“OH NO MR. BILL the CCNA exam is coming in a few days and even after years of study and preparation I do not feel ready”, the little voice whispers in the back of my head. What to do about those voices.

Just as all others that have come before and for those that follow there no way around this mountain except to climb each day a little further. I have kept a picture of K2 on my wall for many years and I keep whispering to myself that one day I will be over the crest. That day is so soon approaching that it is almost too much to comprehend.
Here is a plan for CCRN board exam preparation that I have used:

Attend a Review Course. I did the Valley Anesthesia Review, there are others?
Select a few concise books for reference.

• Morgan and Mikhail Clinical Anesthesiology
• Barash Handbook
• Sota Omoigui’s Drug Handbook.
• Valley Review Course material. The Sweat Book, the Memory Master and the Mixed Reviews.
• Anesthesiology Review by Ronald Faust

I have read through the Sweat Book twice and the Memory Master a couple of times and The Mixed Reviews from Valley anesthesia I keep with me all the time. I read through these frequently.

The Faust Anesthesiology Review is a great one to look stuff up quickly for refresher. These past three weeks since graduation I have spent 6 to 10 hours a day reading and reviewing questions and looking stuff up quickly that I needed clarification on. I feel that I am ready for the exams but still have so much to learn. I just found out about another on-line review that could be helpful. It is called Prodigy Anesthesia. This is an on-line review and workbook type thing. I checked it out and it seems very good. Highly recommended for someone that has more than a couple of days before the scheduled exam. Another board prep on line I found is CRNA Secrets. If you do check it out let us know if it helped or not with boards.
Thanks to everyone for the well wishes. Our class will get together for a big party once these exams are over so every one will know about our success.

The University of Southern California program of nurse anesthetist awarded Bob Naruse, M.D. the faculty award this year. Dr. Naruse is staff anesthesiologist at Cedars Sinai Hospital where many of us do our neuro rotations. It is here that I met Dr. Bob and became acquainted with the low opioid techniques for craniotomy surgery that are routinely used there. Today several of our classmates were able to present the award to him in person. Unfortunately I was not able to attend but sent my best wishes and called him on the phone as a follow up.

Our lives have been enriched by his mentorship and example of excellence in patient centered anesthesia care. Thank you Dr. Bob Naruse and we will all make you proud. What follows is a letter I received from him after today’s presentation.

Dear ‘SC Class of 2006,I must admit that I am truly touched by your award. Working with such a distinguished group of anesthetists made my job easy and fun. I can’t remember a class that I’ve enjoyed more than yours. I know that each of you will be outstanding anesthetists for years to come and I want to congratulate each of you for the great achievement of completing graduate school. I am proud of you.

Please pass along your knowlege, especially that which is not in the textbooks. I know that eventually your colleagues will be impressed with your airway management skills as am I. We owe it to our patients to provide the best care possible.

Take care and best wishes in the future. Fight On!!!

Yours truly,
Bob Naruse
Da cedarsgasman

So there you have it. This week many of us are studying for CCNA board exams. My test date is the 20th of this month. Pressure, a little, confidence, a lot. I will let you all know how our class does.

The Keck School of Medicine program of Nurse Anesthesia has graduated the class of 2006 this past Saturday. I am so proud to be a part of this class of winners and overcomes. We have all struggled with difficulties to one degree or another but this past Saturday we all stand together as graduates. What a blast that is!
The program for the graduating class took place at the Town and Gown on the University of Southern California main campus in East Lost Angeles. We were privileged to have Elizabeth Visco from the University of Washington as our Key Note speaker. Her credentials are too long to discuss. She was wonderful.

Awards to faculty went to Robert Naruse, M.D. as faculty of the year and Tracy Valdez, CRNA as clinical instructor of the year. Dana Grogan received a well-deserved recognition for her didactic instruction. Lifetime achievement awards from the Nurse Anesthesia program at the University of Southern California were awarded to Janette Peter and Dr. Vladimir Zelman. Student awards went to Robert Olson for Leadership as well as the Agatha Hodgins award while the other leadership award went to Karyn Embrey and the scholarship recognition went to David Godden.

