Watchful Care: Nurse Anesthesia History US

The narrative of American healthcare includes the dedicated practice of nurse anesthetists, a profession deeply rooted in the concept of watchful care. Alice Magaw, often called the "Mother of Anesthesia," represents the early pioneers who significantly advanced anesthesia techniques. The American Association of Nurse Anesthetists (AANA), founded in 1931, establishes standards and advocates for the practice, ensuring quality patient outcomes. Ether, one of the first anesthetics employed, revolutionized surgical procedures and highlights the ongoing evolution of pharmacological agents used in anesthesia. The Civil War marked a crucial period where nurses first administered anesthesia on a wide scale, laying the groundwork for what would become the highly specialized field; watchful care a history of america's nurse anesthetists during this era showcases resilience and adaptability.

The Enduring Legacy of Nurse Anesthesia: A Profession Forged in Care and Innovation

Nurse anesthesia stands as a vital pillar within the modern healthcare system. Certified Registered Nurse Anesthetists (CRNAs) are advanced practice registered nurses who administer anesthesia and provide related care before, during, and after surgical, obstetrical, and other procedures.

A Cornerstone of Patient Care

These skilled professionals play a critical role in ensuring patient safety and comfort. They manage pain, monitor vital signs, and respond to emergencies, making complex medical procedures possible and more manageable.

Historical Roots and Enduring Relevance

The profession's roots trace back to the Civil War era when nurses provided anesthesia to wounded soldiers. Over the decades, nurse anesthesia has grown from a supplementary role to a highly specialized and independent field.

Today, CRNAs administer more than 50 million anesthetics to patients each year in the United States. Their expertise is particularly crucial in rural and underserved areas where they often serve as the sole anesthesia providers.

The Enduring Impact

Nurse anesthesia continues to be of the utmost importance in healthcare, as it offers patient-focused care, especially in underserved communities where access to anesthesia is limited.

The relevance of CRNAs in the medical field is undeniable, and their dedication to patient care is paramount.

A Thesis of Transformation

The evolution of nurse anesthesia is a testament to human ingenuity and dedication. This evolution has been profoundly shaped by:

• Key Individuals
• Core Principles
• Technological Advancements
• Ongoing Efforts to Define Scope and Autonomy

These forces have collectively propelled the profession forward, transforming it into the respected and essential field it is today.

Pioneering Figures: Shaping the Foundations of Nurse Anesthesia

The evolution of nurse anesthesia is a testament to the vision, dedication, and expertise of individuals who carved a path for the profession. These pioneers, through their groundbreaking work, established the core principles and practices that continue to define nurse anesthesia today.

Let us explore the remarkable contributions of these foundational figures, whose legacies remain an inspiration to current and future generations of nurse anesthetists.

Alice Magaw: The "Mother of Anesthesia"

Alice Magaw's meticulous approach to anesthesia at the Mayo Clinic revolutionized the field. Her meticulous record-keeping and analysis of anesthetic outcomes provided critical insights into patient safety and the effectiveness of various techniques.

Her dedication to painstaking observation and data collection led to the development of standardized anesthesia protocols, drastically improving patient outcomes.

Magaw's tireless work earned her the well-deserved title of "Mother of Anesthesia," cementing her place as a pivotal figure in the profession's early development.

Agatha Hodgins: Champion of Education and Training

Recognizing the need for structured training in anesthesia, Agatha Hodgins established the Lakeside Hospital School of Anesthesia.

This institution became a cornerstone for nurse anesthesia education, providing nurses with the specialized knowledge and skills necessary to deliver safe and effective anesthesia care.

Hodgins' vision for standardized training laid the foundation for the rigorous educational programs that exist today. Her dedication established a benchmark for the profession.

The Enduring Impact of Lakeside Hospital

The Lakeside Hospital School of Anesthesia played a vital role in shaping the profession, training numerous nurse anesthetists who went on to become leaders in the field. The institution's commitment to excellence in education helped to standardize practice.

Helen Lamb and Dagmar Nelson: Stalwarts of Lakeside Hospital

Helen Lamb and Dagmar Nelson were instrumental in shaping the educational environment at Lakeside Hospital. Their contributions were essential to Lakeside Hospital.

Lamb and Nelson were dedicated to nurturing the next generation of nurse anesthetists.

