The clinical days with the students amount to four days a week and my schedule lines up pretty well with theirs for the most part.  I choose it this way.  But I did have a Monday or two over the last couple of months where potential students have shown up for “Shadow Days”.  These days are another of the great pleasures I have being associated with the Keck School of Medicine in the Anesthesia department.  Mostly I just take care of the patients while the shadow person observes.  We discuss the anesthesia care and the surgical cases.  What I do is to lead the candidate into a discussion of what it takes to be a nurse anesthetist, the background and individual talent that is needed to succeed in any rigorous anesthesia program.  We also discuss the various program options that are available now including the DNAP and the DNAP degrees that are just around the corner.  More on that in another post to come.

After our day in the OR I always ask the participant to write back to thank the administration and to submit a little description of their experience in the operating room to me.  This helps me get better at seeing what the candidate has identified as important to them and clues me into a better tailoring of the experience for those that are scheduled to come to the OR next.  This has been a work in progress.  Frankly, the Shadow Program has been extremely successful in introducing new candidates to USC and helping the faculty here to get to know the persons that are planning on applying to the program in the future.  I think it saves a lot of time for the candidates preventing wasted effort for the potential students.  By receiving a couple key clues they are able to better prepare, study and present their application in the best light.

What I tell the candidates is based on the individual but in general there are a couple of tips that any wise potential nurse anesthesia student will take to heart.  I always recommend studying for the CCRN exam prior to application as this demonstrates a commitment to excellence and is a land mark indicator for a baseline degree of knowledge.  The achievement of the CCRN certification is a laudable achievement and comes highly recommended.  If a candidate goes through an application process and is not accepted for what ever reason one of the things that is told to that individual is that if they wish to apply again the CCRN certification will help them to be more successful with the next interview process.  Enough said about the CCRN certification.  You can check the requirements to sit for this exam with the American Association of Critical Care Nurses.

One of the other tips I give out is to get the book, “Watchful Care” by Marianne Bankert.  This book chronicles the history and nurse anesthesia in America and is a great inspiration for nurses wanting to go into the field of anesthesia.  This is important background information that is critical to know if you want to sound like a candidate that has done their homework and knows what they are getting into.  Another book I highly recommend is Paul Marino’s great text, “The ICU Book“.  I find that too many candidates coming in to either shadow or to interview do not have enough experience or the base knowledge that will ensure their success in a rigorous nurse anesthesia program.  The information in Paul Marino’s book is fundamental prerequisite knowledge.  There is just too much to learn about anesthesia while in graduate education to try and catch up with the basics that are contained in The ICU Book.  A word to the wise should be sufficient!  As a guide for studying for the CCRN exam, the Core Curriculum for critical care is highly recommended as well.

OK, enough for now.  What follows are a couple notes form recent Shadow days.

David,

I learned a wealth of information when I shadowed a CRNA at LAC-USC medical center today.  I have shadowed anesthesiologists in the past and anticipated my CRNA shadowing experience to be similar.  After about an hour of being in the operating room, I quickly learned my anticipations were mistaken.  The tasks of a CRNA and anesthesiologists may be similar, but the roles are very different.  The CRNA had 90% of the face time with the patient as he performed the pre-operative assessment, explained the procedure, obtained consent, and transferred the patient into the operating room himself.  The CRNA was the person who comforted the patient when he was scared and gave him assurance as he administered sedation to the patient.  The anesthesiologist was there to review the anesthesia plan of care with the CRNA and was informed when the patient was ready to be extubated.  The CRNA touched base with the anesthesiologist, but the CRNA did all of the hands on work. It seems like the anesthesiologist is the coach calling the plays, while the CRNA is the quarterback, controlling what happens on the field. Providing anesthesia is a team effort that requires collaboration at all times.

Every facility has a different idea of the roles each team member should play, which brings me to the next thing I learned.  A CRNA has to be able to adapt to a variety of situations and roles.  To quote a paper I read on nurseanesthetist.org, “There are numerous approaches to administering anesthesia for any given patient and for any given surgery.  The variation in anesthesia is due to the individual differences in patients and patients’ preferences, the requirements of the surgery, the large selection of anesthetic agents to choose from, and the preference of the anesthesia provider.”  A good CRNA has to be able to adapt his/her routine to any given surgical case, taking into consideration the preferences of all team members and the needs of the patient.

In addition to learning about the role of a CRNA, I learned a lot about anesthesia itself.  Thus far, I have only shadowed anesthesiologists in different outpatient centers so it was very informative to watch anesthesia from the inside of a technologically advanced operating room.  I learned about MAC, and how it is used to determine the level of sedation the patient is experiencing.  The MAC, vital signs, and patient’s clinical presentation all help the CRNA in delivering the appropriate level of balanced anesthesia.  Balanced anesthesia is about finding the right combination of inhalation gases and intravenous medications.  The right combination is one that achieves the desired level of sedation for the patient as well as one that is best for the patient hemodynamically.  A good CRNA utilizes balanced anesthesia, keeping in mind the side effects of titrating each type of medication.
In conclusion, I now have a much better understanding of what it means to be a good CRNA.  Learning more about the role of a CRNA has made me realize that it is a perfect job for me.  I want to be the hands-on caregiver watching over the patient, making sure he/she is comfortable during what can be one of the most frightening experiences in one’s life.

