This is the last week of my Cardiac Surgery rotation at the County Hospital. The anesthesia techniques that I have learned this past month have been very interesting. Today I was able to put it all together for a sort of cap-stone experience in a big case.

Aortic dissection repair is not a surgical case that is approached lightly. This condition may result from chronic hypertension and possibly congenital weakness of the intima of the aorta leading to aneurysm formation and dissection. Unchecked an aortic dissection often proves to be fatal. Remember John Ritter from Three’s Company – he fell victim to a ruptured aortic dissection. Death from a ruptured aortic aneurysm is usually extremely quick and mercifully without drawn out pain.

This vascular case required not only sternotomy but a thoracotomy as well. These are big surgeries. Initially, the plan was for circulatory arrest and profound hypothermia with lumbar drain for cerebral protection. The surgical team decided on the double incision providing a greater exposure and was able to perform the surgery without the circulatory arrest. This was a good thing for everyone. Rewarming after a complete circulatory arrest with profound hypothermia takes several hours. As it was the surgery was long.

Preparation and setup for anesthesia was nevertheless extensive with two arterial line placements both a right radial and right femoral; a double lumen introducer central line placement in the internal right jugular and floating a pulmonary artery catheter were also part of the plan. Additionally, because of the thoracotomy and the extensive dissection into the left chest that was required we used a double lumen endotracheal tube which allowed us to deflate the left lung improving the surgical exposure on the left side. At the end of the case the double lumen tube was replaced with a single lumen endotracheal tube. This was a great experience and wonderful case for me to participate in. You can see the entire Slide Show of the case at flickr. I must warn you that some of the pictures are very graphic and not for the squeamish.

These cases require cardio-pulmonary by-pass. For this case it was a partial bypass that was used when the surgeons isolated the aortic arch. Never the less this resulted in full heparinization and use of the “heart lung machine”. You can see Julia here with her bight smile behind the mask. The presence of the perfusion team in the cardiac room is always a pleasure.

Enjoy the pictures at flickr. If you can recall your anatomy you will notice the structures of the aortic arch repair and marvel at the gortex graft creation by the sugical team.

My name is Fraser MacFarlane and I am a nurse anesthetist student at the University of Southern California. Our class is 5 weeks into the process of nurse anesthesia studies. I can’t tell you of the excitement, hope, anticipation, fear and intense expectations I have felt here on the runway into this profession. The volume of information and the realization of the full responsibilities that come to the student through the learning process are almost too much to handle. Talk about sympathetic stimulation!

Just a little bit about me. I was born in Scotland and moved to the U.S. when I was about 10. I’ve lived in Los Angeles most of my life. However, I married my sweetheart, LaRae in Utah. I have an awesome wife. She is rock solid with a back bone of steel. I wouldn’t be perusing my education without her tremendous encouragement and support. She is currently in Utah tying up some loose ends I have with rental properties. I have two teenage daughters, Megan 14 and Brianna 13. My wife and children will move to L.A.
after Christmas. I miss them a great deal right now.

I have 12 years nursing experience. I did home care for almost 5 years. This prompted me to open a residential care facility for the elderly. My family lived in this home along with dementia clients. Yeeeehaa… what an experience that was. My kids learned what getting old can really be like. Your furniture starts taking on a new odor. Diapers appear in the hallway, and sometimes you’ve just got to take an anxious, confused old man for a walk
before he hurts someone. I sold that facility 2002.

Anyhow, I have 1 year CCU, 2 year Telemetry, 5 years Home health, 1 year ICU and 3 years med/surg. I am stoked for this opportunity to become a CRNA.

Thank you for this opportunity to post on the Nurse Anesthetist web site. There has been a great deal of effort put into creating this web site and adding my post to it now is sweet. Here are just a few thoughts from a green first year nurse anesthetist student. Looking at the posting on valve surgery replacement scares the tar out of me. At the same time I understand that divide and conquer is the process to greater confidence and skill. A large portion of educational motivation stems from psychological preparation and that belief in ones self precedes true learning. For me the inner battle will be fought on this ground; having confidence to believe in ones self.

