Archive for Student Life

Nov
11

What does the Shadow Know?

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GarretWhat does the Shadow Know?

Recently I had the chance to interview and conduct a day long orientation to a potential candidate to a Nurse Anesthetist Residency Program.  Good candidates are hard to find ala May West.  Some of you may know the reference.

There are SRNA programs out there that like young blond inexperienced candidates for their programs thinking that they can mold them into subservient technicians that could fit into their semi-national workforce.  Not so here at our facility.  Ideally, we are looking for experienced ICU nurses that can think, have the experience to give them some wisdom and those with leadership skills to direct and manage future anesthesia cases.  Do I ask for too much.  I would hope not certainly in the 21st Century with Health Care evolving into something none of us had anticipated nor expected.

The medical world is in total flux and non of us in “the Business” of health care know how the future will play out.  What is central in my thinking is patient care and what is best for our clients.  Who are our clients as anesthesia providers?  Certainly our patients come first but that is not all.  Our clients include the surgeons and nurses that work in the peri-operative arena as well as the families and visitors that come to our “peri-operative home”.  We serve them all but primarily it is the direct patient care in the operating room that defines our practice as safe and efficient Nurse Anesthetists.

This brings me back to the Shadow.  What do our candidates bring to the table.  What is it that we want for a base line level to go into nurse anesthesia training?  These are huge questions.  I get candidates that have one to two years of ICU experience and have been awesome and I get some with ten years of ICU experience that have faded and not up to the rigors or challenges academically or clinically for anesthesia training.  In a previously very popular post with the commentaries, Fire In The Belly, I talked about what I thought was the most important thing to look for in a candidate to nurse anesthesia school.  My thinking has not changed much.

If I were to give you the potential applicant the ideal credentials, here they are in my personal view.  I would look for an ICU nurse that has between 3 to 7 years of experience working is a SURGICAL setting not medicine.  Pediatric experience is a PLUS not a minus while NICU is a very special category all by itself.  If you have been an ICU nurse for several years and have not stood for the CCRN I have to ask why.  Is it that you do not have motivation to excel?  So the CCRN credential is important.  When was the last time you were enrolled in an academic program.  Have you forgotten how to study?  If it has been “years” since you have taken a rigorous scientific course take one and demonstrate excellence.  I look for driven motivated people that know what they want and are willing to make the sacrifices that it takes to get into a nurse anesthesia program and excel.  Are you willing to move to complete your goals?  These are questions only you can answer.

What I am motivated to do is to encourage the best and the brightest nurses to pursue a course of study in the field of nurse anesthesia.  It is not for every one certainly but the rewards are tremendous for you and our patients.

Here is a letter from Garret.  He is a wonderful example of what I consider an ideal candidate for our program. Maybe he would not fit into everyone’s program but he meets all of the criteria I have found to produce fabulous results.  This is not an endorsement that he will be accepted into our program only my opinion.

 

David,

As discussed I am writing this letter as a reflection related to my shadow experience with you in October 2014.  I had to put some thoughts together on paper for this response.

In order to provide you a better picture of where I am in the process of becoming a Nurse Anesthetist let me inform you as to how I got to meet you.  I am certain this process started when I was in junior high school.  Unfortunately like approximately 40% of American parents my mother and father divorced when I was young and eventually we left our hometown in east Pennsylvania and moved to Maryland.  While there we lived with my mother’s aunt until her job stabilized; she was a Nurse Anesthetist in Baltimore.

While living with her I had many enjoyments and challenges, going to work with her from time to time proved to be new and ever stimulating adventures.  I remember sitting in emergency and operating rooms watching patients come in with, various illnesses, gun shot wounds, stabbings, and all sorts of complex injuries.  I got a chance to meet other nurse anesthetists, physician anesthesiologists, and all sorts of surgeons.  I was always star struck, as these people were rock stars to me.  My aunt was typically calm during most of these circumstances and then like magic the patients were calm or sedated and having surgery.  She seemed like to captain of a ship so busy yet so in control of a large complicated circumstance involving the life of another person.  Every time I saw this I loved the complexity, the science she discussed, and our conversations related to what I saw.

