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.

Most people have no idea of what General Anesthesia is all about.  When I ask someone coming into the OR with me what they think the goals of a general anesthetic would be, the common answers are, “Sedation and no pain”.  I have to guide them into a better understanding.  I ask, “Is a sedated patient awake?”, and the answer usually takes a bit to tease out.  So obviously sedation is not part of a general anesthetic but hypnosis is (medical term for sleep).  It helps to think in proper terms.

In my taxonomy of general anesthesia I have a list which goes like this: 1) amnesia 2) anxiolysis 3) analgesia 4) hypnosis 5) plus minus muscle relaxation – patient does not move regardless 6) lastly, blunting of the sympathetic response.  In the most basic terms General anesthesia produces a patient that does not move and does not remember the procedure.  There could be some debate on this which is good.  So, the Shadow person has an opportunity to observe this process irrespective of the surgical procedure which is a whole learning experience in itself.

Thats enough out of me.  Here is a letter from a recent Shadow person with a couple of my comments which follow.

Dear David,

Thanks again for the shadow experience last Friday. This was just the beginning of my research regarding a CRNA career and finding the right school to provide an excellent education. I thoroughly enjoyed the time I spent observing patient care under anesthesia in the operating room with you and the ease with which you practice. The passion you have for your chosen profession is admirable—very few find that type of satisfaction in life.

After my shadow experience with you, I still have an extremely strong desire to pursue a CRNA career. As I discussed with you during our day together last week, I have always been an ICU nurse for a very particular and important reason. I promised myself to only work in a hospital environment where I am able to thoroughly understand and appropriately monitor my patients. The intensive care unit offers an environment of constant supervision providing a nurse with the proper tools to predict and prevent rapid deterioration in a patient’s status, similar to the culture of the operating room. As observed with you in the OR, I know that CRNAs have a job that offers not only critical thinking & increased autonomy but also an environment that pledges safety for the patient in need of a surgical intervention. The limited knowledge I have surrounding anesthesia was a bit intimidating during my shadow experience but this only makes me more determined to get back into school.

Additionally, I am in search of a culture of people that desire to acquire more understanding and knowledge within their specialty. During my day of observation, I was very impressed with the CRNA clinical instructor’s enthusiasm for teaching as well staying informed on the latest information regarding Nurse Anesthesia practice. Bedside nursing does not demand RNs to seek more knowledge. The status quo is fine and honorable for many nurses. I often find myself frustrated with the lack of complete knowledge I hold as a Bachelor prepared Registered Nurse. I seek the more intimate and comprehensive knowledge surrounding a patient’s pathophysiology and medical diagnosis.

As observed, you understood the patient’s medical history in order to proficiently administer and monitor the person under anesthesia. It is also noted, that there are many anesthesia cases that involve much more complex disease processes and patient care interventions (brun cases). All of this is very exciting and extremely frightening but I cannot imagine life without a challenge. CRNAs are trouble- shooters by nature—both technically and mentally. I would be honored to become a part of this autonomous and enthusiastic nursing profession.

Thanks again for taking a complete stranger under your wing for a day at such late notice. Your flexibility was greatly appreciated. At your recommendation, I have officially signed myself up for the CCRN examination and will be sitting for the test in the very near future. I hope you have a wonderful Summer/Fall and that your wife makes it back to the USA safely.

Sincerely,

Libby Patton

There you have it.  I do have to comment about Libby’s idea of autonomy.  I work in an Anesthesia Team practice with Anesthesiology and happen to enjoy the back and forth exchange of ideas.  Team is always good.  So where does the idea of autonomy come in?  No one in the operating room is totally autonomous.  All of us from the nurses aids that help bring the patient and the surgical scrub technician as well as the assistant and attending surgeon all work towards a common end.  Nursing has a big roll to play as does our surgical colleagues.  Anesthesia has its own team as well and we all work together.  I will say it again, no one is an island.

I think what Libby was impressed with is the level of practice that CRNA’s have achieved.  While there are some States and areas where CRNA’s truly are autonomous that is not what is happening in my practice setting and I do not try to engender that idea.  I really don’t want to get any more political than that, period.

