Jose Anesthesia Tech

Jose Anesthesia Tech

Geetings to all readers that have been waiting for a new post from the Nurse Anesthetist.  Today, the focus on anesthesia equipment is increasing both in board review preparation and in the practicing anesthestist.  I will highlight this by a short vignette from this week.

This is another day in the OR with simple cases and a time crunch to get the room set up before the CRNA meeting set for 6:30.  This is the usual state of affairs.  Doing the machine check is a habit that we all have and usually goes off without a hitch but not today.  The first thing I usually do is to check to see if the anesthesia techs have done a machine check for the day.  Arriving at 6:00 in the OR I checked and NO machine check done yet.  That’s unusual.  OK, I can do it no problem and I always have to check the ventilator and tanks anyway so this is just another step.
The first run through results in a high leak failure.  Lets trouble shoot this.  Fist, change the circuit and recheck – plus I changed the CO2 canister which is sometimes the source of a leak in the system if there is a crack in the plascic.  I did a another recheck and this resulted in a failure with high leak.   OK, now its 6:15 and I have to get this done and all the meds drawn up so I call my buddy Jose the anesthesia tech.  Jose to the rescue I am thinking.
Jose goes through a couple of maneuvers and scratches his head quickly and then decides to change out the anesthesia machine BLOCK.  For those that have not seen this done its pretty cool.  Its like a lobotomy of sorts.  The Block in the ADU houses the one way valves for inspiration and expiration.
anesthesia block parts
Even after Jose changed the Circuit, the CO2 absorber and the Block the damn thing still failed because of a high leak.  I have never seen this go this far and still fail.  I am out of clear territory now and ask Jose what to do next.  He said, “well once and awhile we have to check the bellows.”   Really, the bellows can fail as well?  DAMN it, if there was one thing that I thought was sacred it was the bellows.  The sky is falling and its now 6:25.
Jose changed out the bellows housing and wiped down the O’rings on the bottom of the frame between the bellows housing and the rest of the anesthesia machine.  So now we have changed out the CO2 canister, the circuit, the Block housing the fresh gas flow and now the bellows.  Is there anything left I asked Jose.  Of course, I thought that maybe there is a crack in the internal flow meters which could cause a catastrophic failure as I’m seeing here.  It could happen.
Here is the naked fresh gas flow without the bellows in the ADU.

anesthesia machine naked

In the end Jose got the machine working within 15 minutes and thanks to his help I got to the meeting on time. There are several points here I want to make sure all of you understand and take to heart.  There is only one person responsible for an anesthesia machine full check out.  It’s not Jose.
Jose helped me but it is my responsibility to my patients and my profession to make sure that every day without fail not matter what, I DO A COMPLETE AND FULL anesthesia machine check out.  I do not leave this to the techs and bless them they are willing to help.

The other day I had to switch rooms with another anesthesia provider at 07:15.  Did I assume that he had checked out his machine???  Did I rush off to see my patient because we were running late due to the room switch???  NO, I went to the room and did a complete anesthesia machine check out myself.  What I found was an empty O2 cylinder.  No problem, I called the techs and had it changed.  Later that day I talked to some one in charge telling him what I had found hoping that he would make it a point to emphasize the importance to all Anesthesia providers the necessity to check their machines.  I was disappointed to hear him say, “well the techs have to do a better job.”  What about the person doing the case I asked.  “Sometimes we are all too busy” or some such nonsense.  I respect the people I work with greatly but was very disappointed in this response.

The point here is that YOU, the provider, is the only one that is responsible for a complete and thourgh machine check out.  No one else will take the Stand for you in the court room.
If there is an issue with the anesthesia machine and there is morbidity or mortality due to a machine issue the wonderful anesthesia tech that you have relied on will not be named in the law suit.  It’s you and me or any other anesthesia provider that starts a case with a malfunctioning machine that will pay the price of NEGLIGENCE.  The biggest price that will be payed will be in patient insult.  Let me say that again, it is the patient that pays the biggest price.  I do not want any injury to my patient’s on my conscience or imputed to my profession as a Nurse Anesthetist.  I am hoping that all this rant will at least open your mind to the things we all know to be basic.
1)  Never start a case without a complete machine check.
2)  If you have trouble ask for help from some one that knows more than you.
3) Do not ignore any equipment malfunction in the OR.  GET IT FIXED.  DO not jerry rig anything.
4) If all else fails change the bellows.  Kari, knows this one.
OK, thanks for reading and taking this simple cautionary tale to heart.  NEVER start your day without a complete anesthesia machine checkout.
Categories : General
Comments (1)