Fast forward through high school in Montgomery County Maryland, ten years of training (graduated top of avionics class), working, and traveling the world for the US Navy (5 years in uniform and 5 not), attending CSU Fresno (BSN Nursing 2006, Academic Deans Medalist for Department of Health and Human Services), completing a two year externship in Pediatric Critical Care (early acceptance based upon academic performance) as well as Burn and Trauma Nursing (Community Regional Hospital Fresno, CA), ten years of working in the Pediatric ICU, promoting to Pediatric Critical Care Transport  and Charge Nurse (Summer 2010), sprinkle in some adult post-op in patient care at a surgery center and here we are today.  I started talking to Dr. Gold in 2011 about how to become a candidate for selection into the Masters of Nurse Anesthesia program at USC.  Most of our conversations have been her advice for choosing required coursework and my decision to not pursue medical school in order to practice anesthesia.  She provided me with a solid course guideline in order to prepare me for the application process.  Admittedly I was following an academic track geared up for my own development in critical care and medical school in order to take an MCAT; a lot of math, chemistry, and physics, you know the drill.  I enjoy those sorts of courses and plan to continue some related education after the master’s degree.  That training and coursework has me a stronger critical care nurse and has provided a stronger foundation to my practice.  In order to further research my decision to pursue nurse anesthesia I have recently, through a close friend, contacted Dr. Jane Fitch, President of American Society of Anesthesiologists, whom used to be a practicing nurse anesthetist.  I wanted to get some advice on choosing a school in which to train and know why she decided to go back to medical school after so much training and academics in order to become a physician anesthesiologist.

A year ago I realized my window of academic opportunity was near based upon my family circumstances with one of our children nearing her college graduation at Davis, the other entering junior high, and my financial plans getting set for being a full time master’s student.  I again contacted Dr. Gold and reviewed my academic record to ensure I was on track.  We met in February 2013 and discussed not only my academic record but also the ability for me to sit in on one of the SRNA lectures.  After some emailing and date confirmations I was able to sit in on a OB lecture this past June with Dr. Jabbour.  For me this was the entrance to the Disneyland of an experience.  I could not sleep thinking about this and had to make sure all was perfect on my end (outfit, shoes, background knowledge search, timeliness, etc).  Since I had been to Dr. Gold’s office before getting there was not much of a challenge, but I was nervous as I waited for the students and Dr. Jabbour to arrive; this was a backstage pass for sure that I am extremely grateful for.

That day was exciting.  Dr. Jabbour and the other students made me feel welcome and I was able to ask a few questions to the students.  My biggest concern and still remains to a slight degree is my clinical background; PICU.  As I was researching the Master’s Degree of Nurse Anesthesia most of the requirements across the country contained adult critical care work experience, and some emphasized more specific areas within that were preferred.  At the end of the lecture I was able to speak to a student, a young lady, that was a PICU nurse prior to becoming an SRNA.  She expressed a great deal of comfort with much of the material throughout the program based upon her past work as a PICU nurse.  She further explained that everyone in the class comes from various specialized areas and their strengths are obviously a result thereof.  Not everyone was from some high profile, high acuity trauma and / or cardiac adult critical care area as I had previously imagined.  Between that information and the awesome lecture presentation my pursuit of this career was even further energized and more intrigued for applicable related knowledge.

After the lecture I was able to meet Dr. Norris at the program office.  She discussed with me some feedback of my experience and eventually recommended some related texts to obtain and read as a foundation to anesthesia practice.  Dr. Jabbour joined us and I was able to thank them both for the experience and their time.  I ordered the book from my phone on Amazon before I got back to my car (Stoelting and Miller).  As I was leaving we discussed what was available for me in terms of shadowing CRNA’s.  I explained that there was not a practice available at my facility and that we had only MD anesthesiologists; of which very few are supportive of CRNA’s.  We eventually decided to set up a shadow experience at LAC/ USC and that is how I got to meet you and Kari Cole.