Enjoy, and as always, keep the goal in sight.

We all received news today from Sean CRNA (left) that he passed his Board Exams this past week.  How wonderful is that!  After all of the hard work blood sweat and tears to finally reach the Board Exam and pass.  Awesome.  Sean was a very talented student excelling in clinical rotations.  Good luck dude.

Its been a bit since I last sat down to write for the Nurse Anesthetist Org blog.  In the intervening time there have been several comments that some of you have been so gracious to send in.  There have been a few questions too.  Here I will attempt to answer some of the questions that have come in about Nurse Anesthesia.  First, I wanted to start out with a question about general anesthesia asked by Jeff in a comment from the last post.  He asks,

“Any chance you’ll let us in on how accurate the author of last note was regarding the components of anesthesia? And perhaps fill us in on the missing 6th component?”

What Jeff is referring to is what a “Shadow” person wrote as he remembers it concerning the goals of general anesthesia that I tried to impress upon him.  As far as the accuracy of his memory is concerned I make no comment.  The validity of what I teach has often been called into question.  But no matter, you make up your mind.

One of the things that I try to do when having a candidate for any anesthesia program in the OR with me is to try to get them to think about what the goals of general anesthesia are. Spend a couple of minutes to think about it yourself. What would your goals be for someone undergoing general anesthesia?

What I have come up with is a short list of goals as teaching points. This is my creation based on years of experience and extensive study. Feel free to use these ideas but give credit to me for elucidating them.

Here are my teaching point goals of general anesthesia for the learner:

1) We often give midazolam (versed) in the preoperative area to reduce anxiety and produce amnesia. Goal number 1 for a patient undergoing general anesthesia is anxiolysis and amnesia. We do not want our patients to worry or to remember the experience of surgery.  For patients that can not or do not wish medication the hand holding techniques are wonderful.  This is particularly the case in obstetric anesthesia.  The practice of the “Therapeutic Use of Self” is a nursing technique that is extremely powerful and is often neglected.

2) With induction of general anesthesia we often use opiods such as fentanyl to facilitate tracheal intubation and begin producing analgesia. During the surgical case more opiods are some times used or other agents such as nerve blocks to produce analgesia. Goal number 2 is analgesia. We do not want our patients in pain.  Reduction of pain in surgical patients is a major goal whatever the method.

3) In general anesthesia cases, do you want your patient to be awake? I would say that in my practice the answer is no. Propofol is often used to induce hypnosis.  The maintenance of hypnosis during the surgical case may be accomplished with a propofol infusion and volatile inhaled agents. Goal number 3 is hypnosis throughout the case. We want our patients to be asleep during surgery and not to experience recall of any intra-operative events.

4) During surgery it is expected to have our patients still and not moving around with surgical stimulation. We want a quiet surgical field so the surgeons can do their best work. So, we do not want patients to move but do we need muscle relaxation or muscle paralysis? There are certain procedures that require a degree of muscle relaxation such as reduction of a femur fracture or large intra-abdominal surgeries. For these surgeries we use muscle relaxation medications to facilitate the surgical procedure. Goal number 4 is a plus minus – maybe yes maybe no – do we need muscle relaxation. We do not need muscle relaxation so that our patients do not move. A quiet still patient is taken care of with a balanced use of general anesthetics. Muscle relaxation is a different story and is used when it is a surgical necessity.  This is my opinion and practice.

5) In general surgery cases the patients are asleep (hypnosis) and they do not remember (amnesia) and they cannot tell you what they are feeling so do they have pain? In my view if a patient is asleep and does not remember and cannot tell you what they are feeling – then by definition they do not have pain. What they do have is sympathetic stimulation. Now obviously this is an extensive subject but the short course is to see elevations in heart rate and blood pressure as a sympathetic response. What we want during a surgical case is for the patient to be stable hemodynamically with normal heart rates and blood pressures. There are multiple pharmacologic agents and techniques to do this, which is not the subject here. So goal number 5 is to blunt the sympathetic response. We want stable patients.