After the festivities at the Town and Gown we all went our separate ways to celebrate with family and friends. Douglas Brannan and his family and I spent the evening together with our families at a little Greek restraraunt in Manhattan Beach. Douglas has been a great friend and fellow traveler on this road with me.

To view all of the pictures you can go to the flickr web site here. Follow along with me on this journey to see how this graduating class of 2006 soldiers on.

Its all finished folks. After two years and a lot of hard work the class of 2006 from the Keck School of Medicine department of Anesthesia has graduated the next group of nurse anesthetists. The University of Southern California program for nurse anesthetists has been terrific but I am so glad to be finally finished with this step in education.

After this weekend I will buckle down to several weeks of intensive study for board examinations. Following this Jennifer and I will take some time for ourselves before I start work November 1st. Isn’t life great!

This Saturday evening Douglas and I had an early dinner together at the famous Irish Pub in Pasadena, Lucky Baldwins. We are winding down now from our clinical rotations with only eight days left to go before our graduation celebration September the 2nd. The University of Southern California program of Nurse Anesthesia has been a wonderfully difficult experience. The graduating class of 2006 is just about finished with course work and will be stretching our wings shortly. Pictures of the class can be perused at flickr.

Friends of Douglas joined us at Lucky Baldwins. What made this interesting is that Sonny and Dianne will be starting “The Program” this coming Monday and are part of the Class of 2008 program of nurse anesthesia at USC. During our early dinner at the Irish Pub we discussed and rehashed the trials and tribulations of being an anesthesia resident. All of the usual subjects came up that new students have. Its great now to be on the other side of this mountain. Douglas and the girls went off for an evening of “Pub Hopping” while I happily traveled home to be there when Jennifer came home from a long day at work.

Douglas and I have been having our study sessions and dinner now on Saturday evenings for the past several months now but I always make sure that I am home to greet wifey when she arrives home from work. This past evening we finally got around to talking about future work related things. No matter where we both end up we agreed to continue to meet regularly for bicycle riding and “Pub Hopping”. Next year Douglas his mother and I are planning on riding the RAGBRAI. For those that do not know, this is one of the oldest sponsored group rides in America. The ride across Iowa will be its 35 next year and I am looking forward to this get away 7 day trip. Douglas and I have planned this now for the past year and come next July we will be flying across those rolling Iowa hills. More to follow on this one.

Congratulations to all around. This came in the mail today and to say that I am happy is the least of it. The long hard road through this part of our education is coming to an end while the broader path is open for us.
Right now I am going to make a few phone calls just to hear the cheers go up and see the streamers fly when people hear the news. This makes it official and the reality of actually graduating is sinking in. Maybe for others this has been a cakewalk but that has not been my experience. Anesthesia training is tough, rigorous and very demanding as it should be. To finally approach this milestone is… hmmmm…what is it? I guess my breathing is just coming a little easier now and the smile on my face will not leave for a long time it seems. That just about sums it up for me at the moment. Just like this picture of a happy birth that I was privileged to participate in, my joy is complete.

August 17, 2006

Dear Mr. David Roy Godden:

Congratulations! The Degree Progress Department is pleased to inform you that your Master of Science in Anesthesiology degree has been conferred and posted to your academic transcript at the University of Southern California. The conferral date of your degree is August 8, 2006.

Your diploma has been ordered and, unless you have requested that it be held for pick-up or you live in the 90007 zipcode, it will be mailed to your address of record. If you have not received your diploma by September 21, 2006 please contact the Degree Progress Department at (213) 740-7070.

