CRNAs Play Critical Role in Lifesaving Mission in Field of Battle

With Veterans Day upon us, I want to share a story about a military mission (Wall Street Journal: “A Secret U.S. Rescue in Yemen Played a Role in Mideast Peace Deal,” Oct. 19) in which CRNAs were involved at the highest level.

This mission actually was executed three years ago in August 2017. At that time, my Critical Care Air Transport Team (CCATT) had just returned to Al Udeid in Qatar from Germany. We were exhausted and hungry, and we all needed a shower. We were unloading our equipment from the Boeing C-17 Globemaster III military transport aircraft when we were alerted to the next mission.

Our briefing was limited to the following facts: 1). Secretary of Defense (SECDEF) General James Mattis authorized the mission; and 2). we were headed to a contested airfield to rescue a foreign nation’s military members from a helicopter crash.

Our commander asked if we were up for the task, considering that we had just been awake for more than 24 hours completing our previous mission. The team quickly discussed and decided that if the SECDEF authorized this mission, then we better proceed.

When we arrived at the other C-17 for use in this mission, they were hot loading and preparing to take off quickly. We were met with numerous “high-fives” and hugs as the other CCATT team and the AE crews were happy that we joined them. (We were considered the more experienced team with a trauma surgeon and CRNA components.)

Almost immediately, we began to strategize the rescue.

I looked around and noticed that the Phoenix Ravens had joined us. They are an elite team that is deployed to provide extra security for U.S. military aircraft. They were armed with weapons that I won’t mention here. I will admit that I was a bit nervous once I saw them --- if they were part of the mission, then I knew we were heading to an area of elevated terrorist activity.

We landed on the contested airfield in low-light operations (no lights on plane). The skill of our pilot was incredible! As soon as we landed, we rendezvoused with several Ospreys and began treating the wounded. The first person to board our C-17 was a special operations CRNA with night vision goggles (NVGs) and a huge patch on his body armor that said “CRNA.”

I was so proud! CRNAs are everywhere --- on the front lines and in special missions!

We did a hot load and had to quickly secure the patients for a long flight to Germany. Many of our patients were critically injured and required resuscitation during flight. We ended up giving lots of whole blood, placed chest tubes, and performed other procedures while en route. All of our patients survived.

We arrived in Germany to a large coalition of Middle East leadership who had beat us there in their private jets. At this point, I pulled up a CNN television newscast on my phone and realized the purview of our mission. We were debriefed by SECDEF General Mattis once we returned to home base. He told us that we had just performed “Medical Diplomacy” that would pay dividends for years to come.

The Wall Street Journal just published an article about that mission. It’s copied in full below.

I would like to thank all those who have served and are currently serving our country. You make a difference and are more important than you may ever realize. CRNAs are there --- for every heartbeat, every breathe, every second and have been huge assets worldwide in many conflicts and peace missions. Some of my fondest memories and closest friendships were cultivated during my military days. I am blessed and humbled to have served.

For all you do, thank you --- and have a wonderful Veterans Day!

LT Col. Laura L. Wiggins, CRNA, DNP

United States Air Force (Retired)

*****

WSJ News Exclusive

A Secret U.S. Rescue in Yemen Played a Role in Mideast Peace Deal

The U.S. helped rescue U.A.E. soldiers after a 2017 helicopter crash, building a reservoir of trust that helped lead to recent agreement

By Dion Nissenbaum

Oct. 19, 2020

WASHINGTON—On Aug. 11, 2017, a United Arab Emirates helicopter filled with soldiers taking part in an offensive against al Qaeda militants crashed in Yemen, leaving three soldiers dead and seven seriously wounded, including a young member of the royal family.

As Emirati leaders scrambled to rescue their soldiers, they turned to the U.S. and asked America to organize an urgent rescue mission.

In a matter of hours, according to U.S. military officials, American special operations forces rushed to save the Emirati royal and the other soldiers. In ways that couldn't have been anticipated at the time, the unusual military mission helped pave the way three years later for the Israel-U.A.E. peace deal that is reshaping the Middle East.

Until now, the U.A.E. and U.S. military have never acknowledged that American forces saved the young royal that day.

The American at the center of the rescue mission was Maj. Gen. Miguel Correa, a gregarious Puerto Rican who now serves as a special White House adviser and the top National Security Council official for U.S. policy in the Gulf.