Thanks

Here is another one that worked out well.

David,

Thanks again for allowing me to shadow you and your student on Friday. Each time I shadow a different CRNA, I see a slightly different style and it gets even more interesting to me. Ironically, it also scares me to death because although I may be a good ICU nurse in practice, I realize I know only a small fraction of what is out there. How am I going to cram all of that in in just 2 years?!  As a matter of fact, since I froze when you grilled me on propofol the other day, I went home and studied it! So, to answer your question, Propofol (in high concentrations) directly activates GABA A receptors inhibiting post-synaptic potential and causing general inhibition of the CNS!

In many ways, I feel like my last couple of years of researching the profession and preparing myself clinically just culminated in the OR on Friday. Unbeknown to you, some of your original postings on your blog changed the way I thought about nurse anesthesia,  profoundly affected my career path, and perhaps partially influenced my decision to apply to USC. However, I never really thought I’d meet my “online mentor”  in person!  So, thanks for blazing the path for future generations of CRNAs.

Respectfully,
Joe Romero

Finally the last for now.

Dear David,

Thank you for the investing the time and energy into my shadow experience this past Wednesday! I truly learned more than I imagined possible for just a few short hours. The experience solidified my decision to pursue nurse anesthesia education over other advanced education options I had been considering. The degree of professionalism and clinical knowledge of the faculty CRNA’s and students is very inspiring! In addition to clinical knowledge, I was impressed with everyone’s current knowledge of the political environment and changes regarding CRNA practice both in California and nationally.

One of the first topics we discussed was that Governor Schwarzenegger decided last year for California to opt-out of the physician MDA supervisory requirement for CRNA’s. This has huge future implications for anesthesia practice for both MDA’s and CRNA’s. From what I understand this means that CRNA’s are not required by state law to be “supervised” by an MDA in order to remain in compliance with CMS regulations and receive full reimbursement for both the anesthesia provider as well as the facility in which the procedure occurs. This is a huge win for nurse anesthesia practice and in general seen as a negative event within the MDA community. For nurse anesthesia, as much as individual facilities find appropriate for their needs, this could potentially expand job opportunities for future CRNA’s. Also, it seems that this has the potential to allow for CRNA’s to be involved in a bigger scope of procedures for which they are already adequately trained to perform, but which the current practice environment restricts CRNA’s from performing. Though it seems that individual facilities will have the power to decide how many anesthesiologists and CRNA’s they want to hire, I was impressed to learn that the studies show the best patient outcomes overall when both MDA’s and CRNA’s are involved in the patient’s care.
Next, we discussed the differences between the different degrees offered at the various CRNA programs around the country. One place to quickly compare some basic information regarding the different programs is the AANA website which displays a listing of the programs by state including the duration of the program, degree type offered, and contact information. Currently, as of 2015 the entry level degree to enter nurse anesthesia practice will move from the Master’s level to the Doctorate level. I was impressed to hear that USC is ahead of the curve and will be starting a DNAP degree beginning 2011. Thank you for explaining the difference it makes that the nurse anesthesia program at USC is part of the School of Medicine and not the School of Nursing and as a result of this the degree is not technically a nursing degree such as a DNP. From what I understand, this fact has a positive change on the curriculum to have a stronger science emphasis, as the requirement for traditional nursing theory does not apply because the DNAP is not a nursing degree. I feel that details such as this are often overlooked or misunderstood by applicants such as myself when researching programs.

Applicants, such as myself, also often misunderstand and have many misconceptions about how to prepare for and interview for a position in a nurse anesthesia program. I am especially grateful to you David and also to your senior student Shawn for giving me great advice to prepare for the interview and also for the nurse anesthesia education in general. Upon discovering your nurse anesthesia blog a few years ago, I was inspired to purchase and begin reading The ICU Book and was told to REALLY have a good working knowledge of this material. I can tell you that so far this book has been really helpful! It is also critical to be familiar with the commonly used medications and drips used in your ICU and to be well versed in your patient’s diagnosis and co-morbidities. On top of all this, one must have a sense of what nurse anesthesia really is. I take this to include many dimensions of practice including clinical knowledge, political developments, legal implications of practice, and more.

Regarding a working knowledge of what anesthesia is in a clinical sense, I tried my best to remember your six components of anesthesia although I may come up short on this! The first element is anxiolysis and serves to help relax the nervous pre-operative patient. This is achieved both through a caring professional demeanor and pharmacologically through a benzodiazepine such as midazolam. This benzodiazepine along with the sedative-hypnotic propofol helps to achieve the second element of anesthesia: amnesia of the induction and operative phase of the case. Neither of these medications will prevent the patient from experiencing pain however, so opiods such as fentanyl are given to achieve the third element of anesthesia known as analgesia. The fourth element to the best of my memory (forgive me David if I am incorrect here!) is to maintain hemodynamic stability for the patient during the case.