Sophie Granston Kurtz: An Early 20th-Century Innovator

Sophie Granston Kurtz stands as a representative of the many unsung heroes of early 20th-century nurse anesthesia.

Her pioneering spirit reflects the dedication and resourcefulness that characterized the profession's formative years.

She demonstrated the value of nurse anesthetists within evolving medical practices.

Goldie Brangman: A Legacy of Service and Compassion

Goldie Brangman's career as a nurse anesthetist is distinguished by her role as the last nurse anesthetist to administer anesthesia to Martin Luther King Jr.

This historical event underscores the deep commitment to patient care and social responsibility. It demonstrates the importance of nurse anesthetists throughout history.

Brangman's legacy serves as a reminder of the profession's dedication to serving all members of society.

Ira P. Gunn: Breaking Barriers in a Changing Landscape

Ira P. Gunn challenged gender roles in the profession by becoming an early male nurse anesthetist.

His presence broadened the diversity within nurse anesthesia and contributed to dispelling gender stereotypes within healthcare.

Gunn's contributions highlight the ongoing evolution of the profession.

Mildred Clark: Contributing to the Knowledge Base

Mildred Clark's contributions to the literature of nurse anesthesia helped to formalize and advance the profession's knowledge base.

Her dedication to scholarship contributed to the development of evidence-based practice in nurse anesthesia.

Clark helped to establish a foundation for future research and innovation in the field.

Centers of Innovation: Institutions That Shaped Nurse Anesthesia Training and Practice

The evolution of nurse anesthesia is a testament to the vision, dedication, and expertise of individuals who carved a path for the profession. These pioneers, through their groundbreaking work, established the core principles and practices that continue to define nurse anesthesia today. However, the impact of these individuals was amplified by the institutions that provided fertile ground for their innovations. These centers of innovation served as hubs for education, research, and practice, shaping the trajectory of nurse anesthesia and ensuring its place in modern healthcare.

Lakeside Hospital: A Cradle of Nurse Anesthesia Education

Lakeside Hospital, located in Cleveland, Ohio, stands as a cornerstone in the history of nurse anesthesia. It was here that Agatha Hodgins established the Lakeside Hospital School of Anesthesia, a program that became a model for nurse anesthesia education across the country.

Hodgins' vision extended beyond simply training nurses to administer anesthesia; she emphasized a holistic approach that included a strong foundation in anatomy, physiology, and pharmacology.

This comprehensive curriculum, coupled with hands-on clinical experience, produced highly skilled and competent nurse anesthetists who were well-prepared to meet the challenges of a rapidly evolving medical landscape.

Lakeside's commitment to excellence and innovation solidified its reputation as a premier training center for nurse anesthetists. The hospital became a vital source of qualified anesthesia providers.

Mayo Clinic: Pioneering Protocols and Patient Safety

The Mayo Clinic in Rochester, Minnesota, played a pivotal role in the early development of standardized anesthesia protocols, thanks in large part to the work of Alice Magaw.

Magaw, often referred to as the "Mother of Anesthesia," meticulously documented her anesthesia practices, carefully tracking patient outcomes and refining her techniques to maximize safety and efficacy.

Her emphasis on data-driven decision-making was revolutionary for its time and laid the groundwork for evidence-based practice in anesthesia.

The protocols she developed at the Mayo Clinic became widely adopted, contributing significantly to the reduction of anesthesia-related complications and the improvement of patient outcomes.

S. Military Hospitals: Anesthesia Care in Times of Crisis

The demands of wartime have often driven innovation in medicine, and nurse anesthesia is no exception. U.S. military hospitals have long relied on nurse anesthetists to provide anesthesia care to wounded soldiers, often in challenging and resource-constrained environments.

During both World Wars, as well as in subsequent conflicts, nurse anesthetists played a crucial role in ensuring that injured servicemen received timely and effective pain relief and surgical support.

The experience gained in these high-pressure settings honed their skills and broadened their scope of practice.

This experience also solidified the value of nurse anesthetists as essential members of the healthcare team. Their contributions in military hospitals helped to advance the profession and to demonstrate the critical role they play in providing anesthesia care.

Frontier Nursing Service: Bringing Anesthesia to Rural Communities

Mary Breckinridge and the Frontier Nursing Service (FNS) in Kentucky recognized the need to provide quality healthcare services to underserved rural populations.