Gen. Correa, then the defense attaché at the U.S. Embassy in Abu Dhabi, coordinated the risky 2017 mission, leading to a celebration of the young royal’s homecoming six months later.

The rescue mission made Gen. Correa something of a hero among Emirati leaders, including Crown Prince Mohammed bin Zayed al Nahyan, the country’s ruler, who is also uncle and father-in-law of the wounded soldier saved by the Americans that day.

Gen. Correa’s close relationship with the Emirati leaders became an unanticipated asset in the Trump administration’s secret talks between Israel and the U.A.E. that led to the historic peace deals—known as the Abraham Accords—signed last month at the White House.

The accords marked the biggest achievement in efforts by the Trump administration to solidify ties between Israel and its Gulf neighbors, based on mutual interests in countering Iran that have shifted relationships in the Middle East in recent years.

Officials from the various countries acknowledged the notable behind-the-scenes role played by Gen. Correa. At the White House, before the Sept. 15 signing ceremony, according to people in attendance, the Emirati foreign minister—who is the crown prince’s younger brother and an uncle to the soldier America saved in 2017—pointed to Gen. Correa and told President Trump: “That general is part of my family.”

“This would not have happened without him,” said Abdullah bin Zayed al Nahyan.

That was a feeling shared by the White House team led by Jared Kushner, the president’s son-in-law and the White House point man on Middle East policy. While Mr. Kushner and his deputy, Avi Berkowitz, did much of the heavy diplomatic lifting, they both said Gen. Correa played a key role in securing the deal.

Yousef Otaiba, the influential Emirati ambassador to the U.S. who played a central role in the talks, said their success was built on the confidence the U.A.E. had in Gen. Correa and the rest of the White House team.

“The truth is, for the Abraham Accords to have materialized, there was a very much-needed element of trust, and we had that trust with Miguel Correa and the White House,” he said. “A pretty big leap of faith was required from all sides for this to happen.”

The 2017 rescue mission took place days after Yemeni forces, backed by the U.S. and U.A.E., launched a military operation to drive al Qaeda militants from one of their biggest strongholds.

For years, the U.S. had carried out airstrikes against al Qaeda militants in Yemen, who were considered some of the extremist group’s most dangerous leaders.

Gen. Correa was at his home in Abu Dhabi in 2017 when he got a call that the Emirati helicopter had gone down in Yemen while carrying out a counterterrorism mission.

Officially, Emirati officials said mechanical problems brought down the helicopter. But U.S. officials have said the cause was unclear, leaving open the possibility it was shot down by militants in Yemen.

Three Emirati soldiers were killed. Zayed bin Hamdan al Nahyan, a 27-year-old nephew and son-in-law to the country’s crown prince, was one of seven others seriously injured. U.S. officials soon learned that the young Emirati royal was among those being rescued.

Two American Ospreys carried a special operations forces medical team to the helicopter crash site in Yemen. The American medical team flew the seven injured soldiers to the USS Bataan, a U.S. Navy amphibious assault ship in the Gulf of Aden, said Capt. Bill Urban, spokesman for U.S. Central Command. One soldier died on the way to the ship as a surgeon on the Osprey revived a second Emirati whose heart stopped, said Capt. Urban.

Medical teams on the Bataan worked frantically for 48 hours, Capt. Urban said, as American forces onboard lined up to give blood for the Emirati soldiers. The medical team used 54 of 66 units of blood, making it the largest such “walking blood bank” the Navy has used since World War II, said Capt. Urban.

Meanwhile, U.A.E. leaders asked the Americans for special permission to fly the six soldiers, including the Emirati royal, to Landstuhl, Germany, where the U.S. Army has a medical hospital that specializes in treating combat injuries.

Gen. Joseph Votel, then head of Central Command, called then-Defense Secretary Jim Mattis, who quickly approved the plan as Gen. Correa kept the anxious Emiratis apprised.

The U.S. flew the Emirati soldiers from the ship back to an airport in Yemen, where an Air Force C-17 cargo plane equipped with a special medical unit was waiting to fly them to Germany,

Flying the massive plane into Yemen posed a risk. The U.S. landed the plane at night and flew out before the sun rose to ensure everyone’s safety.

Last year, Gen. Correa’s career was interrupted by complaints that, as defense attaché in Abu Dhabi, he cultivated ties with Emirati leaders without keeping his civilian boss apprised, according to current and former U.S. officials.