This can be a complicated balancing act as the induction agents and inhaled volatile anesthetics used to achieve the first three elements of anesthesia are know to cause vasodilation (thus decreasing SVR) and are also negative inotropes. These two physiologic changes can both make it easier to start IV’s and also produce marked hypotension that must be mitigated possibly with a combination of IV fluids, adjusting the amount or rate of anesthetic agents given, and possibly giving vasopressor medications to mention just a few interventions. All this is to ensure adequate perfusion throughout the case to the sensitive vital organs. The fifth element is the possible need for muscle relaxation or paralysis and this is dependent on the type of surgery being performed or the particular stage of the surgery. For instance, the orthopedic surgeon needs muscle relaxation in order to reduce a femur fracture because the body’s own physiologic splint gets in the way of external manipulation of the bone. And here is where I must apologize David, as I can’t seem to remember the last element you taught me that day.

To summarize, I must say that this was by far the most informative and inspiring day of shadowing nurse anesthetists or anesthesia residents that I have experienced thus far. It was interesting to see just how different anesthesia practice for CRNA’s can be in different types of facilities. I had previously shadowed at an outpatient surgery center and the cases are relatively simpler in nature and there is a somewhat more relaxed pace overall. The practice at USC seemed much more dynamic and an overall quicker pace that I felt more at home with. I also especially enjoyed the teaching environment and collaboration among the anesthesia providers as well as the surgical team in this environment with high patient acuity. While I had a fantastic experience at the outpatient surgery center and had an incredible CRNA to follow there, the environment of practice at a major medical center such as USC suited my personality better and I was already imagining myself working along side that team or one very similar!

David, thank you so much for taking the time and energy out of your day to take me under your wing for a few hours. I have a better understanding of your devotion to nurse anesthesia and also of your “fire in the belly!” I look forward to submitting my application for the class starting 2011!

Wes Easter RN, BSN, CCRN

Its one thing to have a book understanding of concepts and basic science theory about anesthesia; it is another matter to deliver anesthesia care for a live breathing patient.  I guess that is what makes what we do so much fun.  The clinical rotations now are in addition to continued class room work.  I want to discuss more about what its like to start clinical rotations but first.

Here is a little digression.

There are basically two types of Nurse Anesthesia programs out there.  There are those that “Front Load” with all of the didactic and class room work up front and then put the clinical rotations at the end.  These programs are usually longer because the clinical applications and specialty rotations take at least 18 months of solid work.  Then there are programs that start some clinical rotations immediately combining class room study and clinical rotations.  The USC approach is to give at least one semester of didactic then start the clinical rotations.  What we have been doing for the past two years now is to expose the new students to the operating room environment through the use of “Shadow” experiences and now “Simulation” during the first semester to ease the transition to the Clinical sites.  This seems to be working really well.

Simulation work is the frontier for learning new skills and crisis training.  There are some programs that have really jumped on the Simulation Bandwagon.  The University of Pittsburgh Nurse Anesthesia program has one of the largest Simulation Laboratories in the country.  I was fortunate to visit their fabulous institution during my search for a program for myself.  Pittsburgh or just plain “PIT” is an awesome program.  Fortunately, we have one of the former clinical professors from Pit now as part of our department.  One of his passions is to get the LAC + USC simulation room up and functional.  We have all the equipment but the whole simulation package here is improving with Lou’s help.  Last month we had an all day event with the first year students in the simulation room.  We all learned a lot about what it takes to make it “real”.  One of the “patients” died during the simulation.  It was real “Art”.

Samuel Merritt University has a simulation center as well.  A couple of our faculty here went up to visit their facility to see how they are progressing in their simulation work.  You can read about Sam’s Health Science Simulation Center here.  Samuel Merritt University is one of the great Nurse Anesthesia programs here in California.  They are our San Francisco cousins, sort of.

First Year Nurse Anesthesia Students in the OR

Combining physiology and pharmacology in a hands on application is what the practice of anesthesia is all about.  I have heard it said that anesthesia is an Art and a Science.  For the first year student nurse anesthetists here at LAC + USC in their first clinical rotation it’s more like Effort and Guidance.  The Art comes later maybe way later.

For me as a clinical instructor, watching the growth of the students over the first several months during their clinical trials is like watching your first born learn to crawl then stand.  Crawl mostly, the standing is a little shaky right now.  The first walking steps with minimal if any assistance will come later in the second year of clinical rotations, hopefully.

