The end of the First Year at USC Anesthesia School has come at last. At the end of the month of August – it has come so quickly – will mark the beginning of our senior rotations. This means for me that I will start at LAC-USC in the Cardiac Surgery rotation September 1st.

To celebrate the occasion a little letter from the Chief CRNA at LAC-USC is recorded below. Kari Cole is one of the most outstanding CRNA’s I have had the privilege to work with and her letter of encouragement is heartily welcome by all of the new senior students.

Dear All,

I hope this email finds you in good spirits.
Here are a few housekeeping issues:

1. BACKPACKS:
If you haven’t already, please reduce the size of the backpacks you are bringing into the ORs. At this point, the only thing you need to bring in the OR is ONE reference book, a couple of pens, stethoscopes (regular and precordial) and maybe a nerve stimulator and head strap (depending on where you are rotating). You may want to think about losing the backpack altogether and move into something a bit more professional like a black attaché.

2. VALLEY REVIEW:
For those of you who are planning on attending Valley Review Courses, please inform me (and the schedulers at other sites) when you are planning on attending. Since you are now in the ORs on your own at LAC, I will need to know when you will be out for the review.

3. POLISHING:
Start working on polishing your skills. You all have the basics down, now start fine tuning your anesthetics and your approach. Push yourself to try new things…..do NOT use roc and propofol on every induction! You may have to “sell”: your plan to the attending and/or CRNA, which can be a lot of work but in the long run, it is worth it. You need these skills (anesthetic and interpersonal) before you graduate.

4. CHANGING OF THE GUARDS:
The seniors are graduating and you will be taking their places as seniors and as mentors. The new group starts in a week and a half so be prepared to meet and greet your new colleagues in the ORs and in class. Remember, first impressions are lasting impressions! Think about the senior that impressed you the most when you first started. Were they: approachable? genuine? enthusiastic? helpful? Your attitude makes a world of difference to those individuals who are just starting.

5. CONGRATULATIONS:
Be sure to give yourself (and your classmates) a pat on the back and/or a congratulatory hug for successfully completing the first year of the Program!! YOU ROCK!!!!!!!!!!!!!!!

Aloha,
Kari

Kari M. Cole, CRNA, MS
Chief Nurse Anesthetist
Assistant Clinical Professor
Keck School of Medicine, USC
Department of Anesthesiology

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

Josette Salas, RN BSN

Josette Salas is an RN from California. She has worked as a traveling nurse in some of the busiest Medical Centers on the West Coast including UCLA, USC University Hospital, Cedars Sinai and others. Her specialties includes Cardiothoracic ICU and Neuro/Trauma intensive care. She comes to Nurse Anesthesia School with a lot of great preparation and motivation.

Hey Gang, How is it going for everyone? I have been reading the blog and it sounds like everyone has been very busy. FUN FUN FUN at the old anesthesia corral. My clinical rotation is not as scary yet as others so I am kind of jealous about that. But I can’t wait for the good stuff to come around. Right now I am just doing a lot of hernias, D&C’s, laparoscopic stuff, tons of Orthopedic surgery and hysterectomies.

I can finally say I like the MAC blade and I have been pretty successful with tracheal intubations these past two weeks so I am feeling better about the whole induction thing. I hate placing Laryngeal Mask Airways but I am getting the hang of those too. You know I have small short fat fingers which is not helpful.

Today I got to do a spinal anesthesia case and ooooh-la-la first one here so of course I was all thumbs and asked a lot of dumb questions. Learning is such a great adventure but I hate feeling stupid all the time. I can’t wait till I am past that point of feeling stupid every single day to where I am feeling stupid just every other day.

I love using local anesthetic for my IVs starts. I think all nurses should do this but I don’t know if this is in the scope of practice for the RN instead of our purview as Advanced Practice Nurses in training – Oh just give me a break already!

OH I am going to the Washington DC in August for the annual AANA meeting which lasts for 5 days. I have never been to DC so this is going to be cool. I want to see the Capitol building if I can.

Currently I will be ending a rotation at the end of this month and then I will be going to the big Buffalo General Medical Center so hopefully I will see some interesting cases there. I don’t know when I will have the opportunity to go to the County Hospital for a Call/Weekend shift. I don’t think everyone here gets to do this but I am excited about doing this and am planning of learning so much there. I want to get the experience to equip me to handle anything that comes through the door.