If you require official confirmation of your degree, you can find information on ordering an official record verification by visiting http://www.usc.edu/verification. There is a $5 charge per record verification. You can also find information on ordering an official transcript of your entire academic record, including your degree, by visiting http://www.usc.edu/transcripts. There is an $8 charge per academic transcript.

Again, congratulations on this achievement. You have completed a demanding course of study and we are proud to have you join that select group of individuals who are graduates of the University of Southern California.

Degree Progress Department
University of Southern California

Our graduation ceremony will be September 2nd…just a couple of days…..Yippppy!!!! I will see all in clinical tomorrow bright and early. Only 10 days left of clinical rotations. For me its Big County general surgery in the morning.

Karen Embrey is a Nurse Anesthetist extraordinaire, my classmate and friend. I just received this note from her and had to pass it along. In the future she will make her own posts, which I am looking forward to. All of the graduating Class of 2006 at USC is able to register and log on to make posts at their leisure. I am looking forward to hearing from everyone. OK, enjoy! DG

Hi all –

Just back from AANA in Cleveland, Ohio!! Greetings from former President Bill Clinton, Dr. Eger, the Rock and Roll Hall of Fame and the Cleveland Clinic. If you all have not seen the latest edition of the International Journal of Student Nurse Anesthesia – you just have to know that our own Robert Olson is now officially a “Cover Boy” – and a fine job he appears to be doing as a vigilant and skilled (not to forget handsome) Anesthetist!!! Congratulations to whoever took such a fine picture and also to the person who submitted this fine photographic display. Robert, I told everyone in Cleveland that I was your classmate J ! They all want autographs!

Kären

I received a wonderful email today from Gina my Pal with a capital P. As you may recall Gina has been a practicing doctor of chiropractice medicine and decided that this was not enough for her. We have now been classmates for two years in the anesthesia program at the University of Southern California and will be graduating soon….this month in fact. This short note came today in an email from her which I just had to share. I will get back to you about what has been going on with me and why it has taken me so long for any new posting on this web site. Her letter follows. Thank you Gina for for your friendship and genius. You have been an inspiration to me.

Dear Class,

The clock is ticking my dear friends and we are so close to the end, my pulse is quickening as I type this. My very best hopes and wishes for all of you as you start your careers. You are such an amazing, talented group of people, and it has been a tremendous privilege to know you and experience this adventure with you. If ever I can be of service or help to any of you, please never hesitate to call.Which brings me to the point of my email. We are spending our last moments as the class of 2006, and already are starting to spread our wings; we know amy is headed to the great Northwest, and several others are looking across the country for our first positions (Aloha, Manda Manda?). I would like to propose that we elect one of us as a point of contact person for the Great and Wonderous USC Class of 2006; someone whom we could email or call for current contact info on a classmate. Douglas won’t have that usc.edu email address forever [unless he starts an affair with Dr. McDonaugh (sp)], and I’m pretty sure Helen will be getting a new address and phone number once she’s married. I know from past experience, as I’m sure you all do, how quickly a class can get scattered to the winds, all the more so with a profession such as ours where mobility is a key feature.

Is there any of us who would proclaim themselves stable enough for such a role? If I want to know what Joy’s new email address is, or Lunsford’s phone number, who could I call? Keep in mind that we could be using each other for letters of reference as our careers develop. Or in the case of Lunsford, I might just be thirsty and want to have a beer with my old friend from USC (Downtown Brown, of course). Remember part of why we chose USC was for the alumni connection. Since it’s not bloody likely most of us will be active in the USC Alumni Association proper, let’s create our own little Association. Let’s stay connected.

I immediately thought of either David Godden or Karen for the role, as they are both Uberorganized, and soon to be entrenched, I mean immersed at LAC/UH, which sounds pretty stable to me. Either of you interested? Somebody else feeling ultra stable and want to volunteer? I just don’t want to risk losing touch with this group of people I have learned to love like family (without the hairpulling, namecalling, and clothes borrowing dysfunction).