Airway management is on every one’s mind and developing the needed skills to maintain an airway is something that takes time effort and practice.  Eventually the skills in assessment improve to the point where surprise is a rare occurrence.  For the First Year SRNA’s, just Hand Mask Ventilation can be a challenge, depending on the patient.  I think its important to note that the students are never left in a position where there is any risk to a patient.  A fully trained licensed CRNA or anesthesiologist is with the patient at all times during the first year of nurse anesthesia training at our institution.

Here is a former USC student during anesthesia training.  He was late to a very early mandatory student meeting.  He was setting up his room when he should have been in conference.  We work them hard.

After passing his board exams recently, Geoff is now part of the USC anesthesia team.  We are glad to have him.

The New York Times Opinion section had a great statement today concerning this announcement,

“Mr. Obama has bolstered this country’s global standing by renouncing torture, this time with credibility; by pledging to close the prison camp at Guantánamo Bay, Cuba; by rejoining the effort to combat climate change and to rid the world of nuclear weapons; by recommitting himself to ending the Israeli-Palestinian conflict; and by offering to engage Iran while also insisting that it abandon its nuclear ambitions.”

In the NPR news program Left Right and Center, the topic of discussion turned toward the awarding of this prestigious award.  The comments were mixed and portrayed the ambivalence that surrounds this announcement.  Will Pres Obama fulfill the expectations that are now heaped upon him or will he like Henry Kissinger, secretary of state to Richard Nixon who won the prize in 1973 for establishing a cease-fire in Vietnam be viewed as a total disappointment?  Henry Kissinger winning the Noble Peace Prize is thought by some to be the theater of the absurd after he escalated the war in Vietnam!

Former President Jimmy Carter received the Nobel Peace Prize in 2002 for his efforts to “wage peace” through negotiations with world leaders. But the award was also viewed as a signal of disapproval toward the Bush administration’s march to war with Iraq, of which Carter was a vocal opponent.  Is the election of Obama is another world vote of disapproval against the Bush campaign of disinformation, and global US government expansionism.  Maybe.

My bet is that this is a voice from outside the US saying, “Thank you America for waking up!  Thank you for joining the civilization of the world and seeking to end the proliferation of atomic weapons, encourage the reduction of global warming and initiating talks that will settle the disputes between the Israelis and the Palestinians.  I think the New York Times said it better.

The best months to set up a “Shadow” day to follow a nurse anesthetist is now – between the months of September and January.  These are the months when our first year students are busy in the classroom and the clinical staff in the operating rooms are free to turn their attention to potential candidates entering the program of nurse anesthesia.  We do allow candidates to shadow all year long but the days are more restrictive.

Recently a persistent young man was able to come by and was shown around our dearly loved County Hospital.  It was a busy day.  Maybe that is for the best because it gave a realistic picture of whats its like to have a clinical practice in a large public hospital.  My kinda place.  What follows is the beginning of a screenplay I am sure.  The names have been changed to protect the innocent but the gist of the story is all factual.

Enjoy and let me know what you think.

Red Blanket?…What’s a Red Blanket?

By Hugh Adair

I met David at the double doors of the hospital entrance on the second floor. 6:30 sharp. The introduction was brief and to the point. “We need to get you into scrubs,” he said. Scrubs…awesome. I couldn’t believe this was actually happening.  I was so excited. I came across David’s blog Nurse Anesthetist, several months ago as I was scouring the web trying to find as much information as I could about CRNA’s.  At 35, I decided the life of a television producer was no longer going to fit. For 13 years, I worked in post-production for network and cable television. As a husband and relatively new father of two (a 3 year old son and a 1 year old daughter) I realized the 15-hour day, 6-day workweek was not going to work, plus I yearned to do something rewarding. A strong desire to help others drew me to my decision to become a nurse. I had always been interested in medicine – surgery specifically. When I found out there were nurses that provided anesthesia to patients in surgery, it seemed like a perfect match. Nursing and Surgery. After reading through David’s blog about his life as a CRNA and the journey that got him there, I was even more intrigued. I wanted to speak with him and ask him questions.

One particular page that leaped out at me was an entry on the importance of a shadow day. A shadow day is when a prospective student follows a CRNA from case to case. As a shadow, you are observing right alongside the anesthetist as he or she is working. Having an opportunity to shadow a CRNA for the day would be a good test to see if this was something I was truly interested in pursuing. I reached out. I sent David an email explaining who I was and that I was interested in talking with him about being an anesthetist. I wanted to ask questions like, am I too old to do this? What are the career prospects and opportunities? I also asked if it would be possible to shadow him for the day. I sent the email. I never heard back. I was bummed.  I moved on. I searched the web looking for other possible shadow opportunities. I contacted local hospitals that employ CRNAs to see if they offer a shadow experience, I even asked an OB/GYN friend if she could help, she tried with no luck. Every request was a no. How was I to know if I would enjoy being a CRNA if I couldn’t get a chance to see what it was like? What if I were to invest all of my time, effort and tuition (not to mention the personal toll on my family) to go through nursing school, work for two to three years in ICU and then go back to school for 2 ½ additional years to finally become a CRNA – only to find out it was not for me? I needed confirmation.

