With Memorial Day just around the corner, we have summer square in our sights! This time of year it's easy to fill our minds with pleasant thoughts of picnics, days at the beach and hours spent on the tennis court or golf course. But let's all interrupt our busy schedules for just a moment to reflect on why the upcoming holiday weekend even exists. Memorial Day is a time to celebrate the bravery, dedication and honor of all those who have given their lives serving and defending our country. The courage of these great men and women and the sacrifices they made are the reason we enjoy the freedoms we do.
In our ongoing effort to connect with you, National recently attended the PANA meeting in Hershey, Pennsylvania, where we were privileged to meet many of our CRNAs and clients in person. It's always nice to put a face with your name and to strengthen our relationships.
This issue of "National News" contains an article that links improving your health and forgiveness, as well as a great article about how chloroform is opening new avenues in modern anesthesia. We have a feature article on two of our own CRNAs, Tom and Cheryl, and their experiences working with the less fortunate outside the United States. Lastly, increased risk of death and complications during surgeries outside of hospitals are discussed in Study: More Risk in Office Surgeries.
We still have plenty of wonderful opportunities for CRNAs and MDs looking for that perfect summer assignment, whether you're looking to visit southern beaches, Midwest lakefronts or travel the East Coast. We also have coverage available for those groups and hospitals looking to cover vacations and staff vacancies. Call your National Account Manager for the best solution to your needs. Don't forget to check our website frequently at

www.nationalanesthesia.com

Our openings can change quickly and are updated daily so they are always current.
Once again, thank you for allowing us to "Connect" with you through our Newsletter and I hope you will enjoy this issue.

Let's Stay Connected!

Stephen Read, President
National Anesthesia Services, Inc.

U.S. researchers say forgiveness may be good for your health.
A report, published in the Mayo Clinic Women's HealthSource, said holding a grudge appears to affect the cardiovascular and nervous systems.
One study found that people who focused on a personal grudge had elevated blood pressure and heart rates, as well as increased muscle tension and feelings of being less in control. The tension dissipated when participants imagined forgiving the person.
The report said forgiveness doesn't mean forgetting, condoning or excusing whatever happened. It's acknowledging hurt and then letting it go, along with the burden of anger and resentment. The Mayo Clinic recommended talking with a friend, therapist or adviser to help sort through feelings and stay on track.

One of the earliest general anesthetics to be used by the medical profession, chloroform, has shed light on a mystery that's puzzled doctors for more than 150 years - how such anesthetics actually work.
A discovery described as "true serendipity" made by Leeds University PhD student Dr. Yahya Bahnasi, has provided a clue that may unravel the enigma of general anesthesia - and offer the opportunity to design new generations of anesthetics without harmful side effects.
"We take general anesthesia for granted nowadays, but it's still true to say that we don't know exactly how it works on a molecular level," says Dr Bahnasi, a qualified medical doctor on an Egyptian Ministry of Higher Education Scholarship at the University's Faculty of Biological Sciences.
"However, I was examining the relationship between lipids and atherosclerosis (the furring up of arteries) and it just so happened that the lipids I was using were supplied already, dissolved in chloroform . I noticed that the chloroform inhibited, or blocked, the calcium ion channel TRPC5 - it was quite a striking effect."
Ion channels are pathways that allow electrically charged atoms to pass across cell membranes to carry out various functions such as pain transmission and the timing of the heart beat. TRPC5 calcium ion channels are found in many tissues around the body but are predominant in the brain.
"We know that this ion channel plays a signaling role in the central nervous system, which regulates the conscious and unconscious states, so I was left wondering whether inhibiting this calcium ion channel was one mechanism by which anesthesia works," says Dr Bahnasi.
Dr Bahnasi then carried out further experiments with several other modern anesthetic compounds, both intravenous and inhaled, and found that the blocking effect on the TRPC5 ion channel was the same.
He says that the discovery opens up the opportunity to design and develop new generations of anesthetics which directly target TRPC5, but with minimized side effects.
"Of course there are multi-molecular events that work together in anesthesia, and inhibiting the TRPC5 ion channel may just be one of them. But it's a great start in piecing together the underlying mechanisms and providing a novel molecular target for new drug design," he says. "And it's particularly fitting that this evidence was revealed by chloroform, the 'grandfather' of modern anesthetics."