I am surrounded by an excellent group of fellow students that are with me here at USC. The excellent support system and well educated and very skilled instructors are all here participating. I have been given the opportunity of a life time to study anesthesia.

Next time I post will be at the close of the first semester and as we shall see if I still am as excited as I feel now.

The cardiac surgery rotation here at the County hospital has been a tremendous experience for me. This is the first of my senior rotations and this has been a great start of our second year clinical. Getting up at 4:00 in the morning has never been better. You may ask why such an early wake up. My only reply has got to be that this is when the plump juicy worms are out for easy pickings. Seriously, the cardiac surgery room requires an extensive set up and the early start helps reduce the stress of rushing.

The heart room at LAC-USC opens at 5:30 and by that time I am waiting at the door with all of my equipment gathered in hand, all of the syringes labeled and waiting to be drawn up. Additionally all of the arterial line and double lumen central line / pulmonary catheter equipment are with me. The set up of the syringes and vasoactive drips takes a little while and luckily I have a second year Resident to help me.

This past month I was able to see a few Aortic Valve surgeries with biosynthetic replacement. I have a Slide Show of an aortic prosthetic valve implantation at the photo sharing flickr site. The amazing part of this surgery is the sewing in of the valve to its new home where the old calcified aortic valve used to be. You will note that the aorta is dissected and that the old valve is removed. This procedure requires coronary pulmonary by-pass (CPB) which is an entire topic in itself.

Here is the fun stuff while on CPB it is possible to keep an eye on the surgeons and watch the new valve being sewn into place. Watching the skill of the surgeons and the care that is paid to the individual patient has been a tremendous learning experience.

What I learned today about the induction of cardiac surgery was invaluable. The attending anesthesiologist was able to describe the physiology of stenotic lesions and how to hand ventilate these patients gently with low Pop off pressures; small frequent ventilations during the induction period will keep the mean peak intrathoracic pressures down. The stenotic lesions like aortic stenosis are preload dependant as well as requiring sufficient afterload. Large hand ventilated tidal volumes will increase the intrathoracic pressure and decrease preload lowering cardiac output. This could be a bad thing.

By modifying my hand ventilation technique using less Pop off pressure and smaller tidal volumes with a more rapid rate I was able to achieve lower mean intrathoracic pressures while hand ventilating. I just love this stuff. This was such a great key. I can feel it in my hand now this gentle ventilation technique.

In anesthesia I am continually finding that everything is based on physiology and anatomy. Our techniques must reflect basic understandings of these sciences. This is always more to learn.

In answer to Dawn’s inquiry about the nity gritty of anesthesia and the problems that can come up I have enclosed a correspondence from a very close friend and class-mate of mine who had an anesthesia apparatus setup problem. The Anesthesia machince checkout is one of the first things that we learn to do as beginning practitioners. The file of the Anesthesia Apparatus Checkout Recommendations is available on this site.

Hi guys,

At Hudson (an out-patient facility ed.), you are responsible for changing your circuit in-between cases. I was in a “hurry” and got distracted as I switched out the circuit and forgot to put on the reservoir bag…and obviously I didn’t do a pressure check.

Goodnight guys

Interesting isn’t it how little things can make the biggest difference. This is what it is like to do anesthesia – the constant scanning and checking through lists of set up and detail; Patients Airway is OK, Ventilations, Saturation, Blood Pressure, ECG monitor, IV is running and patent and the list goes on and on; timing of drugs to appropriate surgical stimulation, induction sequences and the Art of Anesthesia – the emergence. One little missed set or timing issue can cause an anesthetic embarrassment and patient compromise. It’s a tough job but someone has got to do it. Are you Man or Woman enough for this?

I wanted to share an experience of mine that happened just a month ago while I was in the Ear Nose and Throat operating room when the director of our anesthesia program came for a facilities check and student evaluation. This visit by Dr. Gold was during my sojourn at Arrowhead Regional Medical Center and a General Surgery rotation. During Dr. Gold’s visit she popped into my room while I was in the middle of a maxillary fracture repair. These cases with ENT are done with a shared airway as well as with the patient turned away from you and the head completely covered with drapes. It was the third case of the day and I had one to follow.

