Valley Anesthesia Review course for those that know is a great three day review for preparing for the CRNA certification exam given by the AANA. This certification exam is a very extensive computer controlled test prepared for the graduate nurse anesthetist. Unlike our physician colleges we cannot practice our profession of Nurse Anesthesia without national certification……you did know that physicians can practice anesthesia without Board Certification, we cannot.

One of the great things about going across the country for this kind of review course is that you run into old friends. Josette was here in Ohio for the review course. You may recall that she is from the nurse anesthesia program at Buffalo New York. It was so great to see her and meet her friends from their program. I did not take too many pictures while at the Review Course but what I have is uploaded to flickr.

Four of us from the University of Southern California along with another one hundred and fifty some odd other graduating students sat, studied and listened to the lectures and presentation given at the Marriott Airport Hotel in Cleveland Ohio this past weekend. Todd, Elisha Christy and I traveled together from Los Angeles to Ohio this past Thursday for the review course. The presentation of the review material was excellent and gave us all a plan of action for studying for the certification exam that will come up for us in another 9 or 10 months or so. That is plenty of time to get a really good handle on all of this material. The amount of information is exhaustive and is the summation of years of studying.

The best story I heard this weekend was about this Navy guy taking the review course with us. After completing his two and a half year program and thousands hours of clinical it all comes down to this one comprehensive exam. If he does not pass on the first try the US Military will ship him out to the front lines as a staff RN. OH MY GOD, can you imagine that pressure. At least we can get a second shot at the certification exam if we do not pass it the first time. Well, we will all pass and go on with our careers so that is not even an option. However, how would you like that kind of pressure on you after several intense years of studying……pass this exam son or to the front lines with you for two years. Actually, it’s not a problem.

Elisha and DG have been getting up at O’Dark thirty every morning to get our seats in the conference room. The first morning I got into the great hall which was almost as dark as the outside landscape here in Ohio to see a figure way down in front huddled over her books preparing for the start of the day. I thought that I was nuts to get there so early but I guess Elisha and I are of the same mind. You know, “The Early Bird………..catches the worm.”

This is the last week of my Cardiac Surgery rotation at the County Hospital. The anesthesia techniques that I have learned this past month have been very interesting. Today I was able to put it all together for a sort of cap-stone experience in a big case.

Aortic dissection repair is not a surgical case that is approached lightly. This condition may result from chronic hypertension and possibly congenital weakness of the intima of the aorta leading to aneurysm formation and dissection. Unchecked an aortic dissection often proves to be fatal. Remember John Ritter from Three’s Company – he fell victim to a ruptured aortic dissection. Death from a ruptured aortic aneurysm is usually extremely quick and mercifully without drawn out pain.

This vascular case required not only sternotomy but a thoracotomy as well. These are big surgeries. Initially, the plan was for circulatory arrest and profound hypothermia with lumbar drain for cerebral protection. The surgical team decided on the double incision providing a greater exposure and was able to perform the surgery without the circulatory arrest. This was a good thing for everyone. Rewarming after a complete circulatory arrest with profound hypothermia takes several hours. As it was the surgery was long.

Preparation and setup for anesthesia was nevertheless extensive with two arterial line placements both a right radial and right femoral; a double lumen introducer central line placement in the internal right jugular and floating a pulmonary artery catheter were also part of the plan. Additionally, because of the thoracotomy and the extensive dissection into the left chest that was required we used a double lumen endotracheal tube which allowed us to deflate the left lung improving the surgical exposure on the left side. At the end of the case the double lumen tube was replaced with a single lumen endotracheal tube. This was a great experience and wonderful case for me to participate in. You can see the entire Slide Show of the case at flickr. I must warn you that some of the pictures are very graphic and not for the squeamish.

These cases require cardio-pulmonary by-pass. For this case it was a partial bypass that was used when the surgeons isolated the aortic arch. Never the less this resulted in full heparinization and use of the “heart lung machine”. You can see Julia here with her bight smile behind the mask. The presence of the perfusion team in the cardiac room is always a pleasure.

Enjoy the pictures at flickr. If you can recall your anatomy you will notice the structures of the aortic arch repair and marvel at the gortex graft creation by the sugical team.

My name is Fraser MacFarlane and I am a nurse anesthetist student at the University of Southern California. Our class is 5 weeks into the process of nurse anesthesia studies. I can’t tell you of the excitement, hope, anticipation, fear and intense expectations I have felt here on the runway into this profession. The volume of information and the realization of the full responsibilities that come to the student through the learning process are almost too much to handle. Talk about sympathetic stimulation!