6) The best monitor in the operating room is a trained Vigilant anesthesia provider.  The sixth and most important goal during general anesthesia is to maintain vigilance as an anesthesia provider.  Nothing else in the OR will take the place of this.  Nothing will be as well attuned to expected and unexpected changes in the patients condition as the person providing the anesthetic.  No one in the lounge, no one in the hallway, no ECG monitor, no pulse oximetry monitor or capnography monitor will be as quick or as skillful in detecting and caring for patient needs as the trained and skilled anesthesia provider in the room.  If you want to discuss this call me any time.

These are the goals of general anesthesia that I have come up with. The list is manly used as a gestalt or way of thinking about what a student needs to learn about general anesthesia. The techniques to produce a good anesthetic have been described as “An Art”. The art of anesthesia is a combination of medical and pharmacologic knowledge with technical skills and expert patient care experience. In my view as a nurse anesthetist, I refine my craft every day both in the operating room and as a clinical instructor of fledgling anesthesia providers.  There you have it Jeff.  I hope that answers your question.  As far as accuracy is concerned Jeff, these are my definitions and ideas and is certainly not the only way to describe the general anesthetic.

Anne writes in a comment:

Hi.. I am a filipino nurse assigned in the OR for 6months now..
Since I am assigned there, I have become interested with anesthesia and thought of becoming a nurse anesthetist.
I am actually gathering some requirements in order to study BSN again in australia.
Is there anyone who could help me find my own path in becoming a nurse anesthetist?
I don’t know where I should start and when.. I’m not even sure if my experience
In OR is enough already or if I really still need some experience in ICU.. I’m glad I’ve
Found this site. Thank you.

Well Anne you have come to one of the places where these questions are asked and attempted to be answered.  Unfortunately, the only country that I know of where nurse anesthetists have a flourishing practice is where nurse anesthesia started and that is here in the good old United States.  The practice of nurse anesthesia in the Philippines has undergone changes in the past several years but as I understand it the practice is fairly limited.  My suggestion to you right now is to complete the BSN degree in Australia.  That is a totally doable goal and one that will benefit you no matter what other path in nursing you take.  Good luck and study hard.  Thank you Anne for stopping by and keep us informed about your progress.

Just as a reminder – all content – pictures and media is the sole property of nurseanesthetist.org web site and nothing is to be used copied or distributed without the expressed written consent of the webmaster – that would be me.  I found a picture that I took and displayed in the web site here published in a local magazine recently.  They never asked for my permission and was published without my consent.  Weird.

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.

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.

The student nurses followed a couple of the CRNA’s until noon and were able to get a glimpse into what we do on a daily basis. For the students it was a good exposure to Nurse Anesthesia practice. This morning I received a note from two of them that I would like to pass along. I have slightly modified the letter to correct a couple of small things and to protect the innocent.

This first letter comes from Chi and details her experience with us at LAC-USC Medical Center:

Dear David,

I wanted to thank you for the wonderful and invaluable experience of shadowing you, your colleagues, and your SRNAs this past Friday. It was a great pleasure to be able to slip into the shoes of a SRNA for a day, an experience that only solidified my decision in pursuing the CRNA route.

From the early morning start to early afternoon, everyone in the program was warm, supportive, and provided a wealth of information. I was immediately drawn in by the warmth and comradery amongst the faculty and students all the while still upholding the impressive professionalism during morning conference. When we gathered for the morning presentations featuring resident speakers presenting their current research findings, I was impressed with how supportive the faculty was as the floor was opened to questions and comments on the presentations. I sensed a safe environment for learning which, in my opinion, can only foster growth and improvement. Even as visiting students on the campus, my fellow classmates and I were invited to participate in the open forums during discussion! As the morning progressed and we were each assigned to shadow a CRNA and his/her student, I was amazed to find how engaged, Karen, the CRNA was during my shadowing experience. I had expected to be her “shadow” instead, she was explaining and teaching me about the various equipments used, the types of drugs and their effects, and even going into “what if” scenarios with me, all the while not skipping a beat with her own SRNA and her patient. I was in absolute awe that one person can do all these multiple tasks and be so efficient in everything!