Months had passed and I had almost forgotten that I had even sent an email. Then I got the word. David emailed me that his blog had been attacked by a virus and that he was sorry it took him so long to respond. He told me to call him anytime. I was ecstatic. I phoned immediately and left a message. After several rounds of phone tag over a couple of weeks (I didn’t want to hound the guy), we were able to connect. After our conversation that was kind of like a phone interview (I was quite nervous), David spoke the words that sounded like music to my ears. “Well, you need to come down and have a shadow day.” Really? Was this really what I was hearing? “How is your schedule?” he asked. The conversation ended and I met him two days later.

After a brief introduction to the incoming fall class of SRNAs and other faculty members, I was given a set of scrubs and we were off and running.

David was covering one of the operating rooms reserved for the E.R. Since these rooms are used specifically for the E.R., there were no scheduled procedures on the board.  By 7:00 am we were sent in to relieve two Resident Anesthesiologists who had been in surgery since 10:00 pm the night before. An 18-year-old male with multiple gunshot wounds to the pelvic region. When David took over, the Orthopedic team was finishing up their work and the OR staff were preparing for the Vascular team to begin their work of repairing this kid’s veins. After the exiting residents briefed David, he signed on and took over the case. David immediately begins assessing the patient, monitors and medications. David works at a rapid, yet controlled and calculated pace. Impressive. Very impressive. The patient is stable and very lucky to be alive as he lies on the table with an incision from his sternum to his lower abdomen, an incision from his inner groin to his knee and several incisions on his hip. The operating room buzzes with adrenalin. David continually monitors and adjusts his medications. He gives me a complete play-by-play of what he is doing and the reason why he is doing it. David even throws out a couple of test questions as any good teacher would. “This is an applied science,” he says. “Anyone can regurgitate information, that’s not good enough. You need to be able to practice it.” This is life or death. No room for errors.

It’s 9:00 am. Time is flying by and I am loving every minute of this experience. David needs to be relieved from this case to take over the room next door. He briefs the Doctor taking over the case. Once finished, David grabs his MP3 player and we move next door. David plugs in his music player and begins prepping for what is coming down the pike. David’s preparation is articulate and precise. Remember, no room for fuck-ups. David checks, double checks and triple checks his medications.  Once satisfied and set-up we take a quick break for a burrito. “You eat when you can,” he says. During our brief breakfast David asks if I’m still interested in pursuing the career. “Very much,” I replied. David, under no uncertain terms, makes it very clear how hard a road it is to become a CRNA. Preparation seems to be a paramount prerequisite for anyone considering applying to the USC CRNA program. In addition to courses taken during nursing school, David recommends taking additional semesters of physics, upper division chemistry and an epidemiology course. Breakfast was brief. We head back upstairs.

A 17-year-old male came in the night before with a clean fracture to both the ulna and radius. David showed me the x-ray on the computer screen. “This could be very complicated,” said David. Hardware was probably going to be needed. The boy’s mother passes by the nursing station as they wheel the patient into the pre-op room. She is visibly shaken and scared for her son’s pending operation. Her English is broken. David speaks to her in Spanish. Her eyes fill with tears. David’s words comfort her. She tells David she will pray for God’s guiding hand over him and the operating staff. I get a little choked up myself. This is real. This is exactly why I want to do this.

I follow David into the room for the pre-operative interview. The patient seems alert and lucid. David asks him how he ended up in the ER. “Skateboarding.” he said. David runs through a battery of questions. “Have you had any kind of surgery before? Any known allergies? Was he born naturally or by caesarian?” The mother had a natural birth, but premature. This was important information. David was writing down his notes when a nurse came in and said they were sending up a RB from the 6th floor. “RB? What’s an RB?”  “Red Blanket,” said David. A Red Blanket is an emergency call for surgery. An RB is a life or death call that apparently supersedes any scheduled or lower acuity procedure. David apologizes to the fracture case and tells them he will be back later.

A 55-year old female was six days out from colorectal surgery. On rounds, a resident was examining the patient and asked her to cough. The patient coughed, her abdominal sutures break and her intestines herniate. Surgery is definitely needed.  After reviewing her chart, David preps his workspace. David works expediently, yet remains cool. The OR is prepping. He turns on his music. David has an eclectic taste in his tunes, mostly British pop. I wondered if his music choices held any significance or if it was just white noise while he worked. The patient arrives, distressed. As described, a small portion of her intestines are protruding out of her stomach. The patient’s gut is severely swollen (gas). She looks like she is nine months pregnant. David reassures her and givers her something to calm her down. The patient begins to relax. As the team transfers her to the table, the patient loses control of her bowels and makes quite a mess. A slight distraction. The nursing staff make quick work and move on. David introduces another medication and the patient quickly falls asleep. Once asleep, the patient is intubated and put on the ventilator. By the way, if I haven’t mentioned this in a while, this experience is incredible. I am mesmerized, like a kid in a candy store. But I digress. The attending surgeon arrives. He and the resident get to work. It seems the patient’s fascia was not strong enough to hold the sutures. Before long, the patient is made whole and the surgery is over. I follow David as he escorts the patient to recovery. Once in recovery, David gives the post-op nurse a run-down from the surgery and follow-up orders.  This case is finished.