Right now I hate the summers here in Up-State New York – it is like tropical hot humid disgusting nasty weather kind of place. Did I tell you about the winters here? Now it’s funny because the people here are just happy that it is hot and not frozen over like it was a few months ago so there’s no place like home.

Anyway I am going on and on. So take care and good luck with the rest of your current clinical rotations and I will write again soon. My picture is in the mail if you know what I mean.

24 hours in the OR on Holiday weekend

Yesterday was my first 24 hour operating room call. I have had to do other overnight OR scheduled time before but this was the first time I was scheduled for an entire day. Being a Saturday night and a holiday weekend made for several interesting cases.

During the day on Saturday we were busy with pick up ortho cases that were left over from the weeks work. Nothing to big just a couple of ankle fracture repairs, an elbow and an incision and drainage of a big old abscess. Nothing like the night to come.

I thought that the Los Angeles County hospital had all of the action but I was mistaken. It seems there were a few parties that got out-of-hand out here in the Inland Empire and friends started shooting friends, brothers started stabbing brothers and what not. We had two ORs going until the very early morning. At 03:45 we broke the two ORs for 15 minutes and then the final gun shot wound came up. It seems this guy was shot through and through across his hips taking out some of his bowel – he had blood in his stool and needed emergency surgery. This case ended up pretty messy and did not finish until 6:45 just 15 minutes before I was scheduled to leave. Oh joy – I can go home now.

All in all for the 24 hour schedule I did 6 cases, a couple of them fairly long. I did get an hour nap Saturday afternoon around 4 o’clock so it was not too bad. Looking at the coming schedule I will be doing another overnighter next week and the following week another 24 hour shift on the weekend. Thankfully it is not a holiday weekend and maybe the natives will not be too restless.

16 Hours in the OR

This past week on Friday evening through Saturday morning I spent in the County Hospital operating room providing anesthesia to the never ending trauma cases that come in over a weekend. Maybe it’s just me but the natives are too restless it seems – especially when you combine alcohol and illicit drugs to the mix.

The last two cases were really special. One a stab wound to the face and the second a gun shot wound to a very drunk mans leg. The stab wound case was technically difficult to secure the women’s airway due to so much bleeding from her cheek and tongue laceration. Really it was more of a HUGE laceration. Her domestic partner, I believe, thought that she was stealing all of his cocaine or crystal meth or what ever and thought to teach her a little lesson. The stab wound went through her cheek and tongue to the other side of the face. You can imagine that there was a lot of blood in her airway. The lady was pretty hysterical and we just induced her (put her to sleep) quickly while she was sitting up on the gurney. After unconsciousness the attending anesthesiologist and I laid her down quickly while the surgeon held some pressure to her cheek. Two suction catheters going and ten seconds later she was intubated and her airway was secure. After that it was simple. I am really glad that the attending anesthesia staff was there to help out. Now that is not something you see everyday. The surgery was fairly straight forward and we left her intubated overnight to make sure the bleeding was under control and her airway was secure.

The next guy had the rudeness to try for another six pack at closing time at the local drive through liquor store at 01:50 in the morning. Evidently there was an altercation of some sort, who knows what really happened here because the guy was so drunk and combative. He came to us in the OR at about 3:30 in the morning just after we had finished up with the younger lady and the stab wound to the face. I could not even close my eyes for a couple of minutes. This guy was really out there jumping all over the place. We could hardly keep him on the gurney let alone transfer him to the OR table. After 10 milligrams of midazolam he saw it our way and we were able to get him to the operating room table and start the case. He ended up with facsiotomies of his calves and some vascular reconstruction. All this for another beer. Seems like to me he had had enough but who would have thunk it.

All in all doing a clinical rotation in a large county hospital and being able to take weekend call time shifts is a great clinical experience. There are things here that you see and do here that are not available at other times. The lack of sleep is not something that I cherish but I would not trade the chance to do this rotation. I will be at this facility for another three months and will be taking overnight call once a week in addition to the regular days during the week that I am there.

The routine week day cases are fairly standard type cases. The obstetric floor is covered by the student nurse anesthetists as well and we see a fairly large population of caesarean sections, tubal ligations, and labor epidural placement management type things. So the mix of cases here is really nice. Right now I will catch up on some sleep and then hit the books for an exam that is coming this Monday.