Aside from getting advice from the faculty and CRNAs about the career and field, I was extremely grateful for the SRNAs’ honest portrayal of the rigorous program. Despite hearing the students confess they sweat blood in the program and having it be the hardest thing they have ever done, every student that I spoke with also said that it was an awesome experience that is well worth the hard work. Again, I just wanted to thank you for this experience and I hope to come back and visit you soon in the very near future.

Sincerely,
Chi D. Huynh
SN, CSULB

The second letter comes from Lisa and reveals her strong desire to pursue graduate level studies. What is important for these nursing students is to have a goal. It is very difficult to reach for such a difficult level of practice such as Nurse Anesthesia so it takes a lot of motivation and time to achieve. These visits and shadow experiences hopefully will provide incentive to keep them driving on through to the next several levels.

Dear David,

It was a genuine pleasure meeting you, Kari, Jim, Karen, Stephanie, JR, Diane, and Hill yesterday. From the very get-go, the CRNAs and SRNAs were warm and welcoming – even with the many questions my classmates and I had!

You patiently and thoroughly answered my questions about USC’s CRNA program, and I greatly appreciated the valuable information and advice you gave me. From the different experiences I would get at a surgical vs. medical ICU and contacting Alice a nurse manager at UCLA; to reading Paul Marino’s “The ICU Book” for preparation as an ICU nurse, I feel more informed in setting up a strong pathway to CRNA school.

What still amazes me about my CRNA shadow experience was not just how knowledgeable and intelligent the CRNA and SRNAs were, but also how supportive and enthusiastic everyone was about our interest in the nurse anesthetist profession. Even at 0530 hours, Kari was excited about us being there and shared different CRNA books and websites to further our knowledge. JR, Stephanie, and Diane (the SRNAs who walked us over for the anesthesia residents’ presentations) were so willing to provide thorough and honest advice about getting into a rigorous CRNA program and also what made them excited to be a part of USC. Also, the morning conference presentations confirmed to us the high level of research and involvement in the anesthesia department at the University of Southern California Keck School of Medicine. We were impressed with the involvement and encouragement of the CRNAs and SRNAs in the department of anesthesia.

Later on in the OR both Jim and Karen were simultaneously focused on teaching their respective SRNAs as well as us observers; I am still excited about seeing my first carina via the fiber optic! How awesome is that!

Thank you again for an experience that has further solidified my decision to pursue the CRNA profession. And if it is OK with you, I hope to keep in touch for advice on my journey to “CRNA-dom.”

Sincerely,

Lisa Chong
CSULB SN

In the future I am hoping that there will be more opportunity for others to come and visit us. If there are those that would like this experience I encourage you to call the LAC-USC anesthesia department office at (323) 226-4597. Ask for Kari is the best bet and tell here I sent you. I’m sure she will appreciate that!

Till next time keep focused on your goals and pay attention to all of the messages you receive. There may be a key somewhere in there that will open the next door.

David

I was in the local court house the other day fulfilling my Jury Duty summons. While passing through the check point the security guard commented on the book that I was carrying at the time, “Basics of Anesthesia” by Stoelting and Miller who are the editors of the current edition. The security guard perks up and asks me, “Could you do anesthesia after reading that book…….its like Betty Crocker right?” I had to laugh and answer that, “No it would take a lot more than just reading this little book to be able to do safe anesthesia.” So I guess the pediatric sheet is like that too. Having the sheet will help you out Students but will not replace studying the big texts, clinical mentor-ship and years of experience.

Thanks Jim for the update I will save a copy and put it in my little folder which I carry with me in to the OR. Small note: Jim recently sent me a couple of pictures from last Halloween and I have enclosed one of them for your amusement. Pardon me Jim it is just too good to pass up!

Why I think year ICU experience isn’t enough by “There, I Said It”.

I am a Nurse Anesthetist and a Clinical Instructor of Anesthesiology at a large metropolitan teaching institution.

I have been a clinical instructor for some years, and have seen many students come and go. We have so many applicants to our program, and each time the interviewing process becomes more and more difficult, as each applicant appears to be cream of the crop. The difficult decisions as to who will be accepted into the program come from a comprehensive process that involves input from many individuals of varying levels of practice; from student nurse anesthetists to department chairs.