BTW, Karen, Godden, and Manda Manda, Dr. Yasafusifusi from Cedars spoke very highly of you today.

Have a great finale everybody. Looking forward to seeing you on the 2nd.

gina~ They can’t stop the clock!

So there you have it from Gina. You are such a peach. My bet is that Gina will be world famous one of these days. She has that special something, the charisma and intellect to really make things happen. It has been such a gift meeting her and the rest of the friends that I have made during these last two difficult years. Which brings me to why I have not posted more in the past months.
This is actually difficult to write or disclose. School, that is academics, is easy – at least for me. Many people struggle with memorizing vast numbers of facts but not me. I am pretty good at that. What has been difficult is dealing with the scrutiny and criticism of a few during clinical rotations. I wish that I could tell you that all it takes to be a great practitioner is intelligence. This is not the case. I have thrived in the clinical arena and done well in supportive environments and have suffered during difficult assignments where small people feel better about themselves when they can dominate and put others down – that means me. I guess this is important information for anyone that is interested in going on and pursuing nurse anesthesia. It is a difficult road where the gauntlet must be run well and no one comes through unscathed. This last month has been particularly brutal. I have survived and continue to thrive which is the good news.
This month of clinical rotations is in General Surgery at a big County hospital and it is our last. This past week has been very busy but wonderful, coming home and back to friends that I have grown up with in anesthesia. The surgeries here at the County have been complicated and intense but really interesting and handled well. My confidence has increased a thousand fold this past week which is the good news. I am so glad to be home.

So I have not written anything for a while now because I have been too stressed out, busy and just plain tired. Working 12 to 14 hours in the operating room then the travel time not to mention all of the preoperative preperation that has to go on just leaves little time for writting. You understand. Maybe this is all good information and will be taken to heart by anyone interested in nurse anesthesia.

Today I am happy to submit for your appreciation a true story. In some tales you hear the line the facts are true only the names have been changed. That applies to the “Road Trip” which was written as a sort of autobiographical recount from a long time CRNA. I hope that you enjoy this example of what it is like to be an anesthesia provider behind the scenes doing the every day work of an anesthetist. In reality this is something about being a rural CRNA keeping your finger in the dike, working hard to keep your skills up for when it really hits the fan; something about being “on deck” for half of your life knowing that in fact for 65% of rural hospitals, CRNAs do this “Road Trip” night after night. Enjoy.

Road Trip

“Damn, damn DAMN!” He thought. Two seconds ago, he’d been rushing across the hospital parking lot, thinking about all the things that could go wrong during an emergency anesthetic for a 400 pound patient, and all the things he’d have to do to make sure that none of those things would go wrong. Ten minutes ago, he’d been writing some last-minute Christmas emails and thinking about yet another New Year resolution to send cards next year.

As the initial shock and anger began to wear off, the hard reality of the slick, cold, gritty black ice of the parking lot began to make itself felt. His right arm hurt like a son-of-a-bitch, and when he tried to flex it, it wobbled uneasily, but bent very nearly as it should. “Nothing broken”, he thought as he picked himself up gingerly off the pavement and fumbled for his ID tag to let himself into the back door.

The reality of winter in the northland hit him, and he reflected that you could take the boy out of California, but you couldn’t take California out of the boy, and that, as long as he had lived in the North Weeds, he still had to remind himself that the footing could be treacherous. Then the reality of the life of a rural CRNA came back to the fore, and his mind tore itself away from the pain, and back to planning for the care of his patient.

Stercus contingit.

“Murphy”, he thought, “was an optimist”. What had started as a simple in-and-out look through a scope at the lining of his sedated patient’s stomach had turned into a desperate emergency. The high-resolution screen of the video system hooked up to the modern gastroscope had told the tale for the entire crew to see – a crimson geyser sprayed from a tiny hole in the lining of the man’s stomach. Under the magnification of the fiberoptic system of the scope, it looked horrible. “We have to open”, said the surgeon. Just like that.