He was removed from the post in April 2019 by the top American diplomat in Abu Dhabi, the officials said. A formal Pentagon inspector general investigation concluded that Gen. Correa did nothing wrong, the officials said, and the general eventually secured a new job at the White House National Security Council as senior director for Gulf affairs. The State Department declined to comment. Earlier this year, Gen. Correa was promoted to two-star general.

In mid-June, Mr. Otaiba wrote an op-ed in a leading Israeli newspaper warning the country that its looming plans to annex West Bank land once expected to be part of a Palestinian state would imperil Israeli hopes of building ties with the U.A.E. and other Arab nations.

The op-ed sparked weeks of secret talks between Mr. Otaiba, Israeli Ambassador Ron Dermer and the White House team. The two ambassadors never spoke directly, according to U.S., Emirati and Israeli officials involved in the talks. Instead, they carried out the negotiations through the White House.

In late July, Gen. Correa, who was dubbed the “Arab Whisperer” by his colleagues, flew to Abu Dhabi for a one-on-one meeting with Prince Mohammed. They talked through details of the deal and Gen. Correa reassured the Emirati leader that the U.S. would ensure the terms were honored, according to U.S. officials.

Before the meeting began, Prince Mohammed invited his son-in-law—the one rescued in Yemen that day in 2017—to see Gen. Correa. The young U.A.E. royal rolled in, smiling from his wheelchair.

“The U.S. didn’t need a thank you,” Gen. Correa said recently. “I wanted to show the Emiratis that this was not transactional.”

Mr. Trump unveiled the Mideast deal in an Aug. 13 tweet.

The White House team worked to come up with a name for the agreements, which Bahrain also joined a few weeks later. Gen. Correa was reminded of an interfaith complex the U.A.E. is building in Abu Dhabi known as the Abrahamic Family House because Islam, Christianity and Judaism are all religious branches from the prophet Abraham. Gen. Correa suggested the agreement be called the Abraham Accords.

“I love it,” Mr. Trump told Gen. Correa and the team in the Oval Office. On Sept. 13, officials from the U.A.E., Israel, Bahrain and the U.S. signed the Abraham Accords at the White House.

https://www.wsj.com/articles/a-secret-u-s-rescue-in-yemen-played-a-role-in-mideast-peace-deal-11603099801

Medicare payments favor opioids over alternatives, and that’s a problem

By Angelarosa G. DiDonato

Our country in struggling with an opioid epidemic. An estimated two million Americans suffer from opioid use disorder, and opioid overdoses kill more than 130 Americans each day, on average.

Studies show that opioid addiction can occur from the very first exposure --- and sometimes, that first exposure may be during anesthesia for a necessary surgical procedure.

Certified Registered Nurse Anesthetists (CRNAs) operate in every setting where anesthesia is administered: hospital operating and delivery rooms; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons; pain management centers and more. With such widespread influence among so many health-care settings, CRNAs play a major role in curtailing the opioid epidemic. We understand the risks and effects of the medications we administer, which is why we’re changing the way we operate. Nurse anesthetists today can manipulate their anesthetic to provide narcotic-sparing and often narcotic-free anesthesia. Our nation’s health programs should be doing the same. Unfortunately, federal regulations from the Centers for Medicare and Medicaid Services (CMS) fail to address a number of outdated regulations that put Pennsylvania’s pain patients in harm’s way. Over the last decade, many non-opioid pain treatment options have been developed, including single-dose injectables that release slowly over the course of up to 90 hours. For many patients, these promising alternative therapies can take the place of traditional more-addictive opioid painkillers. However, CMS rules fail to adequately cover the cost of administering these medications, leaving Pennsylvania’s more than 2.7 million Medicare beneficiaries without the option of affordable, non-addictive pain treatment. In a decade that saw drug overdose deaths skyrocket across the nation, Pennsylvania was among the worst in mortality increases, according to the U.S. Centers for Disease Control and Prevention. Last year, 4,125 Pennsylvanians died, according to the state Department of Health, and two-thirds of those deaths involved opioids. Recently, drug overdoses have spiked in Pennsylvania, with the rise coinciding with stay-at-home orders brought on by COVID-19. Treatment centers closed and counseling and support-group sessions went online. The stress and social isolation of being stuck at home also created a dangerous environment for those suffering from opioid use disorder. Beyond the human toll, the costs of opioid addiction are staggering. The CDC estimates the misuse of opioids costs our nation $78 billion annually in lost productivity, health-care services, addiction treatment, law and justice, and much more. Making alternative treatments more affordable and accessible can make a big difference. National studies suggest a 10 percent reduction in surgery-related opioid prescribing will result in 300,000 fewer people annually developing an opioid addiction, and keep over 330 million opioid pills out of American households, where they are often stolen or abused. These aren’t just numbers on a page --- they speak to lives saved, families preserved, and bright futures kept intact. Given the very real risks of opioid medications and the severity of Pennsylvania’s addiction crisis, we can’t wait to act. Antiquated federal regulations have helped to create our nation’s over-reliance on opioids, which remain the cheapest option for health-care providers because of how insurance payments are administered under the current Medicare reimbursement rule. The federal NOPAIN Act, which has bipartisan congressional support, would change that by requiring Medicare to cover non-opioid treatment alternatives for all Medicare recipients. It’s as simple as that. As a nurse anesthetist who specializes in anesthesiology and non-opioid therapies, I’m worried. I know all too well that legal opioid prescriptions and an over-reliance on pain management with narcotics too often can lead patients down a path of years-long addiction. There is only so much I can do in the operating room. We need help fixing laws that discourage alternatives to have a fighting chance. Passing the NOPAIN Act is a critical step in combatting the addiction epidemic nationwide and deserves our support. Angelarosa DiDonato, DNP, CRNA is president of the Pennsylvania Association of Nurse Anesthetists, online at https://www.pana.org.