SRNA Boot Camp

By · Comments (2)
Credit: Keith Weller

Credit: Keith Weller

It is now April and our new Registered Student Nurse Anesthetist’s (SRNA’s) have been in the OR now since January – just a total of three months now.  The progress that they have all made in the operating room really has been tremendous.  To see students come into the operating room for the first time, seeing their nervous hands attempt their first intubations, watching their progress in anesthesia management has really be a privilege to see and participate in.  One of the questions I have always asked myself is, what are the qualities in students that make for their success and what are the things that we can do as mentors and clinical instructors to facilitate that development.  For so many of our students success comes easily and its really difficult to do anything wrong with them.  It seams that that these students just fly right from the start.  Then there is the rare student that will try your soul in getting them to progress into the safe and efficient anesthesia provider you envision for them.

I think there is an answer.  SRNA boot camp is certainly part of the solution.  We have a program that a couple of the faculty CRNA’s / MD’s have started a couple of years ago that puts all of the students into a simulation setting before getting them into the operating room.  The amount of work that has gone into this program really has been great.  The scenario production alone takes a great deal of time.  My good friends Charlotte and Catherine have headed up our program for the students doing a fabulous job in the simulation room.  Each year now the transition into the operating room setting has been smoother for our students in great part due to the time they have spent in the simulation room.

Terrie Cheryl and LaurelIn leading Universities across the country the use of simulation is becoming increasingly important in the education and training of Nurses.  As an example, Duke University School of Nursing has a web page devoted to simulation here.  The University of Southern California department of Emergency Medicine has a very active simulation training as does the Anesthesiology department.  Simulation will be integral in the future of recertification for Certified Registered Nurse Anesthetists. The NBCRNA, the organization that sets the standards for certification and recertification has indicated that in the future simulation will play a big part in that process.  Rectification is the future but for right now getting our students through the educational and training program safely and expertly is key.  The use of simulation is certainly a growing part of that training.  If that does not work I have another thing we can try, a real boot camp.  No I am not kidding.  Here is Geoff as a student and now one of our excellent faculty going through a former boot camp session.

Boot Camp

Actually, Geoff was late for an AM meeting and this was his reward.  All in good fun because our SRNA’s train hard, study hard and play infrequently we hope.


SimMan is a registered trademark of the Laerdal company and is used in simulation centers across the country.

Categories : Student Life
Comments (2)

NBCRNA Updates

By · Comments (4)

DGThere has been so much going on.  One of the projects that is in the works is to get others to participate and write for the web site.  I have invited several to submit articles that would be beneficial to the SRNA community.  Here I am opening the door to others that may want to write for the web site.  Our focus here has been the SRNA but we could open the window a bit and include general anesthesia topics.  These ideas would also certainly be welcome reading for the potential SRNA candidate as well as those already in programs.

The reason I am writing today is to make sure everyone is aware of the moves in the certification process set forth by the NBCRNA – the certification body for all CRNA’s nationally.  Periodically the NBCRNA does a review of their criteria for the certification examination.  An email was just received this morning with news that will certainly effect junior SRNA’s that will be graduating after January 1st 2014.  The bar is going to be higher.  To quote the NBCRNA, “The Board’s decision to raise the passing standard recognizes that healthcare in general and the provision of anesthesia services grow ever more complex, requiring practitioners to have greater knowledge and skills. The new standard will continue to provide assurance to the public that entry-level nurse anesthetists possess the knowledge required to provide anesthesia care.”