Breckinridge understood the value of nurse anesthetists in providing anesthesia services in remote areas where access to physicians was limited. The FNS nurse anesthetists delivered care in challenging conditions, providing anesthesia for surgical procedures and childbirth in rural Kentucky.

The work of the FNS demonstrated the versatility and adaptability of nurse anesthetists. It showed their capacity to provide essential healthcare services in diverse settings. It also highlighted their commitment to serving vulnerable populations.

Early 20th Century Schools of Anesthesia: Expanding the Workforce

While Lakeside Hospital holds a prominent place in the history of nurse anesthesia education, it was not alone. Numerous other schools of anesthesia emerged in the early 20th century, each playing a role in expanding the workforce of qualified nurse anesthetists.

These schools varied in their size, curriculum, and affiliation, but they shared a common goal: to provide rigorous training that would prepare nurses to administer anesthesia safely and effectively.

The collective impact of these early training programs was significant. They helped to meet the growing demand for anesthesia services and to establish nurse anesthesia as a distinct and respected profession within the healthcare landscape.

These schools, alongside the pioneering hospitals and organizations, built a robust foundation for the present state of nurse anesthesia.

Core Principles and Techniques: Defining Nurse Anesthesia Practice

The evolution of nurse anesthesia is a testament to the vision, dedication, and expertise of individuals who carved a path for the profession. These pioneers, through their groundbreaking work, established the core principles and practices that continue to define nurse anesthesia today. This section explores the fundamental tenets, techniques, and principles underpinning the practice, highlighting their evolution to enhance patient care and safety.

"Watchful Care": The Bedrock of Nurse Anesthesia

At the heart of nurse anesthesia lies the concept of “watchful care.” This guiding principle underscores the unwavering vigilance and commitment to patient safety that characterize the profession. It encompasses meticulous monitoring, proactive intervention, and a deep understanding of the physiological complexities of each patient.

The early nurse anesthetists often served as the sole anesthesia provider. In the absence of advanced technology, they relied on astute observation and clinical judgment. This legacy of careful attention persists, now amplified by sophisticated monitoring tools and evidence-based protocols.

Early Anesthetic Agents and Their Administration

Ether and Chloroform: Pioneering Agents

In the formative years of anesthesia, ether and chloroform were the primary anesthetic agents. Nurse anesthetists played a vital role in the administration of these agents. They developed protocols to minimize adverse effects.

Ether, while effective, presented challenges. It was flammable and often induced nausea. Chloroform, similarly, was potent but carried a risk of cardiac complications.

Nitrous Oxide: A Safer Alternative

The introduction of nitrous oxide marked a significant step forward in anesthetic safety. Nurse anesthetists were instrumental in its adoption and widespread use.

Nitrous oxide offered a less toxic alternative, providing analgesia and mild anesthesia with fewer side effects than its predecessors.

Expanding the Anesthetic Toolkit: Regional Anesthesia and Intubation

Regional Anesthesia

Nurse anesthetists were among the first to embrace and refine regional anesthesia techniques. These techniques provide targeted pain relief. They avoid many of the systemic effects associated with general anesthesia.

Their expertise in anatomy and pharmacology made them adept at administering spinal, epidural, and peripheral nerve blocks. This expanded the scope of their practice.

Advancements in Intubation

Intubation, securing the patient's airway, is a critical skill in anesthesia. Nurse anesthetists have been at the forefront of developing and refining intubation techniques.

From the early use of direct laryngoscopy to the introduction of video laryngoscopy, nurse anesthetists have consistently embraced innovation to improve airway management and patient safety.

The Technological Revolution: Monitoring and Beyond

The Dawn of Modern Monitoring

The advent of sophisticated monitoring technologies has revolutionized nurse anesthesia practice. Tools like EKG, pulse oximetry, and capnography provide real-time physiological data. These allow for immediate detection and correction of any deviations from the patient's baseline.

Data-Driven Decisions

Nurse anesthetists leverage this data to make informed clinical decisions. They ensure optimal patient safety and comfort throughout the perioperative period.

Pain Management: A Holistic Approach

Beyond Anesthesia

The role of nurse anesthetists extends beyond simply inducing and maintaining anesthesia. They also play a crucial role in pain management.