SHADOW DAY

6 Oct 2014

After contacting Kari Cole and finalizing a date I decided to arrive in town a day early.  I stayed at the Marriott in downtown Pasadena.  The night before my shadow day I could not help but to think about what I kinds of cases I might get exposed too, what sort of questions will I be asked, how will my first impression come across, do I have my question list cleaned up, am I going to make myself look bad, etc.  I thought about every one of these things all the way across the bridge from the parking garage as I waited for Mrs. Cole and Mr. Godden at the security entrance.  I really wanted my hands to not sweat as I reached out to shake their hands.

David and Kari appeared from the side door near the entrance and Kari greeted me with a smile while David appeared in assessment mode, but welcoming.  I liked that.  After a few minutes Kari explained to me that I would be spending my morning with David and I hoped he would be accepting of my level of excitement and inquiry.  I knew there was something about him that smelled experienced yet government like. The more we began to talk the more we had in common.

After a stop at the Keurig machine he explained to me that we would be going to the fast track OR area to see some patients that he was preparing to do their anesthesia cases.  We started out by looking at their charts, recent lab data, reviewing any pertinent information with the bedside nurse, performing a physical assessment, and then waiting to speak to the physician performing the procedures.  Our first patient was a 76-year-old man having eye surgery for cataract removal.  He had some previous labs that were abnormal and his initial assessment did not support him being generally healthy, but David’s conclusion was that his clinical condition was satisfactory for his anesthesia plan.  It was this case that I learned about the narcotic Alfentanil; I had never heard of this before. We discussed this medication and some of its pharmacokinetic data as it related to traditional fentanyl that I was accustomed to using in my ICU.  We discussed this patient’s tolerance and level of comfort related to the medication’s David was using as well as the procedure itself.  As I asked a few questions David pointed out the importance as well as some vital aspects of his safety checks within his equipment.  I wanted to take apart the anesthesia machine in order to understand how it worked but as it was a shadow day, no time for that.  A ticket to that show would have to wait.  The most interesting concepts to me within this case was not only David’s competency but his logical approach to what his patient needed and tolerated during the case, what the physicians needed in terms of space and comfort, and me finding out the anesthesia table did indeed have a sort-of closed circuit system with regard to the respiratory circuit.

During the next cataract removal case David was considering a change in his original plan based upon the amount of deviance from the patients baseline vital signs and the patient’s tolerance to the procedure.  He called to confer with the chief anesthesiologist to conference in on his decision and they quickly decided to use more midazolam in order to provide the patient additional comfort.  In both of these previous cases David asked the patients if they were anxious or worried prior to entering the operating room.  Based upon their answers and his assessment he administered a small dose of midazolam as an anxiolytic prior to surgery.  As I sat in during the second case David continued to allow me ask questions and often elaborated into them displaying a much deeper understanding of medications and physiology that I not only admired like a teenager at my first rock concert, but that I truly craved as a lifelong skill; I did not want our discussions to end.  My top take away here were some text recommendations and David’s description of the stages of anesthesia; anxiolysis, amnesia, analgesia, hypnosis, plus / minus muscled relaxation, and blunting the autonomic response.  I was glad to find out there are a subset of nurses that believe in having a small working library within their possession.   I honestly thought I was of very few that had looked upon my bookshelf as an alter worth every dime invested and much more.  I am currently ordering a text called, “Watchful Care” by M. Bankert.

As an observation, I also noticed the amount of passwords and associated computer based systems David had to use in order to complete his documentation.  Unfortunately I believe this circumstance to be true in a lot of medical facilities.