David makes tracks to prepare for the 17-year old with the fracture. I follow. David stops and tells me I need to go eat. My day in the OR was over. I was bummed. I was hoping he would say, “Ok, let’s go”, but I was done. Then I realized that it must be tiring having someone looking over your shoulder for six hours.  I thanked him once again and changed out of my scrubs.

David escorted me to the door where I met him. He told me once I was actually in nursing school that I should call and do it again. He was very gracious. We shook hands and he went back inside. What an experience. Thank you David.

There you have it straight from the horses mouth.  I think Hugh should stick to writing screenplays what do you think.  Just kidding.

Just so its clear, what Hugh did not notice is the communication and team work in the anesthesia department at the Big House.  We work in a team setting with M.D. anesthesiology and CRNA’s.  This is one of the great benefits for our patients.  Without being political, two heads and four hands are often better than one.  Get it?

As you can see by just looking around that the look of the web site is different.  This comes from a new format, thanks to iThemes and updated software from WordPress.  With all of the revamping going on, the work has spurred me into more diligence in keeping things rolling here.  The result is that there should me more frequent updates and added content to the web site in the coming months.  Stay tuned and again thank you to all the well wishers.

Now, lets eat!

First I believe you have to make a commitment to what is important to you and your education.  Most of us have complex lives and can not simplify and dedicate to one thing only.  Even with busy lives family and multiple commitments you have to say, “This is my time.  This is my time to be selfish for OUR future and dedicate myself to this course of study”.  If you can not do this then maybe you have chosen the easier way that will not lead to the promised land.

Here is the small list of things I try:

Immersion

Writing out your ideas or lists to remember

Making note cards to carry around

Taking naps

Reading a lot!

Rereading more.

Ok, so this is the short list from a non expert in the field.  If you want to get the real low down on learning follow the link to an article that just is better than sliced bread for the student.  I highly recommend reading the article Hacking Knowledge.

Before the immersion process into anesthesia practice many of us had assumptions about what the world of anesthesia care is and what it takes to be a nurse anesthetist. Its only by being in the mix can it be demonstrated.  It’s only my opinion now – every one has their place in the world where they can be their best and do good work.  Where is it for you? For me its in the operating room giving kind attentive care with anesthesia and mentoring others to do the same.  Only you will be able to know if this a field that you have enough passion and drive to sustain you in order to attain the necessary skills to excel as an anesthesia provider in today’s world.

Here are a few comments from two “Shadow Experiences”.  What will yours be?

Dear David,
My observation experience was pivotal in understanding the dynamic practice of a CRNA and increased that a fire in my belly pursuit for this field of nursing.  The moment I met Kari Cole, I was greeted with warmth and welcomed to the new state of the art LAC + USC Medical Center facility.  I met various individuals on my observation day such as the anesthesia attending Dr. Leipzig, and CRNAs Charlotte Garcia and David Godden.  Everyone was extremely friendly and receptive to my presence in the OR department.  The CRNAs that I met enjoyed teaching and it proved to be a great learning experience for me.

Through speaking with David, I learned about the goals of anesthesia and received a mini lesson on respiratory physiology.  Thanks David for taking the time to teach and give advice to me.  I spent the morning and afternoon shadowing Charlotte Garcia CRNA and gained further insight into the CRNA profession.  She provided a holistic approach to the plan of care starting with a very thorough preoperative work up that included a review of history and physical, consents, labs, EKG, x-ray films, and assessment of the patient.  CRNAs possess exceptional knowledge and astute skills which enables them to respond to the dynamic patient changes in the operating room.  On this particular day, I saw those attributes come into play as the Charlotte demonstrated diligence with induction, intubation, and positioning of the patient.  During surgery, she manipulated various medications and fluids to maintain hemodynamic stability and to ultimately achieve the goals of anesthesia.

I learned a plethora of new and interesting concepts from Charlotte such as MAC, calculating blood loss, and reversal agents.  I also received advice about the educational rigors and expectations of the USC Program of Anesthesia.  While in the OR, Kari and Charlotte taught me about anesthesia and the elderly, an approach that is unique because geriatric patients respond to anesthesia very differently than adult patients.  I would like to thank everyone for taking the time to teach me about the CRNA profession.  My shadowing experience was extremely positive and I hope to return to this facility for another observation day in the near future.

Sincerely,
Mabel RN

Thank you Mable.  You were terrific and I am looking forward to seeing your application and encouraging you during the interview process.  Mabel demonstrated the attributes that potential candidates need to succeed.  Good luck and keep the fire burning.