According to the AANA, requirements for admission to an accredited program of nurse anesthesia include a minimum of 1 year of acute care experience, such as in ICU or ER. Herein lies my beef. Applicants or students who think 1 year of acute care experience is enough to perform at an acceptable level, in my view, are sorely mistaken. I feel this requirement should be changed. Can one truly master the art of ICU or ER nursing in 1 year?? Is a year enough time to glean an adequate level of skills or experience in adult critical care or ER nursing? After one year, can you throw up epi, levophed, dobutamine, dopamine, nitro, etc. and truly be comfortable with what you are doing?? Do you think you’ll be able to insert a swan and know what in the hell you’re doing? How much code experience occurs over 1 year? Is a year time enough to mature the development of interpersonal relationships with other members of the health care team much less the patient? Ask yourself these questions and I bet your answer will be no, no and no!

The students who have slithered through the interview process with what looks good on paper but have never been realized in practice have a hell of a time in residency. The clinical instructor has to work overtime to protect the patient from the student. I daresay there are those individuals that just have met the minimal requirements and are truly stellar students. However, these are few and far between.

I suggest the minimal requirement in an acute care setting be increased to at least 3 years. Applicants, if you barely have the minimal requirements for admission, ask yourself if you truly have enough experience to entertain delivering anesthesia care to an elderly individual with an aortic aneurysm, a child with epiglottitis, or an individual with multiple gunshot wounds to the chest and abdomen.

Signed,

There, I Said It

Your graduation is approaching rapidly. If you have not done so already, get together as a class soon and get some ideas going for a graduation celebration. Each of you will need to pitch in and assign yourself to a committee.

If you need to do a fundraiser, I highly recommend the USC Anesthesia sweatshirt, t-shirt, and hat sales from last year’s class. Thanks to the 2005 grads, you have a nest egg to start up a project such as this. Besides, there a number of people asking for these items, both local and international!!!

Let me know what you think.

Kari

May you always do for others and let others do for you.

Bob Dylan

Hey David, here is a funny story,

As student nurse anesthetists we are fortunate to have some common sense especially since we have some critical care background and have actually touched patients. Anesthesia physician residents often do not have this luxury. They get thrown into an operating room because they have graduated form medical school and are expected to perform. While SRNAs are guided on how do things should be done in the operating room for a long time.

Recently I heard a story about a M.D. resident that was interesting. The surgical case involved a patient scheduled for a total knee replacement with an epidural catheter and an Laryngeal Mask Airway (LMA). A Nurse Anesthetist enters the OR to send the physician on a break. The patient is breathing 38 breaths per minute and chewing on the endotracheal tube. The physician states, “Oh that’s new this must have just started”. Propofol is then slammed intravenously and B/P drops precipitously and then the low blood pressure is then chased with ephedrine trying to bring the blood pressure back up.

There is a lesson to be learned here. You can’t blame the physician resident because many times when they are new in their training they do not have sufficient oversight. The patient obviously needed something other than slamming propofol – possibly a dose of narcotic and not hypnosis. The epidural was infusing but did the patient get a loading dose up front? These things may all effect how the patient was tolerating the surgery. What I have seen clinically is that when epidurals catheters are working well you need far less opioids and less volatile agent as the MAC is lowered. These patients usually wake up very comfortable.

The morale of the story is to feel good about the education that we receive as nurse anesthetists and feel proud to be apart of this prestigious profession of Nurse Anesthesia. Remember that 65% of all rural anesthesia is given by Certified Registered Nurse Anesthetists (CRNA’s). Some day you might be taking care of me or my loved one and I want the best and most competent anesthetist on the job.