Being a nurse anesthesia student has its ups and downs. The stress is pretty intense and there is a lot that is demanded of you both academically and clinically. I love it when you are trying to get a difficult case started and the staff starts asking you questions about the case and all of the pharmacology and pathophysiology involved just when you are trying to get the endotracheal tube placed. If you thought that chewing gum and rubbing your tummy at the same time was difficult come join us for an afternoon or maybe hang out and spend the night at the County Hospital during a holiday weekend. Now that would be an education worth remembering.

The past several months have been so terribly busy that I have not written anything, I mean not written anything for any of the projects that are web based that I have going. The end of our first clinical rotations, finals and of course personal stuff that always comes up has kept me from writing and keeping the Anesthesia Log up to date.

Finals are finished, thank God we all passed. USC is a tough educational institution. One of our classmates decided to drop out for personal reasons and she is planning on coming back next year if the creeks don’t rise. We all wish her well. The rest of us are on to new rotations.

This semester Gina and I are at Arrowhead Regional Medical Center located in Riverside County California. This is one of the home sites for the Texas Wesleyan students and the Texas Christian University Students. The clinical site also has students from the Kaiser program and from the Navy. All in all the experience that I anticipate at Arrowhead Regional is going to be fantastic. There are NO anesthesia residents MD types only SRNA’s from these several programs which cover all of the operating rooms 24 / 7.

I am starting this week at Arrowhead and will certainly keep a running log of how things are going with Gina and myself. Its great to have a friend like Gina at the same clinical site together. I feel like our friendship is growing stronger since we now have a clinical site together. That is a great plus. Hopefully in the coming weeks Gina and I will be able to make some contributions to the Anesthesia Log that will be important.

Back to study time now.

Gina Wald, DC BSN CCRN

Gina comes to nurse anesthesia practice prepared as a doctor of chiropractics. Her experience includes several years as an RN in a neuro/trauma ICU. Her insightful assessments and understanding of anatomy is enormous. Here are a few of her insights at the start of clinical anesthesia rotations.

Though I am not the blogging sort, I am supportive of this forum; I would have loved a resource such as this when I was investigating and applying to NA school. The webmaster has graciously invited me to “join the conversation”, so here I am…

We started our first rotation a month ago, after a meager but grueling semesters’ preparation. I will never forget the tension in our classroom the week before we were to be cast to the lions.

Even the loudmouths of the class (myself included) were scared into silence. We knew what to expect, and while all 16 of us started this journey anticipating, even desiring a life-altering residency experience, we were scared. It was a strange mix of “I can’t wait to get started” and “Wait, I’m not ready yet”.

I am in the “kindest” of first year rotations, a So. California Veteran’s Administration Hospital where the CRNAs and attendings are brilliant, eager to teach, and supportive of our endeavors. And still I am exhausted. I cannot find time to do it all. I feel strapped beyond belief. I want to read more, to know and contextualize more, to have time to reflect on all that I am learning and doing. But there is no time. I determined last week that I must stop working, as much as I love having a place to go where I actually have some competence. It’s time to leave the nest, and begin the plummet we all must take before feeling our wings.

Days in the OR are wonderful. We start morning conference at 7:00 am with the CRNAs and Attending anesthesiologists. We present our cases for the day, and take whatever beating is dealt out. They kindly remind us that while we have looked everything up in the books, we still don’t know much about anesthesia. It’s important not to take it personally, and I worry about those of us with too thin skin. (Dermal hypertrophy should be listed as a prerequisite for all NA programs). There is no coddling here, but I know they are grooming us. We have only 18 months to go from inept to competent. I love the regional anesthesia exposure we are getting at the VA. As a chiropractor, I know my hands are good, I know the anatomy intimately and can visualize the structures as I place my needle. This is fun for me. Intubation is another story, and while my first couple seemed easy enough, I have struggled since then, taking in everyone’s advice, trying to keep my frustration from invading my thoughts during induction. There is always something I forget to do in a case, and I wonder how long it will take me to “get it”.

I love what we are doing. I love watching the transformation take place in my classmates, and feel my own mind making a very clunky shift. The skills and knowledge I brought from my experience as a neurotrauma nurse serve me well, but the thought process in anesthesia is a different paradigm, one which is much more in line with my background. This is such an exciting time, and everything I was looking for. If only I could get some sleep. To be continued….