Just a little bit about me. I was born in Scotland and moved to the U.S. when I was about 10. I’ve lived in Los Angeles most of my life. However, I married my sweetheart, LaRae in Utah. I have an awesome wife. She is rock solid with a back bone of steel. I wouldn’t be perusing my education without her tremendous encouragement and support. She is currently in Utah tying up some loose ends I have with rental properties. I have two teenage daughters, Megan 14 and Brianna 13. My wife and children will move to L.A.
after Christmas. I miss them a great deal right now.

I have 12 years nursing experience. I did home care for almost 5 years. This prompted me to open a residential care facility for the elderly. My family lived in this home along with dementia clients. Yeeeehaa… what an experience that was. My kids learned what getting old can really be like. Your furniture starts taking on a new odor. Diapers appear in the hallway, and sometimes you’ve just got to take an anxious, confused old man for a walk
before he hurts someone. I sold that facility 2002.

Anyhow, I have 1 year CCU, 2 year Telemetry, 5 years Home health, 1 year ICU and 3 years med/surg. I am stoked for this opportunity to become a CRNA.

Thank you for this opportunity to post on the Nurse Anesthetist web site. There has been a great deal of effort put into creating this web site and adding my post to it now is sweet. Here are just a few thoughts from a green first year nurse anesthetist student. Looking at the posting on valve surgery replacement scares the tar out of me. At the same time I understand that divide and conquer is the process to greater confidence and skill. A large portion of educational motivation stems from psychological preparation and that belief in ones self precedes true learning. For me the inner battle will be fought on this ground; having confidence to believe in ones self.

I am surrounded by an excellent group of fellow students that are with me here at USC. The excellent support system and well educated and very skilled instructors are all here participating. I have been given the opportunity of a life time to study anesthesia.

Next time I post will be at the close of the first semester and as we shall see if I still am as excited as I feel now.

The cardiac surgery rotation here at the County hospital has been a tremendous experience for me. This is the first of my senior rotations and this has been a great start of our second year clinical. Getting up at 4:00 in the morning has never been better. You may ask why such an early wake up. My only reply has got to be that this is when the plump juicy worms are out for easy pickings. Seriously, the cardiac surgery room requires an extensive set up and the early start helps reduce the stress of rushing.

The heart room at LAC-USC opens at 5:30 and by that time I am waiting at the door with all of my equipment gathered in hand, all of the syringes labeled and waiting to be drawn up. Additionally all of the arterial line and double lumen central line / pulmonary catheter equipment are with me. The set up of the syringes and vasoactive drips takes a little while and luckily I have a second year Resident to help me.

This past month I was able to see a few Aortic Valve surgeries with biosynthetic replacement. I have a Slide Show of an aortic prosthetic valve implantation at the photo sharing flickr site. The amazing part of this surgery is the sewing in of the valve to its new home where the old calcified aortic valve used to be. You will note that the aorta is dissected and that the old valve is removed. This procedure requires coronary pulmonary by-pass (CPB) which is an entire topic in itself.

Here is the fun stuff while on CPB it is possible to keep an eye on the surgeons and watch the new valve being sewn into place. Watching the skill of the surgeons and the care that is paid to the individual patient has been a tremendous learning experience.

What I learned today about the induction of cardiac surgery was invaluable. The attending anesthesiologist was able to describe the physiology of stenotic lesions and how to hand ventilate these patients gently with low Pop off pressures; small frequent ventilations during the induction period will keep the mean peak intrathoracic pressures down. The stenotic lesions like aortic stenosis are preload dependant as well as requiring sufficient afterload. Large hand ventilated tidal volumes will increase the intrathoracic pressure and decrease preload lowering cardiac output. This could be a bad thing.

By modifying my hand ventilation technique using less Pop off pressure and smaller tidal volumes with a more rapid rate I was able to achieve lower mean intrathoracic pressures while hand ventilating. I just love this stuff. This was such a great key. I can feel it in my hand now this gentle ventilation technique.

In anesthesia I am continually finding that everything is based on physiology and anatomy. Our techniques must reflect basic understandings of these sciences. This is always more to learn.

In answer to Dawn’s inquiry about the nity gritty of anesthesia and the problems that can come up I have enclosed a correspondence from a very close friend and class-mate of mine who had an anesthesia apparatus setup problem. The Anesthesia machince checkout is one of the first things that we learn to do as beginning practitioners. The file of the Anesthesia Apparatus Checkout Recommendations is available on this site.