PANA Members Recount How Patients and Facilities Benefit from Waiver Removing Physician Supervision

Health-care facilities, patients benefit from waiver removing physician supervision during pandemic

We shared with you previously stories from the frontline among certified registered nurse anesthetists who are experiencing firsthand the effects of the state’s temporary blanket waiver removing the physician supervision requirement for CRNAs.

The waiver was included in an executive order that the governor signed to protect health-care practitioners for good-faith actions taken in response to this crisis, and it remains in effect for the duration of the governor’s disaster proclamation.

As you know, Pennsylvania regulations still require physician supervision of CRNAs in a hospital setting. The temporary suspension gives health-care facilities more flexibility to tap into the unique skillset of CRNAs to fulfill critical roles outside the operating room during this crisis. After all, CRNAs possess a skillset uniquely suited to aid during a respiratory pandemic.

Without a doubt, the waiver has made a real difference. Here are some more voices from the frontline. (Please note that the names of the CRNAs and their facilities have been removed to ensure their anonymity and protection in the workplace.)

“My hospital may not financially survive since elective procedures have been canceled. Our anesthesia team staffing had to change to preserve costs and the governor’s order helped us accomplish that.”

“Our role has been authorized for this expansion of function outside the operating room. The plan is to utilize CRNAs to run overflow ICU beds in our PACU and pre-op areas. CRNAs would manage patient care, manage ventilators, order labs, medications and appropriate radiology studies, and insert central and arterial lines as needed.”

“In our facility, CRNAs served in the OR, in labor and delivery, and on the intubation team for the ED and COVID/PUI patients; we also had a portion of our team train to perform supportive roles in our critical care units and also make the PACU into a makeshift ICU if the need arose but that has not been necessary as of this point.”

“Hospital administration along with the support of our MD Anesthesiologist (MDA) counterparts also suspended MDA supervision at the hospital, allowing the CRNAs to practice to the full extent of our knowledge and training. The CRNAs performed advanced practice skills and critical care decisions independent of the anesthesiologists. CRNAs were also the sole advanced practice provider at night during the first two weeks of the COVID crisis. For five weeks, the CRNAs put into practice the skills and knowledge to assist the ICU physicians, nurse practitioners, and nurses. The CRNAs knowingly put themselves literally face to face with COVID patients, intubating and securing the airways, and placing lines to insure vascular access. Our hospital was the hardest hit in central Pennsylvania by the COVID crisis, and had one of the lowest mortality rates. CRNAs were the keystone in the successful treatment and management of these patients.”

This waiver truly has given CRNAs the chance to showcase the value they bring not only to the state’s pandemic response and recovery efforts, but also to the safe, efficient, affordable delivery of quality health care generally. Stories like these and from our earlier post prove why physician supervision should finally be removed permanently in Pennsylvania.