National Anesthesia is proud to profile one of our hardworking CRNA teams. Tom and Cheryl are well traveled CRNAs who cross the northeast doing locum assignments each year. After working for National Anesthesia in North Carolina this winter, they are soon off to Cap Haitian, Haiti, where they'll spend part of their spring helping people in desperate need. This is one of several relief missions they've made to help the people of Haiti and the Dominican Republic. In their travels, they assist several relief organizations and participate in medical clinics.
Many Haitian families live in small tin huts, work in sugar cane fields, and have very little access to clean water. Cheryl says, "Many people die in Haiti from simple things like dehydration, parasitic infection or infection from a simple cut." On relief missions, they do what they can with minimal supplies working in dirt floor clinics, often without electricity, and treating people who line up all day long waiting for simple medical advice. On Cheryl's last visit, they treated so many patients that they ran out of medicine on the first day.
Cheryl and Tom particularly like working with Hearts for the Hungry, a program whose mission is to feed children, sustain and educate the youth of Haiti. Every dollar donated goes toward food. It costs only $88.00 to feed a single school child for an entire year. In addition, one of the pastors associated with the group has been given 12 acres of land by the Dominican government on which to build a hospital and medical clinic for the Haitian people. He anticipates the hospital could be built for as little as $50,000.00 USD. It is Cheryl and Tom's hope to someday bring a medical team to the newly built hospital where they can truly treat the people in need.
In the meantime, they keep the Haitian children close to their hearts; they've even contemplated adopting a 12-year old boy there. According to Cheryl, it takes just one trip to meet the children in the orphanage and see how precious they are. Even faced with such troubles, the Haitian people are kind and generous. They will give you grapefruits, avocados, anything they have to show you their gratitude. Tom and Cheryl repay this gratitude with dedication and love. It's what keeps them going back. National Anesthesia is proud to work with CRNAs like Cheryl and Tom who display compassion and commitment in their professional and personal lives.

