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The Anesthesia Machine Check

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Jose Anesthesia Tech

Jose Anesthesia Tech

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

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

anesthesia machine naked

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

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

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

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

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

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

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

Study study study is the cure.

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

Friday, February 22, 2013

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


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


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


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



Charles Vacchiano, PhD, CRNA


NBCRNA President










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New Academic Year Thoughts

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

Dear David,

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

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Recertification for CRNA’s

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

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

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

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Really More Shadow Days

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

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

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

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More Shadow Days

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Recently I have been very busy with the new students operating room rotations.  We are now coming to the place I really look forward to in the development of the SRNA’s clinical skills and awareness.  This new class has been in the OR’s now for a little over 6 months and are starting to really shine.  Now is the time to back off as clinical instructors and let the little fledglings fly a bit and see what its like to take care of patients with less direction and more watchful care from the instructors.  I have been really pleased to see how far the students have come in their skills and judgment of basic anesthesia care.  My greatest pleasure now is in seeing the developing SRNA’s taking the reigns and allowing me to back off to more of a watchful position.  Off course I am always there to rescue or to discuss different management systems for the cases we do.  All in all I think that as instructors of clinical anesthesia we are very hands on.  Now is the time to back off a bit.

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.

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Nobel Peace Prize

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Obama_Peace_PrizeIn an unexpected announcement this morning, sitting President Obama was elected the Nobel Peace Prize winner for 2009.  Wow!

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.”

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Upgrades and Revamping

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For all those that have sent along encouragement and well wishes, I thank you.  Yes, it’s true, I have been sick.  Sick and tired of all the bedevilments that a web-slave, AKA web-master, can run into.  The last several months have been interesting to say the least in revamping and updating  Again, many thanks for those that have sent along encouragement.

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Fall Lecture Series

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Graduation_DayThe Fall is here and a new class start their didactic schedule.  This season is a break for the clinical faculty here at the USC program of anesthesia.  The senior students are for the most part off doing advanced rotations such as cardiac or neuro surgery with Staff Anesthesiology in attendance for teaching and patient supervision.  The CRNA faculty is concentrating on lectures and rest from a long 8 months of OR teaching.  Of course we get to now do our own anesthesia cases which is really SWEET!

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Categories : Anesthesia, General
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Do You Have The Fire In The Belly?

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David in OR2Today I will submit two letters that I have received in this last month. The subject of “desire” has come up frequently in those that have written and has caught fire as it were. The idea that a candidate must have a certain, “Fire in the belly” as coined by Wyne Wagaman, really seems to have ignited a response in those that have written to me recently. Here is a good example:

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.

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Categories : Anesthesia, General
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