Our last case of the day was a case that had already started. David took me to an orthopedic case in which a 59-year-old man with schizophrenia had jumped out of an open window and suffered a right tibia-fibula fracture that required surgery in order to facilitate stabilization and healing.  This was a general anesthesia case and the case was nearing an end as we entered the room.  The CRNA there was also a United States military Vet and had been an instructor for David when he was an SRNA.  She gave us a report of the patient’s clinical condition and anesthesia circumstances.  She was very encouraging and engaging with me; she thought best I stay close to David in the small area as he assessed the patient for extubation and what was going on with the anesthetics, monitoring, etc.  I was so amazed at the level of control and respect both CRNA’s displayed for the case.  I wanted to know how he dosed the anesthetic gases and how he monitored it.  He inferred that that level of discussion was not entirely for today but to my amazement he showed me how he could monitor the expired concentration of an anesthetic gas.  That was really cool, along with the BIS, capnography, nitrous oxide / O2 measurements, EKG, respiratory monitoring, constant patient assessment, etc.; I was completely grabbed like the best first date ever.  During the case a new MDA had been participating in the patient’s anesthesia management.  She later joined us and discussed the case thus far, asking a few questions with David she then proceeded to discuss some post-operative plans.  She seemed professional, non-confrontational, and kind in her academic approach.  David expressed a sincere supportive attitude as he spoke to her.  He later told me it was important to remain open and kind; especially to new professionals and those in training.  He said it was a priority that they had good experiences and memories while visiting USC/ LAC Hospital.  I could not agree with him more; as my experiences and memories are just that.  In the post-operative area I was able to see Dr. Jabbour again.  She remembered me from her OB lecture and our brief discussion with Dr. Norris related to indomethacin administration to expecting mothers.

Afterward David escorted me to Kari Cole’s office in order to complete my shadow day.  Kari and I reviewed the key points of my shadow day and discussed some details of the Los Angeles area.  I was able to ask Mrs. Cole and Mr. Godden a few questions related to my candidacy as an applicant to the USC Program of Nurse Anesthesia.  They both provided me with great advice and told me to keep doing what I am doing.  We even had some dialogue and some shared opinions on the future of nursing education and a belief that our baseline as well as advanced practice deserves an academic and professional upgrade.  As a second career nurse this is something I have long believed but could not label.  Due to this experience my confidence as an applicant has grown as well as my confidence within my own abilities as a critical care nurse and knowledge seeker.  It is very exciting to know there are nurses fundamentally practicing and approaching their practice as I do through a continued academic mindset with professionalism and applicable knowledge as priorities.

I am especially grateful for my time with Mrs. Cole and Mr. Godden as well as the administration at the USC Department of Nurse Anesthesia for organizing this experience and meeting with me for advice as I go through my journey to become a nurse anesthetist.

Garrett Kitt, RN, BSN, CCRN

Charge Nurse

Critical Care Transport Nurse

Pediatric Intensive Care Unit

Children’s Hospital Central California

So there you have it.  Go get um Garret.  I will be here for you all the way.

DG

Categories : Anesthesia, Student Life
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Apr
06

SRNA Boot Camp

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Credit: Keith Weller

Credit: Keith Weller

It is now April and our new Registered Student Nurse Anesthetist’s (SRNA’s) have been in the OR now since January – just a total of three months now.  The progress that they have all made in the operating room really has been tremendous.  To see students come into the operating room for the first time, seeing their nervous hands attempt their first intubations, watching their progress in anesthesia management has really be a privilege to see and participate in.  One of the questions I have always asked myself is, what are the qualities in students that make for their success and what are the things that we can do as mentors and clinical instructors to facilitate that development.  For so many of our students success comes easily and its really difficult to do anything wrong with them.  It seams that that these students just fly right from the start.  Then there is the rare student that will try your soul in getting them to progress into the safe and efficient anesthesia provider you envision for them.