David Godden, SRNA

This marks the near mid point for our first semester clinical rotations at the Los Angeles County Medical Center. After a month and a half I have to tell you that I am tired but still very excited to get up at 4:30 every morning to go the hospital and set up the OR. The days are long and difficult at times but so interesting.

The cases that have been completed in this first six weeks have been various general surgical cases. This last week I was in the ER room on Friday and had the good fortune to be able to take care of a 3 year old with a perforated appendix. Little Lucia was so sweet. My preceptor Jim taught me to have her play with the inhalation mask before the induction so that she would not be afraid of the mask when we gave her oxygen. Lucia had a working IV so we discussed the options of an IV anesthetic induction verses inducing anesthesia with sevoflurane. My choice was for the mask induction since I had never done this before and had only read about it knowing the advantages for pediatric cases.

What made this situation additionally stressful for me was all of the people around. I am nervous enough at the start of an anesthetic especially during the induction period. Not only was my preceptor and the Attending Anesthesiologist behind giving me all of their well appreciated advice but Kari the Chief CRNA at the County Medical Center was there with her student Anya. Kari and Anya were between cases and wanted to turn the heat up on me. Actually, little Lucia’s smile was so engaging it was a magnet for everyone around so it wasn’t me they were interested in. It just felt like I was on the Hot Seat with a lot of people observing. Throw in a couple of surgeons and there were enough people for a party with me as the director. Oh my God, I had a Zen moment.

We all trailed off to the OR after I had given Lucia a milligram of midazolam. (Figure that out – 15 kg at 0.1 mg/kg and you get 1.5 mg of versed). The one milligram was not enough and I gave her another one half once we were in the operating room. I was recalculating all of the medication doses a couple times in my head and was getting overloaded. We scooted her to the OR table and handed her the mask. At this time she was pretty groggy but still reached up for the mask feebly.

On the OR table after the sedation she was very calm and took the mask oxygen very nicely. I turned on the sevoflurane and off to sleepy land in a few minutes with an easy hand mask ventilation technique. After a couple of minutes of a mask sevoflurane and rocuronium for muscle relaxation, I was able to do a DL (direct laryngoscopy) with a good view of her vocal cords. Her trachea was intubated without difficulty with a 4.5 uncuffed endotracheal tube and the surgery was begun after another few minutes of preparation. I was almost in a trance myself.

The interesting thing about this surgery for me was not just the first pediatric case but the surgeon. The attending surgeon was someone I knew from UCLA from a few years back. At the time she was a second year surgical Resident doing a month of rotation in the cariothoracic ICU. Eventually she became the Resident of the Year in our Unit. We became quite good friends and it was very nice seeing her again after her training now teaching others. The open appendectomy was performed quickly under competent hands and Lucia did very well.

When I woke Lucia up at the end of the surgery she cried a little even after giving her some IV morphine. My preceptor picked her up from the OR table and carried her back to the PAR unit with me dragging the oxygen tank and IV bags along behind. That must have been a sight. I have to tell you even with all of the work, the lack of sleep and the stress of performing with so many watching eyes, the sight of little Lucia cuddling up on the shoulder of Jim my preceptor on the way to the recovery room makes all of the work and stress worth while.

Gina Wald, DC BSN CCRN

Gina comes to nurse anesthesia practice prepared as a doctor of chiropractics. She is a first year student of Nurse Anesthesia at the University of Southern California. Her experience includes several years as an RN in a neuro/trauma ICU. Here are her first suggestions to James a prospective nurse anesthesia student.

James,

I am a first year SRNA at USC in California.

I knew before I started nursing school that anesthesia was where I wanted to be. While I loved working in ER, I chose my first nursing job in ICU, because I knew I would need experience with invasive monitoring (PA catheters and arterial lines) vasoactive drips, and ventilators. Those were my priorities. I would have started NA school after only a year, but decided to have a baby instead, which pushed back my plans. But the time in ICU was well spent, and I don’t regret one day of it.

There are students in our class who come from an ER background, and they will be the first to tell you that they feel intimidated by some of the ICU type stuff with which they are unfamiliar, but they are doing just fine and we will all graduate as safe and competent anesthetists. I know one CRNA who had all of two months experience when she started the NA program, and she is a fine and knowledgeable anesthetist.

I agree with David that the best thing you can do for yourself right now is to meet with or speak on the phone with several program directors, fax them your CV and ask where you could strengthen it. I did this before I graduated and it gave me a very clear plan of action.