Jo

At first I glanced over this note from Jo and scribble a few notes to myself while reviewing the many interactions that I have had with residents. Jo is a dear friend of mine – however I find that her reasoning incomplete. At least there is more here that is bothering me that I can not mine fully. She states correctly that patients with epidural catheters require lower MAC and less opioids then proceeds to disparage the hypnotic and suggest that the patient needs additional opioids? I began thinking that the idea of giving more opioid for a light patient is the wrong choice and her criticism of the resident could take a different slant. For me the propofol is not a wrong option but the lack of vigilance by the resident deserves comment. So ran my thoughts. To confirm my suspicions I ran off a note to a friend, we’ll call him ‘John’, a long time anesthetist back East. I was dealing with the trees and not the forest. My thoughts continued at that time this way:

John,

I was not there in the OR and all of this is second hand information but an interesting discussion about CRNA SRNA and Resident relations mainly. We all have our prejudices I guess. For me the physicians do just fine and receive extensive training. At times in the beginning of their training there may be things that happen that are not the best practice. Who is to say that Student Nurse Anesthetists do better really? Personally I do not find it profitable to compare providers but to look for a best practice regardless of the practitioner. John, I thought you might get a kick out of this story and look forward to your comments on the scenario. Hope all is well with you and that your scheduled surgery goes well. I am wishing you all the best from Los Angeles.

David.

The response I received back has been lingering in my mind for the past few days. When I started the NurseAnesthetist.org/ web site my goal was to try to put together something with content that would be both instructive and entertaining while showing what it is like to be a nurse anesthetist student. John goes beyond my expectations.

Hi, David

I have many thoughts tumbling through my head at this stage of my career. As to the story your friend related, I find your take on it to be the more reasoned. Yes, the average SRNA is probably much more oriented to the care of the patient, by virtue of the nursing background. This stereotypical SRNA is also more clinically astute because s/he’s been on the front lines, watching actual patients get better or get worse and die, so s/he has earned to look at everything, make no assumptions, and always to keep that “sixth sense” activated whenever s/he is responsible for a patient. Those hard-earned lessons from the ICU on a 12-hour night shift do stand the SRNA in good stead.

And it’s probably true that the average MD trainee at whatever stage of her/his training is probably less experienced and clinically seasoned; more educated in basic sciences than the average RN (notice I said “more” educated which doesn’t necessarily equate to “better” educated). But a friend of mine long ago put it this way: “Good nurses know a lot about medicine while good doctors know a lot about nursing”. When I look back to the people who had the most influence on my developing anesthesia career (and it’s STILL developing) I find nurses who took it upon themselves to be very educated (and very WELL educated) and physicians who had that common sense and humanitarianism that is stereotypically viewed as the hallmark of nursing. What each had in common was a curiosity that motivated their learning, a humility that taught them that their learning would never end, and an empathy for the suffering patient who was at once her/his sacred responsibility and greatest teacher. The other thing they had in common was my enduring respect; you see, I’ve seen callous CRNAs and empathetic and truly altruistic physicians. We must be careful not to be guilty of that error which we decry in others: judging an individual by the letters behind the name and not the character attached to the person.

As to your friend’s assessment of what was needed, we all know that anesthesia is a complex specialty. From first principles, the patient should never have been allowed to come to such a state, under the care of an anesthesia provider, that the patient was chewing the tube and breathing 38 breaths per minute. The rescue of the patient from that unacceptable state can take many forms, some better than others. The bolus of propofol was a “fast” answer. Fast is important, but one must be careful not to overshoot lest one have to engage in the “dueling drugs” scenario as your friend described chasing blood pressures all over the place. You made another astute observation: “I wasn’t there…” This is a very mature approach to analyzing anecdotes about cases; you know that not everything that happens can be reduced to marks on an anesthesia record, and that even the most careful observer is biased to some extent.

I have a feeling that neither you nor your friend would have gotten yourself into the situation of needing to rescue the patient from inadequate anesthesia. In a couple of jobs I’ve had in the past, we’ve had trainees rotating through the anesthesia department. Now, I’m always careful about generalizations, and the following observation is given with the very large caveat that generalizations are poor tools to explain things. That said, I noticed that there were in general two “styles” exhibited by anesthesia trainees. One style was more “high tech” and the other more “high touch”.