Here is another letter I received and held back a couple of weeks trying to figure out what to do with it.  Should I edit it a bit….Hmmmmm.  In the end here it is – another example of work from a great candidate that idealizes so many of the great qualities of nurse anesthesia practice; attentiveness to detail, patience and sound judgment.  Lisa I am looking forward to seeing you again and I know that you will do well what ever program you choose to join.  The only reason I held back on posting your letter without editing is that it seemed a little too much about me which I do not want.  So here it is.

David,

It was a true pleasure meeting you, The Average Man, behind the making of a terrific website for people who are interested in pursuing an advanced degree in Nurse Anesthesia (NA). A few months ago I did a web search looking for sites that could answer some of my questions regarding the NA profession, without all the boring political information, and came across yours. When I arrived at LAC + USC for my shadowing experience and Mrs. Cole said I would be with you I was ecstatic, had goose bumps and was jumping for joy on the inside. I said to her David the one that developed the nurse anesthetist website. She simply said yes. I had the biggest smile on my face that I would like to think made the sun shine brighter that day.
I would encourage anyone who is thinking of going into an advanced degree of nursing to shadow a practitioner in their chosen field.

Personally, I have shadowed a few times which just reinforces my desire to become a CRNA. By far, shadowing at LAC + USC has been the most rewarding for me. Probably because they are a strong teaching and research institution. Along with their expertise staff.

As a seasoned critical care nurse I feel confident in the excellent care I provide. I enjoy and embrace learning and increasing my knowledge base because it allows me to better serve the patients I encounter. During my shadow experiences, I must admit, I am amazed at how little I really know. This in turn just gives me more motivation to continue my professional career growth along the nursing continuum. Although I know that CRNA school will be painstaking rigorous, I am eagerly awaiting the challenge. The coined term a fire in the belly is what I felt at the beginning of my journey. That burning feeling has now become an engulfed fire running through my body.

David, thank you for your guidance and all the wealth of information you had shared regarding the profession, preparing for it and becoming a CRNA. You patiently and thoroughly answered all my questions. In addition, I would like to thank your colleagues for being enthusiastic, warm and welcoming when I was introduced to them. All of them (including you) gave encouraging words and advice. I value and greatly appreciate the experience I had during my visit

Sincerely,

Lisa

There you have it.  When will you call for a Shadow experience?  You have to remember that only The Shadow Knows for sure.  When you do interview for that coveted spot in an anesthesia program no matter where it is the one sure question that will be asked is if you have “Shadowed a nurse anesthetist and what did that experience teach you?”  That is a guaranteed question and one you must be prepared to answer.

The next step is yours.

Mel never lost here enthusiasm through loss of sleep and all the struggles SRNA’s go through.

Here is her letter to Dr. Michele Gold the program director at USC that puts it all in perspective:

Hi Dr Gold,

I just needed to drop you a quick line to Thank You and all of my preceptors and teachers at USC. As you know, I am out here in Florida, and it has been a real eye-opener as to the superior education and training that I have received at USC compared to (unfortunately) a lot of new graduates and students that I have come in contact with.  It has made me appreciate my “painful” two years even more….and I never thought Id say that Hope all is well with you and the program, we are loving our new life in Florida.

Sincerely,
Mel

Its a good thing for current students and candidates to any nurse anesthesia program to hear the stories of others however brief.  During our time in “The Program” at USC Mel and I did struggle more than a few times with what seemed at the time to be unreasonable expectations.  To say that its tough to become a CRNA is a true statement.  Think about it.  Would you want some lazy inattentive provider giving anesthesia to your grandmother?  Wouldn’t you want the brightest most vigilant anesthetist with the experience to handle any difficulty during the anesthetic to be at the head of the bed.  That’s what all anesthesia providers strive for whether physician or nurse anesthetist.

A case in point.  Yesterday afternoon a gun shot wound victim was “RB’d” to the OR.  Three CRNA’s and a first year resident were on hand to start the case that very quickly required all the standard lines, arterial central and multiple large peripheral IV’s.  We began the case immediately when the guy arrived with a Level One rapid infuser in the room.  We ended the case the two Level One’s going for volume resuscitation, I was giving a lot of blood products.  After an hour and a half the surgeons were mopping up and the attending anesthesiologist walked back in the room and smiled saying what a great job we all had done. Thankfully these kind of cases are not common out in the community.  But here at the largest level one trauma center in Los Angele’s we see a variety of crazy things from massive trauma from train wrecks, car crashes and of course the “knife and gun” club action.

I am glad that the training we received has prepared us to handle these as well as the routine.

This year I have been really privileged to participate in the recent graduation of our 2008 class here at USC.  The slide show that was put on by JR included many of the pictures that I took over the past two years of this SRNA group.  They were great to work with and I am sorry that they are now all gone on to study for Board Exam.  One of the things that I have been working on for the past couple of years now is a CRNA board review class that is given to the seniors during their final year before graduation.  Dr. Michele Gold and I will be starting this review again next month and the series will run until graduation next August.  The preparation for these reviews in tremendous but wonderful.  It keeps me in tune.

