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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In 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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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 NurseAnesthetist.org.  Again, many thanks for those that have sent along encouragement.

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Recently I have been in contact with Heather Wilson of Peer Assistance Fame, a National Speaker of Note and good friend. I asked her to send something for the web site and she chose to discuss a little Q and A. Here it is and if any one further questions about Peer Assistance please do not hesitate to call her or anyone involved.

Q: I am a CRNA in the CA BRN Diversion Program. My contract requires me to attend a variety of 12 step program meetings. I don’t feel like they are helping me because I don’t believe in God. In fact, this is exactly why I do not want to attend anymore.

A: You raise an interesting point, and you are certainly not alone. There are some key points to consider here. First, Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) do not mandate anybody to believe in God. Twelve step programs also have 12 Traditions, necessary for the cohesiveness and effectiveness of the group.

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For the senior class members that will be graduating soon, board preparation is on everyones mind or else it should be. I have been doing a little searching around the web for resources for the nurse anesthetist board candidate and found a couple of interesting web sites. Listing these sites does not confer endorsement by me or anyone here. However, I think that checking these things out could prove helpful to you. Not everyone learns, studies or needs the same things. These various resources offer a range of products and services that if they suit your style then will help you to reach your goal of getting that Pass letter in the mail.

The first place to start is to narrow down your reading material. The large text books like Barash and Miller are great for general study and case preparation during your clinical years. When it comes down to the wire and time is getting pinched look for other reading material to help you prepare for boards. I suggest a couple of books. The Basics of Anesthesia, 5th ed edited by Stoelting and Miller is a great start as well as Morgan and Mikhail. Anesthesia Reivew by Faust is really top notch as well as the question and answer books like Anesthesia Secrets. Two books that I feel really are essential are Anesthesia and Co-existing Diseases by Stoelting and Review of Medical Physiology by Ganong. What I suggest is to read these two texts again during the last 6 months of clinical rotations. There is an amazing amount of physiology on the board test as well as stuff found in the Co-existing book.

Other review material and courses are listed below that I have found.

Valley Anesthesia review is a long time standby for board prep offering both review courses and valuable study material. Highly recommended.

Core Concepts Anesthesia Review On line course. I just ran into these folks the other day and they seem legitimate. I poked around their web site and found some interesting stuff like the Question of the Day. Recommend checking their service out.

Prodigy Anesthesia Review is an interesting web site presence. Like the Core Concepts place, here you can find pracitce exams that look very close to the real thing. Check them out and let me know what you think.

CRNA Secrets is another one that I need info on. Please check it out and let me know what you think of this guy!

Good luck and keep me informed about your progress.

I just found a link to an on line review course that publishes on line an anesthesia Question Of The Day.  The course at Core Concepts Anesthesia Review is something that I am going to check out in the near future.

Enjoy!

Well – it’s been several months now since passing boards and vacation time is over. Since November 1st 2006 the gainful employment thing has been happening in full stride. I could not be happier as a nurse anesthetist! All of the hard work and struggle is worth it more than double. There was a running joke about the last year of clinical rotations that goes something like this. “If you can make it through this gauntlet still standing you are a winner.” Let me explain.

Most graduate education is difficult. I should know, this last effort was a second post graduate degree. However, in nurse anesthesia education the stakes are higher and many people feel its their duty and privilege to make life difficult for the prospective candidate for the Certifying Nurse Anesthesia exam. The gauntlet that the student runs is like a small alley way lined on both sides with angry frustrated preceptors that are wielding long bamboo sticks. Any unworthy student trying to run down the alley is beaten from both sides as they try to make it through. You think I am kidding – well maybe the allusion is too graphic but the idea still holds. In the words of one old timer mentor, “Yup, we love to cull the herd!” So its taken me a little time to recuperate from the last two years of very hard work getting through clinical residency. All of the bruises are healed but the scares still remain.

Now I am one! One what you ask. Well now I am one of the mentors and the bamboo is put away.  You’re laughing I am hoping, yes? Actually I have been very fortunate and have been appointed to a faculty position at a leading Medical School that houses a nurse anesthesia program. Just little over six months ago I was a student and now I hold a faculty position with my own students to ed-u-ma-cate. I am humbled by the position I am in and having the time of my life. Love it! The perspective from the other side is of course different but I try to hold on to the kindness for others that suffering produces.