One manifestation of this was the manner in which the trainee monitored the patient. Some stood with their backs to the patient and watched a bank of monitors. These tended to miss things that a more experienced onlooker would see evolving before they manifested themselves on the monitors. These were the “high tech” ones. Many were very intelligent — far more so than I — and usually more educated as well. As a generalization, these were doctors. Others gave their primary attention to the patient, and looked to monitors as a secondary information source, to validate their clinical impression of the evolving anesthetic. Most of their time was spent seated or standing in close proximity to the patient, their backs to the monitors. Sure, this has elements of a false dichotomy, but by and large, these latter were nurses. They didn’t treat numbers, they treated patients. And they usually “picked up” things before the “things” became “problems”.

Sometimes the “high touch” crowd couldn’t even characterize what it was that was about to go wrong. Usually the “high tech” ones could recite the “book learning” about what had just gone wrong. If you haven’t found this out already, in anesthesia it is frequently the case that we are too smart too late. You’ll also know the daily reality of something I once read: Most great discoveries are presaged not by the exclamation “Eureka!” but by “Gee. That’s strange….”

The only good thing that came out of Jo’s experience is that you are talking and thinking about it and learning from it. The occurrence of inadequate anesthesia in this patient — the failure of our specialty, the patient’s trust betrayed — became, if you will, a “chance experiment” in the laboratory that is your learning. No Institutional Review Board would ever have approved of the situation into which this patient had been allowed to deteriorate, even for the pragmatic good of your learning. But it happened. Remember, “stercus contingit”. You have been handed a learning opportunity, purchased at a very high price by your patient. Learn from it, get all you can out of it. And, as you progress in your career and teach others, remember the debt you owe to that patient, in whose care an error was made, allowing you to learn from the remediation — and yes, even the “cover up” — of the error.

Here is where I have a huge problem with many physicians with whom I’ve worked. There’s an attitude of entitlement. “I earned this degree. I got out of training with six figures of student debt. I am owed”. No. Wrong, wrong, wrong. They are who they are, they know what they know, and they have what they have, because of an unending string of patients who held still for their first clumsy attempts at the laying on of hands, who suffered at their mistakes as they repeated lab tests and painful procedures, who died at their imperfect hands — at all of our imperfect hands. David, I submit to you that this is a debt that can NEVER be repaid; the currency to satisfy such a debt has never been minted, nor could it be.

I recently had a physician make some comments to me in passing. I think he meant to encourage me; I’m not sure. He commented on my skill at regional anesthesia, especially in the massively obese parturient with whom we’d just dealt successfully. I described how I’d evolved in my skill to a peak several years ago, and how I’ve had to refine my skills as my senses and strengths change. I used to palpate everything, and my sense of touch was my paramount one. As I age, my tactile sensation has diminished, and I rely more on vision. And even that is failing as I approach my seventh decade of life. But I continue and I do my job well and carefully. He expressed surprise when I told him how old I am — that surprises everyone because I’m blessed with a youthful appearance. Then he told me that he doesn’t intend to work past the age of sixty, not at all while I intend to work until it would no longer be safe for my patients for me to continue to do so. I’ll know when that is, and a carefully selected group of people with whom I work will validate that judgment. Only then will I pursue a lesser career, and I will leave with reluctance and with regret for that huge unpaid debt, with gratitude for every patient who has taught me what I know. For now, CRNA doesn’t describe so much what I do as who I am.

PS: My surgery has been put off until the 22 of this month. Several things have to be in place for it to take place, one of which is some sort of fibrin glue to be used in the repair. I am blessed to have tissue that doesn’t act its age, and a “sports medicine” orthopedist who normally limits his practice to athletic injuries in genuine athletes. He’s agreed to apply his skills for an old man who fell on the ice, whose “athletic” prowess is confined to paddling canoes and kayaks to photogenic places, or slogging along on a mountain bike or cross-country skis to places that aren’t crowded, and whose major competition is against entropy — and gravity. His method includes aggressive rehabilitation. It will return me to my “playing field” sooner, and ease the overwork my absence will impose on my partner and our already thinly-stretched locums. That’s important to me.

Thanks for your kind good wishes. I’ll keep you posted. In the meantime, work is busy, and that’s great therapy.