What prompted me to write after a little layoff was a recent comment by Wes.  Here it is for your enjoyment:

Hello Everyone,

I’ve recently finished reading through most, if not all, of the blogs here on the site. I am really impressed and have enjoyed this personal perspective into the field that I haven’t found on other NA websites including the AANA. Reading through this blog has been a real treat and I consider it half pleasure reading and half personal research into a field that I have increasing interest in.

When I was a nursing student, I must admit that I found the profession to be boring and full of magazine reading. Now as a nurse working in a neuro-surgical-surgical-trauma ICU, I admit that I had no idea of the awesome responsibility and greatly expanded knowledge base of the CRNA. Gaining experience with mechanically ventilated patients receiving anesthetic and analgesic drips, I am beginning to realize just how little I know and how much more I want to know about anesthesia.

This once seemingly “boring” profession is starting to become so very interesting to me as I read websites such as this and as I care for post-surgical ventilated and sedated patients. I also enjoy picking the brains of the anesthesia residents as they do rotations on our unit and find them to be quite knowledgeable.

I apologize for the long personal story, but I just wanted to say thank you for the great insight of all those who have contributed to this site from every step of the journey.

David, I must congratulate you on your hard earned achievements! Reading through the older blogs gives us an idea of how strenuous this journey really is. The great tips on applying to CRNA school and surviving once your in…have been helpful to many I’m sure.

Finally, living so close to USC in neighboring San Bernardino county I can’t help but inquire if you or your colleagues would be interested in taking on yet another “shadow.” Please e-mail me when you find some free time. Thanks again.

Wes

Thank you Wes for really nailing it for me.  Your perception of what this blog is all about is exactly right.  When I started out looking into becoming a CRNA there was nothing on the web where I could find real information about what it was like to be a CRNA, how to get in to a program or what it took to really shine as a student nurse anesthetist.  So I did it myself!

Now the torch is past along to those eager students willing to tell their stories and share their experiences with others.  I invite any interested in becoming a CRNA or those students already in programs to write to me and I will put it “up on the web” for others to read, learn from and be inspired by to become the best they can be.  For me this has been as a nurse anesthetist.  I have never regretted one moment of that decision to go for it.

DG

Dear David,

As I was eagerly reading your blog I could feel my pulse furiously pounding in my neck…. right before I read the part that said
“If you just take a self-check now and measure your pulse you will know.” ….and then I knew I wasn’t crazy, I just have a burning desire for the field.I will begin my BSN studies at Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, MO this coming January. Upon completing my BSN I will then start the path of working my way toward my acceptance into the CRNA program at this same institution.

I am currently an IT professional with AT&T (4 years). I graduated with a BS in Information Systems from Maryville University outside St. Louis, MO in May of 2004. College was a long road for me as I was ill due to what was later discovered as congenital heart defect (ASD), which was successfully repaired mid-college career. This of course was a delay, thus I hastily settled for an IT major knowing my dream was to be a CRNA.

Well… all that aside, the fire has kept burning and I am going to keep it stoked by pursuing my dream. I am VERY excited to begin my nursing studies. I realize I have quite a rigorous road ahead of me, but reading blogs like yours creates even more desire for the challenge.

I am thankful to have read your blog. Congratulations on your hard earned success. One day I will be in your shoes encouraging future CRNA’s.

C. J.

Hello David( aka Professor Plum)

Congratulations on living up to your true destiny, not only a CRNA but a professor also! Remember me, from the CTICU way back when you were down in the trenches?  I came across your blog as recommended by one of your current students.

I am so proud of you! The reason for my email is a plea for help. I resigned from UCLA 12/2007 so that I could be with my love who moved to Oklahoma City. I now live in OKC , the transition was very tough but worth it. During that time I reflected heavily about what it is I actually want to do with my life. I have decided to once again pursue my dream of becoming a CRNA. I guess my ego was shattered by the one and only denied application years ago, I think you were still on the unit , 2003 I believe then.

Anyway, for years I watched many of my fellow coworkers pursue what I wanted enviously but didn’t have the “fire” or confidence in myself since my rejection. Over the years I have been on the front lines in CTICU, even moved up to the ranks of the especially strong- THE CHARGE NURSES- can you believe it? Anyway, enough babbling, I have the fire, the intense desire to pursue this dream. I plan to apply to several programs in Florida, 1 in Maryland, and 2 in Texas. Haven’t taken the GRE yet, but have a good GPA when I graduated form U of Maryl.

What do you think? Any words of wisdom? My experience is strong, I think I interview well, just scared about the GRE I guess. I remember someone, I think it was you, saying to not bother taking the review courses through Kaplan or Princeton Review. Also, what most do you like to see in a personal statement? David, I know it’s been a long time, but as you hopefully recall, I always respected your input. You were one of my senior advisers then and I hope you can give me some pointers now. I hope all is well with you and am looking forward to hearing from you.

Respectfully, M. B.