Laerdal.com

Laerdal.com

I think there is an answer.  SRNA boot camp is certainly part of the solution.  We have a program that a couple of the faculty CRNA’s / MD’s have started a couple of years ago that puts all of the students into a simulation setting before getting them into the operating room.  The amount of work that has gone into this program really has been great.  The scenario production alone takes a great deal of time.  My good friends Charlotte and Catherine have headed up our program for the students doing a fabulous job in the simulation room.  Each year now the transition into the operating room setting has been smoother for our students in great part due to the time they have spent in the simulation room.

Terrie Cheryl and LaurelIn leading Universities across the country the use of simulation is becoming increasingly important in the education and training of Nurses.  As an example, Duke University School of Nursing has a web page devoted to simulation here.  The University of Southern California department of Emergency Medicine has a very active simulation training as does the Anesthesiology department.  Simulation will be integral in the future of recertification for Certified Registered Nurse Anesthetists. The NBCRNA, the organization that sets the standards for certification and recertification has indicated that in the future simulation will play a big part in that process.  Rectification is the future but for right now getting our students through the educational and training program safely and expertly is key.  The use of simulation is certainly a growing part of that training.  If that does not work I have another thing we can try, a real boot camp.  No I am not kidding.  Here is Geoff as a student and now one of our excellent faculty going through a former boot camp session.

Boot Camp

Actually, Geoff was late for an AM meeting and this was his reward.  All in good fun because our SRNA’s train hard, study hard and play infrequently we hope.

 

SimMan is a registered trademark of the Laerdal company and is used in simulation centers across the country.

Categories : Student Life
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Dec
29

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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Categories : General, Student Life
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Oct
24

Money Issues

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At last I get my wish.  For several years now I have asked my colleague’s to craft a post on what they think is important for candidates to know before they apply to a school of  nurse anesthesia.  It’s been a hard sell.  To be blunt, I have been so busy working and teaching that it has been hard for me to write much as followers here can attest to.  However, there are so many good things happening that I think it is important to pass them along in a more timely manner.  With that in mind, here is what I hope to be another chapter in NurseAnesthetist.org’s future: guest writers.

This past week I received a letter from Nick Angelis, a CRNA and a writer.  He is actively working on a book, “How to Succeed in Anesthesia School.  I’ll let him tell you himself.  While I could nit pick a couple of his points, the overall focus of what Nick is saying is right on.

At what point should you start denying yourself the simple pleasures of four dollar coffee or blowing a hundred bucks every weekend?  When do you really need to start saving?  The truth is, it could take decades to dig yourself out of debt if you don’t take the necessary steps now.  There is absolutely no point in putting yourself and your loved ones through years of essentially monastic living if you’ll still be living paycheck to paycheck with a higher salary once you graduate. As I’m writing this book, student loans are at such low rates that financing your life with them (and skipping the next few rambling paragraphs) is a viable option.  I previously recommended that students pay off their undergraduate loans before starting anesthesia school, but it’s an individual decision.  As much as it depends on you, keep your other debts to a minimum.  For example, don’t make illegitimate children—child support really adds up.  Chronic illnesses tend to be expensive too, although avoiding carcinogens may be more difficult than wearing seatbelts, selling your motorcycle, or resisting the urge to sled down an icy hill on a skateboard.  The last time I had such an urge, I at least had the presence of mind to increase my life and disability insurance first–which is a must if you have a family, once you become a CRNA.

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Categories : Anesthesia, Student Life
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Aug
18

New Media for a New Century

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This year is going to be a great year for our new incoming SRNA class here at USC.  We are all so much looking forward to the meet and greet coming up next weekend in Malibu.

What is planned for the coming season is to incorporate New Media and “On the Go” technology into the academic mix. Students today want to find information outside of the class room from their portable devices.  With this in mind I have been looking into a couple of new ways to keep students interested and focused.  A great quote I recently heard is, “Education is not filling a bucket, but lighting a fire.”  William Butler Yeats.