Anesthesia may pose safety issues, especially in cosmetic procedures.
Doctors increasingly perform surgery in their offices instead of at hospitals, but researchers have found a higher risk of death and complications in offices compared with other facilities -- and cosmetic procedures cause the most problems.
"Me personally, I would never have surgery in an office. Never ever," said Dr. David Lubarsky, anesthesiology chairman at the University of Miami medical school. "You never know when something is going to go wrong. Can the doctor in the office handle an emergency as well as in the other settings? I say no."
Yet many health leaders, doctors, insurers and patients support office surgery. The setting is convenient and more private. Physicians can control the schedule and use their own staff, and they usually make more money. There's less risk of infections spread by sick hospital patients.
Because doctors charge low or no facility fees, patients may save hundreds or thousands compared with outpatient surgical centers and hospitals -- important when paying out of pocket for elective procedures such as breast enhancement or tummy tucks not covered by insurance.
As a result, office surgeries have skyrocketed. In 1980, fewer than 20 percent of 10 million U.S. outpatient surgeries were done outside hospitals, the Ambulatory Surgery Center Association reports. Last year, about half of 43 million procedures were done outside hospitals, about 10 million each in doctors' offices and free-standing outpatient centers.
The chairman of Florida's Board of Medicine, which oversees physicians, said he is confident office surgery is safe. After dozens of cosmetic-surgery deaths in the 1990s, the state toughened the rules since 2000 to forbid lengthy operations, demand more training and require an anesthetist be present.
"They [offices] are more efficient and the treatment should be as good as it is in a hospital, as long as the [patients] are properly selected and the doctor and anesthesiologist have the proper training," said board chair Robert Cline, a Fort Lauderdale heart surgeon.
Persistent Problems
But researchers reported persistent problems in their new analysis of the 31 deaths and 146 hospitalizations resulting from Florida office surgeries from March 2000 to March 2007. They found:
*Patients suffered anesthesia reactions, heart emergencies, artery-blocking blood clots, internal bleeding, seizures and other complications.
*Cosmetic surgery accounted for about 60 percent of the deaths and hospitalizations. Liposuction using general anesthesia caused one- quarter of deaths and one-eighth of hospitalizations.
*In the emergency cases, at least 92 percent of surgeons were board-certified and credentialed to perform the surgery at a hospital. Of 18 cosmetic- surgery patients who died, three-fourths were classified as very healthy. In other words, office surgery still led to bad outcomes even when the surgeon, setting and patient were ideal, said the study's lead author, Cincinnati dermatologist Brett Coldiron.
"These data reveal and solidify some disturbing trends," Coldiron wrote in the study, published this month in the journal Dermatologic Surgery. "The pattern of deaths and injuries has remained consistent [since] the first year."
The vast majority of complications arose when using general anesthesia that renders patients unconscious, almost none when using local anesthetics that numb a part of the body or leave the patient semiconscious, the study found.
"The continued use of liposuction under general anesthesia must be called into question," Coldiron wrote.
"Virtually all cosmetic surgery, except tummy tucks, can be done without general anesthesia and probably should be," Coldiron said. Some doctors advocate banning it in office surgery because of the risks.
"You can do them under local [anesthesia], but the docs don't like it," Coldiron said. "It takes [time] to numb them up. They like to be efficient. They like to knock them out and knock them down."
Florida's Complication Rates
A 2003 study found that Florida patients were 12 times more likely to have an emergency in an office surgery than at an outpatient surgical center. The rates: 66 complications per 100,000 office surgeries compared with 5.3 per 100,000 at outpatient centers. Complication rates at outpatient centers have proved to be about the same as at hospitals.
Other researchers who analyzed the same Florida figures found no difference between the safety of office surgeries and outpatient-center surgeries, saying the earlier study miscalculated.
The Kuleba family's attorney, Roberto Stanziale, has questioned why Stephanie's operation wasn't done in a hospital. Her surgeon, Dr. Steven Schuster, would not comment except to say his actions were correct.
Kuleba died March 22, apparently from malignant hyperthermia, which causes a severe reaction to inhaled anesthetics -- not nitrous oxide -- usually when combined with the muscle relaxant succinylcholine. The body super-heats, triggering organ failure and cardiac arrest. Her death will be reviewed by the Florida Department of Health, as is standard in such incidents.
Handling a severe emergency such as Kuleba's can overwhelm an office surgeon and the small staff as precious minutes tick by, anesthesiologists said. The surgeon needs to ice the patient, maintain the heart rate and respiration and inject an antidote that can require mixing dozens of vials to get one dose.
"No matter how good you are, no matter if you do everything right, there's still a chance of death," Lubarsky said.
Dr. Barbara Brandom, an anesthesiologist at the University of Pittsburgh who has tracked and analyzed about 300 malignant-hyperthermia cases nationwide, contends that office surgeons should not use the traditional anesthesia combination.
"The main problem with office setting is that there's not extra people to help if there's a difficulty," Brandom said. "You may not be able to get a recognition of a problem as fast as in a hospital, and you might not get the help right away."
Lubarsky goes further. He suggested inhaled anesthesia be banned in office surgeries.
"There are alternatives. You could argue that in the office-surgery setting, they shouldn't be using drugs that cause MH because a fulminant case like [Kuleba's] is too hard to handle," he said.

General Disclaimer: The materials have been compiled by National Anesthesia Services. Inc. from internal and external sources. However, while we have attempted to provide accurate information in this publication, no representation is made or warranty given as to the completeness or accuracy of the Materials. In particular, you should be aware that the Materials may be incomplete, may contain errors, or may have become out of date. You should therefore verify information obtained from this publication before you take any action upon it.