I wish you all of the best in your endeavors. Do not give up. This is the first test of many regarding your perseverance and determination. You must really want this, and don’t let anything stop you.

Gina Wald, DC, BSN, CCRN

A few months ago I received a very nice letter by way of a comment to one of my blog postings from James a nursing student in Australia. He, like many of us, has questions about the profession of Nurse Anesthesia here in the United States. Most people, not to mention those inside of medicine and its related specialties, have never heard of Nurse Anesthesia let alone could describe what it is that they do. The idea that over 50% of all of the general anesthetics in this country are administered by a Certified Registered Nurse Anesthetist (CRNA), some report up to 65%, is a thought that has never entered the consciousness of the average person. So who are these CRNA’s, where do they come from and what is the preparation that goes into becoming a Nurse Anesthetist? Big questions and far too few answers. Below is James original comment/post and a beginning of a response from me.

Hi David…
I have just finished skimming through your Blog. I am an undergrad nursing student who found your site while researching Nurse Anesthetists for a future career. I have some questions and I am not sure where I should post them. Anyway, it’s about the admission criteria for the MSN program. My undergrad marks should be very strong by full graduation time, but I would like to know what is the average amount of years of experience you and your peers have had in ICU-related nursing? Is anyone in that program with only the bare minimum of one year experience? If this is not the appropriate place to ask questions then is there an email address I could have for further discussion. Thank you for your assistance in these matters, it is quite difficult for me to find information from the other side of the world, Australia.
Your reply would be much appreciated.
Thanks
James

Hello James

Thank you James for your thoughtful inquiry and questions concerning Nurse Anesthesia. I got your message and wanted to reply to you directly but you did not leave an Email address so the only way to give you an acknowledgment and answer to your questions is here in the blog directly. You may email me anytime at for a more personal response.

I too did a lot of research into which were the best schools for Nurse Anesthesia. Beginning with the American Association of Nurse Anesthetists (AANA), I explored many of the web sites of the schools here in the United States that are listed under Certified Programs. In the web pages of the AANA is a document describing what Nurse Anesthetists are at a glance. I guess that is the best place to start.

James, you asked about clinical preparation before being eligible to enter a program of Nurse Anesthesia. The requirement for admission to any school in the US is at least one year of critical care nursing. Different schools interpret what “critical care” is differently. All of them accept intensive care units (ICU) as critical care and exclude all else including Emergency Room experience or Post Anesthesia Care Units (PACU) while other programs are more liberal and examine each person’s application for experience in critical care individually. My advise is to explore the AANA’s web site and the schools that you like to find what a prospective school requires.

The answer to your question about only one year of experience is yes. There are some students that are accepted into Nurse Anesthesia programs with just one year or a year and a half of clinical experience. This may be because the rest of their application is exceptional while for others like myself it takes many years of ICU experience to get ready to apply. Do not be intimidated is the main thing. Get the experience that you need and go for your goal, period.

Academic requirements for most schools include an upper division course in statistics, physics and a year of chemistry including organic and biochemistry as part of your undergraduate nursing program. Many undergraduate programs do not include these as part of their curriculum so adding them now is very important if your goal is to go into Nurse Anesthesia here in the United States. Again, research the individual programs in the AANA web site directory for their requirements.

Finally, it becomes a little bit of a problem for foreign students coming to the US. I advise calling any prospective school now and to talk to the director of the program to see what you can do to make your transcripts attractive and acceptable to their respective programs. I have a friend here in the States who has a Nursing degree from Australia. She has to take classes here to establish a grade point average and to make up some deficiencies including the statistics, physics and chemistry before her application is accepted by a Nurse Anesthesia program here.

One last point about the application process here in the US. Most school require a minimum score on the Graduate Record Exam (GRE). This can stumbling block unless you prepare for it wisely. There are review courses here including Kaplan and the Princeton Review for the GRE. They all are worth while if you are serious about doing well on the GRE.

I hope that some of this helps. There is so much more to talk about but space and time do not permit now. The books that I have found to be essential for anesthesia practice are listed above in the Library Page. Good luck James and follow your dream. I have been struggling with climbing this mountain for a while now and appreciate anyone who wants to do more and make an impact on the world. The bottom line is that as a Nurse Anesthetist your input into patient care becomes very important and valued highly.