“No plan survives initial contact with the enemy”, he remembered from somewhere in his past. That spout of blood was trying to kill this man, and the entire crew stopped and looked at him there at the head of the table, and he suddenly felt very alone. Quickly, he ran a mental checklist for a “rapid sequence IV induction”, a procedure that would quickly and safely exchange the patient’s fuzzy panic for calm sleep, and exchange the poor man’s labored breathing for the efficient mechanical swishing of a modern anesthesia ventilator pumping life-giving oxygen into the man’s lungs along with general anesthesia – the mysterious miracle that has been called “death with a return ticket”.

Years of practice and training informed his quick and efficient movements. Everything was laid out exactly where he knew it would be because everything was ALWAYS laid out where he knew it would be. Years of working alone in operating rooms where everything that could go wrong frequently did go wrong had prepared him to prepare. Even in preparation for the most seemingly trivial procedure, everything that might be needed was there. He knew that, sooner or later, everything that might be needed would be needed. Decades ago, he’d learned that, while there might be “minor surgery”, there was no “minor anesthesia”. In a series of steps that would have occupied several pages of some systems analyst’s flowcharts, but which took only precious seconds, his patient was asleep, a tube safely and surely in his windpipe, his blood pressure and pulse stabilized. With a terse nod to the surgeon and the man’s family doctor who’d been urgently summoned to help, he said “Go”. The incision was a small white rent in the yellow of the iodine-stained skin for a split second, and then drops of blood became a thick red line as the doctors went to work. He scanned all his monitors again, satisfied that his patient was responding as he should. Only then did he reach for the phone.

His partner of several years was home, and he breathed a sigh of relief as she answered the phone. A second pair of educated hands would be a life-saver – perhaps literally tonight. “Damn — I’m a one-armed bandit”, he thought to himself silently as he grunted with the effort of hanging another bag of IV fluid with his arm that did what it was told, but reluctantly and painfully. He could have finished this case alone, but he didn’t have to prove that to anyone, least of all to himself.

Within minutes the other CRNA had come. No questions asked no protestations that it was her night off – because it had often been the other way around and she knew it would be again. With a brief exchange of questions and answers that a visitor might have mistaken for a foreign language, he brought his partner “up to speed”. The doctors, heads nearly bumping over the deep incision into the man’s massive abdomen, murmured in a language all their own and the technician and nurse half-listened, preparing and handing instruments in a frenzy of movements that spoke of years of having done this. A hundred collective years of training and experience came together over the man’s blue-draped body, homing with a grim intensity on that “bleeder”, conspiring to cheat Death yet again.

The two CRNAs worked together in the small area between the head of the bed, the cart full of drugs and equipment, and the anesthesia machine. In a space barely big enough to turn around, they divided the tasks and worked together with a silence broken only by an occasional syllable or two; they both knew what had to be done. Within minutes, another large IV needle was in a vein in the man’s arm, and a slim needle had been run up an artery in the man’s wrist to monitor his blood pressure. With each task completed, their pace became less frantic but no less intense.

Finally, the doctors looked up. “Got it”, said the surgeon, and for the first time, he took a deep breath. “We’re closing him up, and you guys wake him up and we’ll transfer him”. The CRNAs looked at each other, and each knew what the other was thinking. This desperately ill man would “wake up”, all right, but it would be tomorrow, miles away, in an Intensive Care Unit, of which this tiny rural hospital had none. They also knew that the same freezing drizzle that had turned the skating lot into a parking rink would have kept the helicopters parked safely in some hangar somewhere, and that it would be a long and careful trip in the back of an ambulance.

One general anesthetic, with everything, to go.

The ride was long and bumpy. Each breath for the patient came from a plastic football-shaped bag, squeezed by his beat-up sore arm. He thought it would never end, but like everything else in his career, it did.