Let me say that again.  The passing bar for the national certification examination to become a CRNA will be raised.  The questions will not be different on the exam but I am guessing that the passing score will be more of a challenge and consequently passing rates will decline.  What does this mean for you now that you are in school stressed with exam schedules and clinical rotations.  You will have to work harder and study more.  What good would it do to spend all of your resources and time to graduate from a program of nurse anesthesia to NOT PASS THE NATIONAL EXAM.  No pass – no license period.

Every year students graduate and fail to pass the national examination.  Despite all of the review material available there are those that do not pass on the first try.  Eventually most pass.  If you are working as a GRNA – a graduate that has not taken the exam yet – you have several months before you must pass the exam or loose your job.  If as a GRNA you take the exam and do not pass you loose your job.  As a consequence most that hire graduating SRNA’s will wait till the candidate passes the certification examination before taking on a the new employee.  Nervous yet?

Study study study is the cure.

Here is the letter that was mailed out this morning from the NBCRNA

Friday, February 22, 2013

The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) has voted to raise the passing standard for the National Certification Examination (NCE). The passing standard is the level of knowledge or ability that must be demonstrated in order to achieve a passing score on the NCE. Effective January 1, 2014, all graduates who take the exam will be measured by the new standard.


The NBCRNA periodically evaluates the passing standard to ensure it reflects current expectations for competent professional performance at entry-level. The Board’s decision to raise the passing standard recognizes that healthcare in general and the provision of anesthesia services grow ever more complex, requiring practitioners to have greater knowledge and skills. The new standard will continue to provide assurance to the public that entry-level nurse anesthetists possess the knowledge required to provide anesthesia care.


The NBCRNA Board of Directors accepted the recommendation to increase the passing standard made by a panel of certified registered nurse anesthetists who met to analyze the appropriateness of the current standard for the certification examination. Periodic standard-setting studies are required by our own accrediting agencies, and the procedure we follow is firmly grounded in the testing literature and used by numerous other credentialing bodies, including the National Council of State Boards of Nursing in its NCLEX examination. Subject matter experts representing a diverse sample of anesthesia providers throughout the United States participated in the standard-setting meeting. The panel members were nurse anesthetists who were identified primarily for their familiarity with the skills and knowledge necessary for entry-level practice. They were selected to represent a variety of regions, work settings (urban vs. rural), ethnicities and gender. The panel followed the same Bookmark Method that was used when the passing standard was last adjusted in 2008 to reach consensus on a recommended passing standard. The NBCRNA Board of Directors then met and decided to increase the passing standard based on the panel’s recommendation. More information on the Bookmark Method of standard-setting is available on the NBCRNA website at


Students should know that raising the standard does not mean the individual questions on the NCE will be more difficult. The NCE is adaptive, which means that only questions appropriate to the ability level of the examinee will be administered. Providing early notification of the change will enable schools and examinees to prepare for the NCE.



Charles Vacchiano, PhD, CRNA


NBCRNA President










Categories : General
Comments (4)

New Academic Year Thoughts

By · Comments (0)

DGThe academic year is well underway and thoughts now turn to the candidates that will be filing applications for graduate nurse anesthetists programs.  For those that are thinking about or are applying this year here are a few tips from someone fresh in the mix.

Dear David,

Words cannot express the gratitude that I have for the invaluable shadow experience you presented me and all the words of encouragement you provided me.  Forgive my redundancy, but thank you, thank you, thank you, thank you and thank you some more.  My journey to become a CRNA started when I was just in my third semester of nursing school.  During my clinical as a nursing student in the OR I approached a CRNA and his SRNA apprentice.  I asked them “What do I need to do to be a CRNA?”  To my surprise they kindly offered me their contact information and an opportunity to shadow if I was interested enough.  From that day forward the “fire in my belly,” as you put it, was lit.  I dedicated myself to pull the best grades possible, get acute care experience and do anything I could to build towards getting accepted into the CRNA program at USC.

