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:

Continued Professional Certification (CPC)

 The new recertification program for nurse anesthetists beginning January 1, 2015.

 At the AANA Annual Meeting in Boston, the NBCRNA unveiled a draft of the Continued Professional Certification (CPC) program developed over the past three years. The intent of the recertification process is to ensure that the CRNA credential represents an acknowledged commitment to excellence, and continues to distinguish us from others in the field.

 The proposal is in draft form. To accommodate major changes to our website, the official comment period for the proposed changes is scheduled to start September 6, 2011 and runs through November 14, 2011. However, many of you already have written us with questions and comments, some supportive, others challenging the need for change, and most simply asking for more information. We have posted answers to the most frequently asked questions at www.nbcrna.com. We welcome your thoughts prior to the official comment date via email at recertification@nbcrna.com.

 The NBCRNA understands your concerns about changes to the recertification process and wants to reassure you that the proposed recertification exam will NOT be similar to the rigorous entry level certification exam. The recertification exam will evaluate clinically relevant knowledge in which all certified registered nurse anesthetists must be proficient regardless of their practice setting. These areas include 4 core competencies: airway management, pharmacology, pathophysiology and anesthesia technology. The recertification exam will contribute to ensuring that those who hold a CRNA credential are seen as committed to being the best educated, best prepared workforce possible.

 The proposed changes would go into effect in 2015, and the first recertification exam will be available in 2019. Those individuals who are planning to retire by the end of 2023 will not be required to take the recertification examination. To assure constituents fully understand both the goals and specifics of the program as drafted, we will shortly announce a series of web based town hall meetings to give people an additional opportunity to discuss the proposed changes in the Continued Professional Certification program. We look forward to your participation and receiving your input.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 This letter that went out to all of the current Certified Nurse Anesthetists created a firestorm of debate.  So many CRNA’s throughout the country were unprepared for this news and felt that they had no input into this process.  The list serves were lit up for weeks with accusations and denouncements of the AANA and the NBCRNA.  Revolt has been in the works and everyone seems to be gathering on one side or the other of the Mason Dixie Line ready for hand to hand combat.  Because of the mounting controversy, the NBCRNA issued another notice in the form of an email that just arrived today.

To the CRNA community from the NBCRNA

The proposed changes to NBCRNA’s recertification program have given rise to significant controversy among members of the nurse anesthesia profession. Some CRNAs indicated they were unprepared for the introduction of the CPC program at the AANA annual meeting in Boston, while others felt the proposed changes were being rushed through and forced upon them with no opportunity for their voices to be heard.

?From our perspective, the NBCRNA reasoned that the AANA meeting offered the best opportunity to begin a grass-roots communication about the CPC program, in advance of any mass communication and before opening the official comment period. It has since become clear that many CRNAs do not understand that AANA and NBCRNA are independent organizations with different missions and responsibilities, and the announcement caused confusion.

Over the past two years, while the Recertification Task Force was finalizing its work, NBCRNA representatives made presentations at 30 state meetings to solicit feedback on how we can strengthen the CRNA credential and to introduce the idea of moving the recertification process to a continuous competency model. These presentations were done in advance of any specific recommendations of the task force. We felt that when we introduced the proposed changes to the many CRNAs in attendance at the annual meeting, we were simply initiating a dialogue that would result in a healthy exchange of ideas about what the final program should look like, based on input from our community. Having now heard from numbers of CRNAs across the country it is clear that we could have done a better job of communicating about the proposed changes to the recertification program so that CRNAs would have been better prepared to exchange ideas. We regret not doing so. Still, the comments we have received to date from many CRNAs has started the discussion we were looking for about this important issue. We expect this will continue with the official comment period which begins on September 6th.