Hi guys,

At Hudson (an out-patient facility ed.), you are responsible for changing your circuit in-between cases. I was in a “hurry” and got distracted as I switched out the circuit and forgot to put on the reservoir bag…and obviously I didn’t do a pressure check.

Goodnight guys

Interesting isn’t it how little things can make the biggest difference. This is what it is like to do anesthesia – the constant scanning and checking through lists of set up and detail; Patients Airway is OK, Ventilations, Saturation, Blood Pressure, ECG monitor, IV is running and patent and the list goes on and on; timing of drugs to appropriate surgical stimulation, induction sequences and the Art of Anesthesia – the emergence. One little missed set or timing issue can cause an anesthetic embarrassment and patient compromise. It’s a tough job but someone has got to do it. Are you Man or Woman enough for this?

I wanted to share an experience of mine that happened just a month ago while I was in the Ear Nose and Throat operating room when the director of our anesthesia program came for a facilities check and student evaluation. This visit by Dr. Gold was during my sojourn at Arrowhead Regional Medical Center and a General Surgery rotation. During Dr. Gold’s visit she popped into my room while I was in the middle of a maxillary fracture repair. These cases with ENT are done with a shared airway as well as with the patient turned away from you and the head completely covered with drapes. It was the third case of the day and I had one to follow.

The room turn-over at Arrowhead is very fast and the nursing staff and ancillary support is very good at getting the room ready for the next case. Usually the CRNA or MDA that the student SRNA is working with is present during the patients wake up and tracheal extubation and stays in the room to turn the anesthesia machine over for the next case while the patient is taken to recovery. That is if you are lucky.

Earlier I had taken my second case to the recovery room and had drawn up all of my medications to start the next case as well as reviewed the preoperative examination and paperwork for the third case. The patient was dropped off in PACU and I went directly to the preoperative holding area to pick up the next patient. That was my first mistake. I did not go back to the room to recheck that the staff had properly turned the machine over.

Everything with the beginning of the case went perfectly; here I was in the middle of the case number three, the maxillary fracture repair, and the director of the program was in my room interviewing me and quizzing me on my anesthetic choices. All of a sudden the anesthesia machine starts complaining with an alarm. I am already distracted because of the presence of Dr. Gold in the room and her being there to see how I am doing. Running through the alarm check list I see that there is a disconnect in the circuit. There is now no ventilation and no CO2 return on the screen. Great Gods help me.

The patient is turned away from me and I am sharing the airway with the surgeons because they are operating on the jaw. I think, “I taped the hell out of that endotracheal tube and secured it very well”. Yet I still am wondering if the endotracheal tube is secure and the anesthesia circuit is connected. Quickly I jump under the drapes which are completely covering the patient and assess the circuit to the endotracheal tube – the circuit is connected just fine. I come out from under the drapes and am looking at the machine as the CRNA that I have been working with just happens to come is. He says casually from across the room, “hey there, your circuit is disconnected and on the floor.” Of course it is disconnected but where. Dale astutely was able to see the disconnection of the anesthesia circuit from the anesthesia machine at the place where the circuit attaches to the machine. Now I see the problem and fix it quickly. All is well and no harm is done except to my ego.

Dale at Arrowhead Regional Medical Center “Vigilance is written on his Forehead”

You see, when the staff had set the machine up for the next case and pushed the circuit onto the anesthesia machine it was done casually and not pushed on very tightly. With all of the drapes it was difficult to see where it came off. From this time on I started pushing the circuit on very tightly especially if someone else set the machine up. So this is one more item to add to the list; Make sure the circuit attached to the anesthesia machine is tight.

When people ask me about doing anesthesia the comment is often, “That must be really stressful all of the time, how do you handle that?” The answer is that most of the time giving an anesthetic does not seem to be unduly stressful but there are moments of controlled panic in-between moments of calm. So far in the course of my education and training there has been plenty of support with progressive responsibility given to the students. This has allowed us the opportunity to grow and learn by trying new things and rescuing ourselves from any little embarrassment that we get ourselves into. The safety checks and the protocols for giving anesthesia are fairly extensive but the best monitor is an alert attentive person at the helm with ‘Vigilance’ written all over their forehead.

Safety in anesthesia is a great subject. The AANA has a great resource for the pursuit of anesthetic safety at Anesthesia Patient Safety.com/ Another great resource is the Anesthesia Patient Safety Foundation whose mission …is to ensure that no patient shall be harmed by anesthesia.