Read More→

Categories : General, Student Life
Comments (0)

Money Issues

By · Comments (1)

At last I get my wish.  For several years now I have asked my colleague’s to craft a post on what they think is important for candidates to know before they apply to a school of  nurse anesthesia.  It’s been a hard sell.  To be blunt, I have been so busy working and teaching that it has been hard for me to write much as followers here can attest to.  However, there are so many good things happening that I think it is important to pass them along in a more timely manner.  With that in mind, here is what I hope to be another chapter in’s future: guest writers.

This past week I received a letter from Nick Angelis, a CRNA and a writer.  He is actively working on a book, “How to Succeed in Anesthesia School.  I’ll let him tell you himself.  While I could nit pick a couple of his points, the overall focus of what Nick is saying is right on.

At what point should you start denying yourself the simple pleasures of four dollar coffee or blowing a hundred bucks every weekend?  When do you really need to start saving?  The truth is, it could take decades to dig yourself out of debt if you don’t take the necessary steps now.  There is absolutely no point in putting yourself and your loved ones through years of essentially monastic living if you’ll still be living paycheck to paycheck with a higher salary once you graduate. As I’m writing this book, student loans are at such low rates that financing your life with them (and skipping the next few rambling paragraphs) is a viable option.  I previously recommended that students pay off their undergraduate loans before starting anesthesia school, but it’s an individual decision.  As much as it depends on you, keep your other debts to a minimum.  For example, don’t make illegitimate children—child support really adds up.  Chronic illnesses tend to be expensive too, although avoiding carcinogens may be more difficult than wearing seatbelts, selling your motorcycle, or resisting the urge to sled down an icy hill on a skateboard.  The last time I had such an urge, I at least had the presence of mind to increase my life and disability insurance first–which is a must if you have a family, once you become a CRNA.

Read More→

Categories : Anesthesia, Student Life
Comments (1)

New Media for a New Century

By · Comments (4)

This year is going to be a great year for our new incoming SRNA class here at USC.  We are all so much looking forward to the meet and greet coming up next weekend in Malibu.

What is planned for the coming season is to incorporate New Media and “On the Go” technology into the academic mix. Students today want to find information outside of the class room from their portable devices.  With this in mind I have been looking into a couple of new ways to keep students interested and focused.  A great quote I recently heard is, “Education is not filling a bucket, but lighting a fire.”  William Butler Yeats.

With this in mind, I have opened up a Twitter feed called SRNA Cafe focused on education for the nurse anesthetist student.  I hope that you find it useful.  Check it out and if interested in the content “Follow” on Twitter.

Another kind of cool on line way to create content and review material is to connect to to make review cards for yourself.  One of the best methods I have ever found to study is to create flash cards.  The act of making the cards puts the information in another part of the brain.  These connections is what creates memory.  To create recall, frequent review to strengthen the neuronal pathways to that information is what is needed.  For me, making flash cards and reviewing them often works for memorization of data.

We do have a lot of data and information to memorize you know.  The scary thing about medical information is it keeps updating and expanding with time.  In the final analysis there is too much informaiton to know and keep up with.  We have to find ways of on the spot – where we are -access to current thought and research.  Most of this will come later for our students who are just know being introduced to the subjects.  There is much of the basics that do not change much and for now lets focus on that.

Good luck to all of the incoming SRNA’s no matter which program you are in.  Keep focused and above all have fun knowing you are entering one of the greatest adventures of your life.


Categories : Student Life
Comments (4)

At the AANA annual meeting in Boston this past month, the NBCRNA reviled a program for the Continued Professional Certification (CPC) for CRNA’s as opposed to a biannual Recertification process. During the conference the topic of Recertification for nurse anesthetists became the major talking point after hours.  Currently, Rectification for nurse anesthetists requires 40 hours of Continuing Education Units (CEU”S) every two years as well as a work requirement that amounts to about one quarter time in the operating room.  The intent of the NBCRNA in initiating a CPC is to ensure that the CRNA credential continues to represent a commitment to excellence and public safety.