 Going forward we will make every effort to ensure that members of the nurse anesthesia profession are completely informed about the CPC program and we will aggressively encourage constructive suggestions as we work to increase the value of the CRNA credential.

~~~~~~~~~~~~~~~~~~~~~~~~~~~

 So There you have it.  The NBCRNA is “regeting” that they did such a poor job of informing the nurse anesthetist community about the proposed changes in the recertification process.  The official comment period is coming up so get to work on those letters.  Certainly, the future of Credentialing and maintaining the Certification to practice Nurse Anesthesia will require some sort of Continued Professional Certification (CPC) through Simulation testing and / or examination.

For those old timers who plan on retiring before 2023 the Recertification Exam or Simulation will not be necessary.  The first proposed Exam date for Recertification will be in 2019.  Its a bit of a way off but will come and for those that are in school now it will be a certainty.

Simulation training and testing will be a very hot topic in the years to come.  Stay tuned.

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.

The Keck School of Medicine of the University of Southern California has immediate openings for GRNAs or CRNAs interested in becoming an integral part of an expanding University based Anesthesia Department with clinical academic, research and administrative opportunities.  Clinical service responsibilities include the Los Angeles County General Hospital and USC University Hospitals.  Nurse Anesthetists participate in all clinical areas including trauma, neurosurgery, interventional neuroradiology, hepatobiliary, urology, pediatric, ENT, and orthopedic surgery.  The Nurse Anesthetist performs preoperative and postoperative assessments, provides general, regional, and monitored anesthesia care.  Teaching responsibilities include didactic and clinical instruction for student registered nurse anesthetists through the USC program of Nurse Anesthesia.

Excellent salary base and benefit package, which includes:

• Four weeks of Vacation (per year)
• One Week of Education Leave (per year)
• Retirement Package
• Paid Professional Licensure
• Excellent Health Insurance
• Life and Disability Insurance
• Tuition Assistance for Self and Family
• Free CEUs

Academic appointment at the Keck School of Medicine will be at a level appropriate for training and experience.

Please forward your resume to:

Kari M. Cole, CRNA, MS
Chief Nurse Anesthetist and Assistant Clinical Professor
USC Department of Anesthesiology
1200 North State Street, #14-901
Lost Angeles, CA 90033
Phone (323) 409-7735
Fax (323) 441-8085
Email: kcole@usc.edu

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

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

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

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

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

David,

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

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

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

Thanks

Here is another one that worked out well.

David,

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

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

Respectfully,
Joe Romero

Finally the last for now.

Dear David,

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

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

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

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

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

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

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

Wes Easter RN, BSN, CCRN

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

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

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

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

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

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

Now, lets eat!

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.

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.

The Third Tradition states, “The only requirement for membership is a desire to stop drinking/ using”, therefore the atheist or agnostic cannot be denied. Next, the Second Step states, “Came to believe that a power greater than ourselves could restore us to sanity”. We believe in a Higher Power and yes, the vast majority of members choose to believe that God is their Higher Power. Many have even taken the word “God” and made their own acronym, such as “Good Orderly Direction” It is also common to see members using the AA or NA group as their Higher Power; or nature. In the Third and Eleventh Steps where God  is mentioned, it is immediately followed by, “as we understood Him”, because this is highly subject to personal belief and interpretation. Lastly, the only suggestion I would like to offer is to try to have an open mind. If you focus on what makes you different from everyone else in the group, then you will feel isolated and alone. If you focus on the similarities and concentrate on identifying instead of comparing- then you will start to feel “part of” rather than “apart from”.

Q: I am a newly recovering opiate addict/ CRNA. The counselor at my treatment center tells me that I cannot drink alcohol. I don’t even like alcohol! I would much rather do other things. I’ve never had a drinking problem, so I don’t understand why I cannot have a glass of wine with my dinner every now and then.

A: I can sum up the answer in one sentence: “If you can”t have the drug you love, you love the drug you’re with”.  What does that mean?
The basic pathophysiology in the brain can be explained very easily. Anything that is addicting, whether it is opiates, ethyl alcohol, benzodiazepines, cocaine, et cetera- all follow the same final common pathway. At the base of the brain is a structure called the ventral tegmental area (VTA) which projects dopamine to the nucleus accumbens in the frontal cortex. Therefore, whether you are tickling mu receptors, enhancing GABA, or blocking the reuptake of norepinepherine- it will invariably result in a rush of dopamine in the frontal cortex. This rush of dopamine is what we seek; it is the high that addicts crave.
Interestingly enough, whenever there is activity associated with procreation or survival (such as sex and food), the pathway of dopaminergic projection is identical. This is a deeply embedded, primitive pathway. It explains why addicts and alcoholics will do whatever it takes to get their fix- because it is as important as procreation and survival. It becomes a primal drive.
Back to the original question of why an opiate addict cannot drink alcohol: the brain does not know the difference. Even if alcohol is not your drug of choice, you are still pushing the dopamine button. There are countless anecdotal instances of people who, for example, are primary alcoholics who relapse on hydrocodone. Or primary opiate addicts who become full-blown alcoholics. (As a side note, taking pain medication on a short term basis for injury or surgery is an entirely different Q&A.)
If anyone is interested, I would be happy to share some scientific articles via e-mail. Abstaining from all mood and mind-altering substances is an evidence-based suggestion for all addicts and alcoholics. The disease is cunning, baffling and powerful. It is also very patient. It will wait a lifetime for you to pick up again.
Heather Wilson, CRNA, MS
AANA Peer Assistance Advisors Committee
Co-chair CANA Peer Assistance
mocrumbo(at)sbcglobal.net

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.