The safety record in modern anesthesia is impressive. Yet where equipment and people are involved there is always the potential for trouble. To address that end I have enclosed a link to “Troubleshooting the Anesthesia Machine” by J. Jeff Andrews, M.D. which is interesting reading for the so inclined.

This summer marks that last of our didactic class work in the USC program of Nurse Anesthesia. One of the important non clinical courses is the Professional Aspects course being taught on campus and with field trips to other facilities. This afternoon we had the opportunity to visit the Harbor UCLA Medical Center where Chris Stein and Jennifer Woolley (President of CANA) spoke on the current politics and reimbursement issues involved in Nurse Anesthesia.

Both of these guest speakers are well known activists in the field of Nurse Anesthesia on the State level here in California. It was a great pleasure for all of us that were able to attend the lecture at Harbor UCLA to meet and discuss these political topics of the day.
Chris Stein at the helm of our Professional Aspects Class at Harbor UCLA

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The time has finally come to put the “Junior SRNA” title away and pick up the new “Senior SRNA” moniker. Starting this coming Thursday our class will have officially started our senior class rotations and the specialties that go with it. The monthly rotations will start September 1st and change with each coming month for the next year. Of course there will be some rotations that last two months, specifically pediatrics, but each month on the first we all will be shifting gears and on to a new experience.

For me, I will be starting the cardiac surgery rotation at Los Angeles County Hospital. This is a shared experience with the MD resident. Fortunately for me I will be with my good friend AJ who has shown me so much in the past. AJ is a 3rd year anesthesia Resident at the USC Keck School of Medicine program and was there when I started my clinical experience at LAC-USC Hospital.

The way it works is that we share the cases alternating each day who puts in the lines while the other person does the airway management and takes credit for the case. We can not both take credit for the case for certification purposes but the learning goes on anyway. In this way we both get the most out of the experience and for me this is totally acceptable. I will be finishing up my general surgery rotation at Arrowhead Regional Medical Center in Riverside tomorrow and AJ will do the preoperative evaluation for me so that I do not have to travel after a long day in the OR and then do the preop at another hospital for the next day. That is a relief.

David and two Texas Weslean Students at Arrowhead Regional Medical Center

Finishing Up at Arrowhead Regional Medical Center

Being at Arrowhead Regional has been a really great experience. This past month the schedule has been really good for me. In the morning a Whipple procedure is scheduled for my room. This will be the second Whipple for pancreatic cancer that I have done in the past two weeks. These are really big surgeries with the necessity for central line placement and central venous pressure measurement, arterial line placement before induction and two large bore IV’s for access. In addition I will be placing an epidural catheter for post operative pain management. All of this requires extra time so after discussing these plans with the MD attending staff this afternoon the patient will be in the preoperative holding area at 6 AM for the line placement. At least I will get the epidural and arterial lines in and after this gentleman is asleep we will get the central line secured.

David behind the Blood-Brain-Barrier during a hand surgery case

Looking back over the past year and seeing the growth that has taken place is easy today when I think about this Whipple case and how I am comfortable with the issues in the anesthesia management for this surgery. A year ago just getting a patient asleep was a major big deal. So it’s good to review how far we have come and to reflect on what is yet ahead to learn and grown in. This coming year of specialty rotations is bound to be extremely challenging and rewarding in all that we will learn. I am so much looking forward to all of it, the hard work and the satisfaction of knowing that we all have done a great job taking care of our patients when they are the most vulnerable.

The end of the First Year at USC Anesthesia School has come at last. At the end of the month of August – it has come so quickly – will mark the beginning of our senior rotations. This means for me that I will start at LAC-USC in the Cardiac Surgery rotation September 1st.

To celebrate the occasion a little letter from the Chief CRNA at LAC-USC is recorded below. Kari Cole is one of the most outstanding CRNA’s I have had the privilege to work with and her letter of encouragement is heartily welcome by all of the new senior students.

Dear All,

I hope this email finds you in good spirits.
Here are a few housekeeping issues:

1. BACKPACKS:
If you haven’t already, please reduce the size of the backpacks you are bringing into the ORs. At this point, the only thing you need to bring in the OR is ONE reference book, a couple of pens, stethoscopes (regular and precordial) and maybe a nerve stimulator and head strap (depending on where you are rotating). You may want to think about losing the backpack altogether and move into something a bit more professional like a black attaché.

2. VALLEY REVIEW:
For those of you who are planning on attending Valley Review Courses, please inform me (and the schedulers at other sites) when you are planning on attending. Since you are now in the ORs on your own at LAC, I will need to know when you will be out for the review.