What will the Recertification process look like in the future for Nurse Anesthetists is a real question.  The NBCRNA has the sole authority over the process of Certificaiton and Recertificaiton for CRNA’s and has maintained their independence up until now.  Here is a short blurb from their web site:

The NBCRNA is not part of the AANA as so many seem to think.  The certification autority is not part of the function of the AANA.  Here is a recent letter from the NBCRNA “letting us know” about their progress toward Continued Professional Certification:

Read More→

Categories : General
Comments (12)

Really More Shadow Days

By · Comments (9)

The academic year is winding down and the senior SRNA’s are getting ready to graduate while the new incoming students will be arriving soon.  Next week we have a welcoming party for all of the incoming and outgoing students along with their families at the Chief’s house.  It will be a good time to meet the new ones and to congratulate the graduates.

It is a little early to be talking about the Fall season but already the calls for Shadow days has picked up.  Traditionally, the Fall is the time when most prospective candidates that are seeking positions in the nurse anesthesia programs are looking to hone their interview skills and catch that all important Shadow experience.  I have written about this before but feel that the Shadow exposure is really invaluable for those wanting to enter the profession as a nurse anesthetist.  So, what are some of the things that could be learned through this contact with a CRNA in an operating room.  Thats a big topic so lets keep it simple for now.

The Shadow experience is a two way street.  You get out of it only as much as you can bring.  Put another way; what I would teach or explain to a nursing student would be different from the discussion that I would have with a Nurse Practitioner wanting to go back to school to become a nurse anesthetist.  I had the chance last week to precept someone in the OR with a pHd in pharmacology.  Our discussion went back and forth and undoubtedly I learned more than he did during the day.

Read More→

Categories : Anesthesia, General
Comments (9)

The Keck School of Medicine of the University of Southern California has immediate openings for GRNAs or CRNAs interested in becoming an integral part of an expanding University based Anesthesia Department with clinical academic, research and administrative opportunities.  Clinical service responsibilities include the Los Angeles County General Hospital and USC University Hospitals.  Nurse Anesthetists participate in all clinical areas including trauma, neurosurgery, interventional neuroradiology, hepatobiliary, urology, pediatric, ENT, and orthopedic surgery.  The Nurse Anesthetist performs preoperative and postoperative assessments, provides general, regional, and monitored anesthesia care.  Teaching responsibilities include didactic and clinical instruction for student registered nurse anesthetists through the USC program of Nurse Anesthesia.

Excellent salary base and benefit package, which includes:

  • Four weeks of Vacation (per year)
  • One Week of Education Leave (per year)
  • Retirement Package
  • Paid Professional Licensure
  • Excellent Health Insurance
  • Life and Disability Insurance
  • Tuition Assistance for Self and Family
  • Free CEUs

Academic appointment at the Keck School of Medicine will be at a level appropriate for training and experience.

Please forward your resume to:

Kari M. Cole, CRNA, MS
Chief Nurse Anesthetist and Assistant Clinical Professor
USC Department of Anesthesiology
1200 North State Street, #14-901
Lost Angeles, CA 90033
Phone (323) 409-7735
Fax (323) 441-8085

Categories : General, Practice Issues
Comments (0)

In The News this week, a report published by the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation titled, “Future of Nursing: Leading Change, Advancing Health”, received great reviews by many in health care.

The AACN American Association of Critical Care Nurses issued the following press release this past week:

WASHINGTON, D.C., October 5, 2010 – Today, the American Association of Colleges of Nursing (AACN) applauds the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation for their visionary report on the Future of the Nursing: Leading Change, Advancing Health, which includes among its recommendations removing regulatory barriers to nursing practice, raising the education level of the nursing workforce, enhancing nursing’s leadership role in healthcare redesign, and strengthening data collection efforts.

The IOM is calling for policymakers, educators, and leaders across the profession to take collective action to reform education, strengthen nursing roles, and amplify nursing’s voice in transforming the healthcare system. “The IOM’s focus on the future of nursing comes at a time when healthcare reform presents new challenges and opportunities for the nursing workforce,” said AACN President Kathleen Potempa. “AACN stands ready to work with the Robert Wood Johnson Foundation and other stakeholders to ensure the report’s recommendations are implemented to enhance patient safety and the quality of care available to our nation’s diverse patient population.”

Read More→

Comments (7)


Enter your email address:

Delivered by FeedBurner

website security