The room turn-over at Arrowhead is very fast and the nursing staff and ancillary support is very good at getting the room ready for the next case. Usually the CRNA or MDA that the student SRNA is working with is present during the patients wake up and tracheal extubation and stays in the room to turn the anesthesia machine over for the next case while the patient is taken to recovery. That is if you are lucky.

Earlier I had taken my second case to the recovery room and had drawn up all of my medications to start the next case as well as reviewed the preoperative examination and paperwork for the third case. The patient was dropped off in PACU and I went directly to the preoperative holding area to pick up the next patient. That was my first mistake. I did not go back to the room to recheck that the staff had properly turned the machine over.

Everything with the beginning of the case went perfectly; here I was in the middle of the case number three, the maxillary fracture repair, and the director of the program was in my room interviewing me and quizzing me on my anesthetic choices. All of a sudden the anesthesia machine starts complaining with an alarm. I am already distracted because of the presence of Dr. Gold in the room and her being there to see how I am doing. Running through the alarm check list I see that there is a disconnect in the circuit. There is now no ventilation and no CO2 return on the screen. Great Gods help me.

The patient is turned away from me and I am sharing the airway with the surgeons because they are operating on the jaw. I think, “I taped the hell out of that endotracheal tube and secured it very well”. Yet I still am wondering if the endotracheal tube is secure and the anesthesia circuit is connected. Quickly I jump under the drapes which are completely covering the patient and assess the circuit to the endotracheal tube – the circuit is connected just fine. I come out from under the drapes and am looking at the machine as the CRNA that I have been working with just happens to come is. He says casually from across the room, “hey there, your circuit is disconnected and on the floor.” Of course it is disconnected but where. Dale astutely was able to see the disconnection of the anesthesia circuit from the anesthesia machine at the place where the circuit attaches to the machine. Now I see the problem and fix it quickly. All is well and no harm is done except to my ego.

Dale at Arrowhead Regional Medical Center “Vigilance is written on his Forehead”

You see, when the staff had set the machine up for the next case and pushed the circuit onto the anesthesia machine it was done casually and not pushed on very tightly. With all of the drapes it was difficult to see where it came off. From this time on I started pushing the circuit on very tightly especially if someone else set the machine up. So this is one more item to add to the list; Make sure the circuit attached to the anesthesia machine is tight.

When people ask me about doing anesthesia the comment is often, “That must be really stressful all of the time, how do you handle that?” The answer is that most of the time giving an anesthetic does not seem to be unduly stressful but there are moments of controlled panic in-between moments of calm. So far in the course of my education and training there has been plenty of support with progressive responsibility given to the students. This has allowed us the opportunity to grow and learn by trying new things and rescuing ourselves from any little embarrassment that we get ourselves into. The safety checks and the protocols for giving anesthesia are fairly extensive but the best monitor is an alert attentive person at the helm with ‘Vigilance’ written all over their forehead.

Safety in anesthesia is a great subject. The AANA has a great resource for the pursuit of anesthetic safety at Anesthesia Patient Safety.com/ Another great resource is the Anesthesia Patient Safety Foundation whose mission …is to ensure that no patient shall be harmed by anesthesia.

The safety record in modern anesthesia is impressive. Yet where equipment and people are involved there is always the potential for trouble. To address that end I have enclosed a link to “Troubleshooting the Anesthesia Machine” by J. Jeff Andrews, M.D. which is interesting reading for the so inclined.

This summer marks that last of our didactic class work in the USC program of Nurse Anesthesia. One of the important non clinical courses is the Professional Aspects course being taught on campus and with field trips to other facilities. This afternoon we had the opportunity to visit the Harbor UCLA Medical Center where Chris Stein and Jennifer Woolley (President of CANA) spoke on the current politics and reimbursement issues involved in Nurse Anesthesia.

Both of these guest speakers are well known activists in the field of Nurse Anesthesia on the State level here in California. It was a great pleasure for all of us that were able to attend the lecture at Harbor UCLA to meet and discuss these political topics of the day.
Chris Stein at the helm of our Professional Aspects Class at Harbor UCLA

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