From administering multimodal analgesia to implementing regional anesthesia techniques for postoperative pain relief, nurse anesthetists strive to optimize patient comfort and recovery.

Embracing Evidence-Based Practice

Modern nurse anesthesia is firmly rooted in evidence-based practice. Nurse anesthetists are committed to staying abreast of the latest research. They integrate findings into their clinical decision-making.

This dedication to evidence-based practice ensures that patients receive the safest and most effective anesthesia care possible.

Patient Safety: The Unwavering Commitment

Throughout its history, the nurse anesthesia profession has maintained an unwavering commitment to patient safety. This commitment is reflected in every aspect of their practice.

From meticulous preoperative assessments to vigilant intraoperative monitoring and comprehensive postoperative care, nurse anesthetists prioritize the well-being of their patients above all else.

Professional Framework: Organizations and Regulations Governing Nurse Anesthesia

The evolution of nurse anesthesia is a testament to the vision, dedication, and expertise of individuals who carved a path for the profession. These pioneers, through their groundbreaking work, established the core principles and practices that continue to define nurse anesthesia to this day. These accomplishments are not solely the product of individual efforts, but were further shaped by the infrastructure of the nurse anesthesia community.

Professional organizations and regulatory bodies form a critical framework that shapes, standardizes, and oversees the practice. This framework ensures adherence to the highest standards of patient care and professional conduct. These organizations and bodies provide essential accreditation, representation, and licensure. The impact of these institutions cannot be overstated when considering the growth and current position of nurse anesthesia within the healthcare landscape.

The American Association of Nurse Anesthetists (AANA): Championing the Profession

The American Association of Nurse Anesthetists (AANA) stands as the preeminent professional body representing Certified Registered Nurse Anesthetists (CRNAs) nationwide. With a rich history dating back to its founding in 1931, the AANA has been instrumental in advocating for the interests of CRNAs. The AANA also acts as a driving force for the advancement of the profession.

The AANA provides a unified voice for CRNAs on legislative and regulatory issues, working tirelessly to protect and expand their scope of practice. The association actively engages with lawmakers, policymakers, and other healthcare stakeholders to promote policies that support CRNAs' ability to provide safe, effective, and accessible anesthesia care. This political role, alongside the support that the AANA provides its members, makes it essential to maintaining the position of nurse anesthetics.

Beyond advocacy, the AANA is committed to advancing the science and practice of nurse anesthesia through education, research, and professional development. The organization offers a wide range of resources and programs. The AANA provides continuing education courses and certification preparation materials, empowering CRNAs to stay at the forefront of their field.

Council on Accreditation of Nurse Anesthesia Educational Programs (COA): Setting the Standard for Education

The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) plays a pivotal role in ensuring the quality and integrity of nurse anesthesia education. As the accrediting body for nurse anesthesia programs in the United States, the COA establishes rigorous standards that programs must meet to achieve and maintain accreditation.

The accreditation process involves a comprehensive review of program curricula, faculty qualifications, clinical resources, and student outcomes. The COA ensures that nurse anesthesia programs provide students with the knowledge, skills, and clinical experience necessary to deliver safe and effective anesthesia care. By setting high standards for education, the COA safeguards the quality of the CRNA workforce and protects the public.

The importance of Accreditation

Accreditation by the COA is essential for nurse anesthesia programs, as it signifies that the program meets the highest standards of quality and prepares graduates for successful practice. Graduation from a COA-accredited program is a prerequisite for certification as a CRNA. This ensures that all certified nurse anesthetists have undergone rigorous training and have demonstrated competency in the full scope of nurse anesthesia practice.

State Boards of Nursing: Regulating Practice and Ensuring Public Safety

State Boards of Nursing serve as the regulatory bodies responsible for licensing and overseeing nurse anesthetists within their respective states. These boards play a critical role in ensuring that CRNAs meet established standards of competence and conduct. The boards also ensure CRNAs provide safe and ethical care to patients.

State Boards of Nursing establish the requirements for licensure as a CRNA. These requirements generally include graduation from an accredited nurse anesthesia program, passage of the national certification examination, and completion of continuing education requirements. The boards have the authority to investigate complaints against CRNAs and to take disciplinary action. Boards can suspend or revoke licenses in cases of negligence, misconduct, or violation of state laws and regulations.

