahead of you, reflect on the type of anesthetist, the type of person, you want to be. You have the opportunity to lead into the next millennia. I know you won’t disappoint us.
May the Force be With You
Christine Whitten MD
Whitten, C.E. (2015, Oct 2) Graduation Address School of Nurse Anesthesia [Web log post], Retrieved from https://airwayjedi.com/2015/10/02/graduation-address-school-of-nurse-anesthesia/