One of the questions that was asked of me during my interview process for the faculty position at the University of Southern California was how I would deal with a difficult student one who is not progressing or one that is not safe clinically. To be honest I do not feel that I am ready to deal with this case scenario and told them so. I can handle the new student and the ones that are a quick study. Maybe next year I will have a bit more experience to handle the difficult student. Just as an aside I do have many years of as a preceptor in another capacity so teaching and mentoring is not new for me.

So whats it like to be in practice now as a nurse anesthetist. Wonderful – I love my job and what I do. In our practice setting we work in a team collaborative practice with anesthesiology. The joint practice is great when the Staff are good. Every day is another learning experience which I can talk about in the future. For now I just wanted to touch bases with you and let you know that the NurseAnesthetist.org web site is still going strong. I will be recruiting new writers in the months to come and adding links that should prove helpful to the prospective CRNA or clinical resource for the practicing nurse anesthetist.

Your feedback is always encouraged so let me know what your ideas or concerns are. Thanks for reading.

Well its official. I passed boards. The notice of board results can be seen at the AANA web site under Certification Verification. After taking that crazy board exam I was perplexed as to how I actually did on the exam so its been a long ten days checking for results each morning at the AANA web site. We are precluded from discussing the exam itself but I can tell you that the board exam from the CCNA is very probing and examines your knowledge and understanding of physiology and the anesthetic implications at very sophisticated levels. My exam shut off at 90 questions. From what I have heard from other people this is either very good or very bad. The board exam is a test that learns from your answers what questions to give you tailoring each test individually selecting questions out of the very large pool. Each test is different if I understand this correctly. This has been a long and difficult road climbing this mountain but the view from the other side is terrific. Just take a look at the view.

Currently Jennifer and I are in Shanghai visiting her parents for the Chinese Moon Festival. Each morning I would get up first thing and turn the computer on and go to the AANA web site looking for the board exam results. I know that sounds nuts but I just could not wait for the mail and the end of our trip overseas to find out the results of the board exam.

So what can I now recommend as study preparation for the board exams you ask. First I would not put off any review for the board exam but to study daily the entire time while doing clinical rotations. A through review of medical physiology is a must. My choice is the LANGE publication by Ganong, “Review of Medical Physiology” as a must read. This is not a large text but dense and will require several months of careful reading and rereading to gather the appropriate understanding of the specific anatomy and physiology that is required knowledge to do well on the nurse anesthesia board exam. Maybe I could give you a general example of how specific the board exam is.

One of the favorite subjects on the board exam has been the endocrine system and the interactions with anesthesia. The pituitary glad as you may recall is located in the Sella Tursica, a cave like bony structure and is histologically divided into three sections. In humans the intermediate lobe section is underdeveloped and rudimentary. The posterior pitutiary or neurohypophysis is the site of excretion of ADH (vasopressin) and oxytocin which are structurally similar. It is interesting to note that oxytocin has antidiuretic qualities because of the structural similarity of these two hormones. I digress. The point I am getting to is that the source of the posterior pituitary hormones in from higher structures in the hypothalamus, specifically the supraoptic and paraventricular nuclei. Nerve axons project from these structures and descend out of the “Blood brain barrier” down to the posterior pituitary where they are released when physiologically stimulated. A full review of this and all of the physiology surrounding these structures and the actions of all of the hormones along with the anesthesia implications is highly suggested. Ganong’s Review of Medical Physiology and the Anesthesia and Co-existing Disease book by Stoelting are both highly recommended.

Brother, that was a mouth full. So which part of this do you need to know to pass boards? I am afraid that this is just a small example of the detail between structure and function that is requried. Its been overwhelming and the more that I study the more I realize that I know very little.

Good luck to all that are preparing for the board exam and don’t forget the small details. I guess it would be correct to say that knowledge at a superficial level will leave you really perplexed when you take boards while knowing the fine details will help you navigate your way through the questions. Again good luck.