By licensing and regulating nurse anesthetists, State Boards of Nursing protect the public from harm and ensure that only qualified and competent individuals are authorized to practice nurse anesthesia.

Navigating the Landscape: Legal and Scope of Practice Considerations

The evolution of nurse anesthesia is a testament to the vision, dedication, and expertise of individuals who carved a path for the profession. These pioneers, through their groundbreaking work, established the core principles and practices that continue to define nurse anesthesia. However, the journey has not been without its challenges, particularly in navigating the complex legal and scope of practice considerations that govern their role in healthcare.

Defining the Boundaries: The Evolving Scope of Practice

The scope of practice for Certified Registered Nurse Anesthetists (CRNAs) has continuously evolved, shaped by advancements in medical knowledge, technology, and the increasing demands of the healthcare system. CRNAs are advanced practice registered nurses who are qualified and authorized to provide a wide spectrum of anesthesia services.

These services include pre-anesthetic assessment, anesthesia induction, maintenance, and emergence, as well as post-anesthesia care. They also administer pain management therapies and provide advanced airway management.

However, the specific scope can vary by state, influenced by local regulations, hospital policies, and collaborative agreements with other healthcare professionals. This variability highlights the ongoing need for clear and consistent standards to ensure patient safety and access to care.

The Pursuit of Autonomy

Autonomy is a central theme in the ongoing narrative of nurse anesthesia. It is the ability of CRNAs to practice to the full extent of their education and clinical expertise. The pursuit of autonomy is rooted in the belief that CRNAs are capable and qualified to make independent decisions regarding patient care, without unnecessary supervision.

This pursuit is driven by a desire to improve healthcare access, reduce costs, and empower CRNAs to provide the best possible care for their patients. However, the concept of autonomy is often met with resistance from other healthcare professionals who may view it as a challenge to their authority.

Historical Conflicts: Legal Battles with Physician Anesthesiologists

The road to autonomy has been paved with legal battles, most notably with physician anesthesiologists. These conflicts often revolve around issues of scope of practice, supervision requirements, and the perceived threat to physician dominance in the field.

These legal challenges have resulted in a patchwork of state laws and regulations, creating inconsistencies in how CRNAs are able to practice across the country. While some states have granted CRNAs significant autonomy, others maintain strict supervision requirements.

These battles underscore the need for a more collaborative and mutually respectful approach to healthcare delivery, one that recognizes the unique contributions of all members of the anesthesia care team.

Seeking Recognition: Federal Recognition and Reimbursement

Federal recognition and direct reimbursement for services are critical milestones in the advancement of nurse anesthesia. Achieving federal recognition would solidify the role of CRNAs as independent healthcare providers, ensuring they are appropriately recognized and compensated for their expertise.

Direct reimbursement would eliminate the need for CRNAs to bill for their services through a supervising physician, streamlining the billing process and reducing administrative burdens. These steps would not only benefit CRNAs but would also improve healthcare access for patients, particularly in underserved rural areas.

State Autonomy: Navigating Opt-Out Legislation

A significant development in the legal landscape of nurse anesthesia is the implementation of opt-out legislation. This allows states to opt out of federal supervision requirements for CRNAs, empowering them to practice to the full extent of their education and training without physician supervision.

To date, numerous states have opted out, recognizing the value and expertise of CRNAs in providing safe and effective anesthesia care. This trend reflects a growing recognition of the importance of CRNAs in meeting the healthcare needs of diverse communities.

However, the decision to opt out is often met with resistance from physician anesthesiologists, who argue that physician supervision is necessary to ensure patient safety. These debates underscore the ongoing need for evidence-based research and open dialogue to inform policy decisions and promote the best interests of patients.

Tools of the Trade: Technological Advancements in Anesthesia Equipment

The evolution of nurse anesthesia is a testament to the vision, dedication, and expertise of individuals who carved a path for the profession. These pioneers, through their groundbreaking work, established the core principles and practices that continue to define nurse anesthesia. The evolution of these practices has been significantly shaped by the concurrent development and refinement of the tools employed in administering anesthesia. From rudimentary devices to sophisticated, computerized systems, technological advancements have revolutionized the field, enhancing patient safety and expanding the scope of anesthetic possibilities.