With this in mind, I have opened up a Twitter feed called SRNA Cafe focused on education for the nurse anesthetist student.  I hope that you find it useful.  Check it out and if interested in the content “Follow” on Twitter.

Another kind of cool on line way to create content and review material is to connect to FlashCardExchange.com to make review cards for yourself.  One of the best methods I have ever found to study is to create flash cards.  The act of making the cards puts the information in another part of the brain.  These connections is what creates memory.  To create recall, frequent review to strengthen the neuronal pathways to that information is what is needed.  For me, making flash cards and reviewing them often works for memorization of data.

We do have a lot of data and information to memorize you know.  The scary thing about medical information is it keeps updating and expanding with time.  In the final analysis there is too much informaiton to know and keep up with.  We have to find ways of on the spot – where we are -access to current thought and research.  Most of this will come later for our students who are just know being introduced to the subjects.  There is much of the basics that do not change much and for now lets focus on that.

Good luck to all of the incoming SRNA’s no matter which program you are in.  Keep focused and above all have fun knowing you are entering one of the greatest adventures of your life.

DG

Categories : Student Life
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Recalling with fondness the distant past when super-hero’s roamed the earth and The Green Hornet series was still in vogue, I remember The Shadow.  No, not the sinister menace that waited for little boys and girls around every dark corner on cold windy nights.  This Shadow is the one that introduces a new and exciting path for those that seek it.  Recently we have had many requests for “shadow” experience here at the Big County and the nurse anesthesia program.  We try to accommodate.

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Dec
15

How To Learn

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David in ORStudents have lots of problems not the least of which is trying to cram huge amounts of material into a 7 to 10 lb head and have it stick.  What are the real keys to learning and making that knowledge part of you.  These are questions that I have been pondering for many years and I have come up with a couple of ways that work for me.

First I believe you have to make a commitment to what is important to you and your education.  Most of us have complex lives and can not simplify and dedicate to one thing only.  Even with busy lives family and multiple commitments you have to say, “This is my time.  This is my time to be selfish for OUR future and dedicate myself to this course of study”.  If you can not do this then maybe you have chosen the easier way that will not lead to the promised land.

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Dec
03

The Shadow Knows

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The Shadow2The “Shadow” experience for potential nurse anesthetist students is one of the critical preparatory moves that anyone interested in the field of nurse anesthesia must take before deciding that this is “it”.  What better way for a person to find out if this is a field that they would like to be a part of and be able to adapt to than to spend a day with a nurse anesthetist.  The experience in the operating room Shadowing a provider taking care of patients will not only demonstrate what we do in dramatic fashion but give the potential nurse anesthetist candidate an opportunity to be challenged to be more – way more.  That’s what “The Shadow” knows.

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Nov
27

Is the Pain Worth it?

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Its always nice to hear from former classmates and today was no exception.  Mel moved with her husband out to Florida after graduation and is now working and living it up in the Sun State with her husband.  While going through the “educational process” of becoming a CRNA here at the University of Southern California, all of the difficulties and seemingly unending struggles both in the classroom and in clinical rotations tend to dull the enthusiasm a bit.

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Categories : Student Life
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Apr
06

Student Nurses Visit the OR

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David_Karyn_ORLast Friday we were privileged to have several student nurses visit us from the California State University at Long Beach. Friday’s is our conference day with a late start in the operating rooms. This week’s presentation featured a couple of Residents presenting poster boards in preparation for their showing in a couple of weeks before a state assembly. Following the morning conference it was back to the Operating Rooms for the days cases.

The student nurses followed a couple of the CRNA’s until noon and were able to get a glimpse into what we do on a daily basis. For the students it was a good exposure to Nurse Anesthesia practice. This morning I received a note from two of them that I would like to pass along. I have slightly modified the letter to correct a couple of small things and to protect the innocent.

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Categories : Anesthesia, Student Life
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