The Evolution of Anesthesia Machines

Early anesthesia delivery systems were relatively simple, often consisting of little more than a container for the anesthetic agent and a means of delivering it to the patient. As the understanding of respiratory physiology and pharmacology deepened, so too did the complexity of anesthesia machines.

Modern anesthesia workstations are marvels of engineering, integrating multiple functions into a single, user-friendly unit. These machines precisely control the delivery of anesthetic gases, monitor vital signs, and provide sophisticated ventilation capabilities. They are equipped with alarms and safety features designed to prevent human error and ensure patient safety. The incorporation of microprocessors and software control has further enhanced their precision and reliability.

The Laryngoscope: A Window to the Airway

The laryngoscope, a seemingly simple instrument, has played a pivotal role in advancing anesthesia practice. By providing a direct view of the vocal cords, the laryngoscope enables the safe and efficient placement of endotracheal tubes, securing the patient's airway and facilitating controlled ventilation.

The evolution of the laryngoscope has seen the introduction of various blade designs, each optimized for different anatomical considerations. Furthermore, the advent of video laryngoscopes, offering an enhanced view of the airway on a monitor, has significantly improved intubation success rates, particularly in patients with difficult airways. Video laryngoscopes have revolutionized airway management in anesthesia.

Anesthetic Agents: From Ether to Modern Pharmacology

The history of anesthesia is inextricably linked to the development of anesthetic agents. Early pioneers experimented with various substances, including ether and chloroform, which, while effective in inducing unconsciousness, were associated with significant side effects.

The introduction of nitrous oxide marked a significant step forward, offering a safer and more controllable anesthetic option. Over time, pharmacologists have synthesized a wide array of modern anesthetic agents, each with its unique properties and applications. These agents, including volatile anesthetics like sevoflurane and desflurane, and intravenous agents like propofol and ketamine, allow for a tailored approach to anesthesia, optimizing patient comfort and minimizing adverse effects. The development of new anesthetic agents with improved safety profiles has been a continuous pursuit in anesthesia research.

Patient Monitoring: The Vigilant Eye

The ability to continuously monitor a patient's vital signs is essential for safe anesthesia practice. Early monitoring techniques relied primarily on clinical observation, but the introduction of electronic monitors has revolutionized the field.

EKG and Pulse Oximetry: Cornerstones of Anesthesia Monitoring

The electrocardiogram (EKG) provides real-time information about the heart's electrical activity, allowing anesthetists to detect arrhythmias and other cardiac abnormalities. Pulse oximetry, a non-invasive technique that measures the oxygen saturation of the blood, has become an indispensable tool for monitoring respiratory function. Pulse oximetry is a standard practice in modern anesthesia

Capnography: Measuring Ventilation Effectiveness

Capnography, which measures the concentration of carbon dioxide in exhaled breath, provides valuable insights into ventilation effectiveness and metabolic rate. These monitoring modalities, coupled with continuous blood pressure monitoring and other sophisticated techniques, empower nurse anesthetists to detect and respond to potential problems before they escalate. Capnography has improved detection of ventilation issues

Airways: Maintaining Patency

Maintaining a patent airway is paramount in anesthesia. Oral and nasal airways, simple yet effective devices, help to prevent airway obstruction by keeping the tongue from collapsing against the back of the throat. These airways come in various sizes and designs, allowing for a customized fit for each patient.

Breathing Circuits and Masks: Delivering the Gas

Breathing circuits and masks are essential components of anesthesia delivery systems, providing a conduit for anesthetic gases to reach the patient's lungs. Early breathing circuits were relatively simple, but modern systems incorporate features such as carbon dioxide absorbers and scavenging systems to minimize the risk of rebreathing and exposure to waste anesthetic gases. Different types of masks, including face masks and laryngeal mask airways (LMAs), offer various options for securing the airway and delivering ventilation.

In conclusion, technological advancements have profoundly impacted the practice of nurse anesthesia, transforming it from a largely empirical art to a highly scientific and data-driven discipline. The ongoing development of new tools and techniques promises to further enhance patient safety and expand the capabilities of nurse anesthetists in the years to come.

So, next time you're undergoing anesthesia, remember the rich and fascinating journey of the CRNAs who came before. Their dedication and expertise, chronicled in Watchful Care: A History of America's Nurse Anesthetists, have paved the way for the safe and effective anesthesia care we benefit from today. It's a legacy worth knowing!