3. POLISHING:
Start working on polishing your skills. You all have the basics down, now start fine tuning your anesthetics and your approach. Push yourself to try new things…..do NOT use roc and propofol on every induction! You may have to “sell”: your plan to the attending and/or CRNA, which can be a lot of work but in the long run, it is worth it. You need these skills (anesthetic and interpersonal) before you graduate.

4. CHANGING OF THE GUARDS:
The seniors are graduating and you will be taking their places as seniors and as mentors. The new group starts in a week and a half so be prepared to meet and greet your new colleagues in the ORs and in class. Remember, first impressions are lasting impressions! Think about the senior that impressed you the most when you first started. Were they: approachable? genuine? enthusiastic? helpful? Your attitude makes a world of difference to those individuals who are just starting.

5. CONGRATULATIONS:
Be sure to give yourself (and your classmates) a pat on the back and/or a congratulatory hug for successfully completing the first year of the Program!! YOU ROCK!!!!!!!!!!!!!!!

Aloha,
Kari

Kari M. Cole, CRNA, MS
Chief Nurse Anesthetist
Assistant Clinical Professor
Keck School of Medicine, USC
Department of Anesthesiology

May you always do for others and let others do for you.

Josette Salas, RN BSN

Josette Salas is an RN from California. She has worked as a traveling nurse in some of the busiest Medical Centers on the West Coast including UCLA, USC University Hospital, Cedars Sinai and others. Her specialties includes Cardiothoracic ICU and Neuro/Trauma intensive care. She comes to Nurse Anesthesia School with a lot of great preparation and motivation.

Hey Gang, How is it going for everyone? I have been reading the blog and it sounds like everyone has been very busy. FUN FUN FUN at the old anesthesia corral. My clinical rotation is not as scary yet as others so I am kind of jealous about that. But I can’t wait for the good stuff to come around. Right now I am just doing a lot of hernias, D&C’s, laparoscopic stuff, tons of Orthopedic surgery and hysterectomies.

I can finally say I like the MAC blade and I have been pretty successful with tracheal intubations these past two weeks so I am feeling better about the whole induction thing. I hate placing Laryngeal Mask Airways but I am getting the hang of those too. You know I have small short fat fingers which is not helpful.

Today I got to do a spinal anesthesia case and ooooh-la-la first one here so of course I was all thumbs and asked a lot of dumb questions. Learning is such a great adventure but I hate feeling stupid all the time. I can’t wait till I am past that point of feeling stupid every single day to where I am feeling stupid just every other day.

I love using local anesthetic for my IVs starts. I think all nurses should do this but I don’t know if this is in the scope of practice for the RN instead of our purview as Advanced Practice Nurses in training – Oh just give me a break already!

OH I am going to the Washington DC in August for the annual AANA meeting which lasts for 5 days. I have never been to DC so this is going to be cool. I want to see the Capitol building if I can.

Currently I will be ending a rotation at the end of this month and then I will be going to the big Buffalo General Medical Center so hopefully I will see some interesting cases there. I don’t know when I will have the opportunity to go to the County Hospital for a Call/Weekend shift. I don’t think everyone here gets to do this but I am excited about doing this and am planning of learning so much there. I want to get the experience to equip me to handle anything that comes through the door.

Right now I hate the summers here in Up-State New York – it is like tropical hot humid disgusting nasty weather kind of place. Did I tell you about the winters here? Now it’s funny because the people here are just happy that it is hot and not frozen over like it was a few months ago so there’s no place like home.

Anyway I am going on and on. So take care and good luck with the rest of your current clinical rotations and I will write again soon. My picture is in the mail if you know what I mean.

24 hours in the OR on Holiday weekend

Yesterday was my first 24 hour operating room call. I have had to do other overnight OR scheduled time before but this was the first time I was scheduled for an entire day. Being a Saturday night and a holiday weekend made for several interesting cases.

During the day on Saturday we were busy with pick up ortho cases that were left over from the weeks work. Nothing to big just a couple of ankle fracture repairs, an elbow and an incision and drainage of a big old abscess. Nothing like the night to come.

I thought that the Los Angeles County hospital had all of the action but I was mistaken. It seems there were a few parties that got out-of-hand out here in the Inland Empire and friends started shooting friends, brothers started stabbing brothers and what not. We had two ORs going until the very early morning. At 03:45 we broke the two ORs for 15 minutes and then the final gun shot wound came up. It seems this guy was shot through and through across his hips taking out some of his bowel – he had blood in his stool and needed emergency surgery. This case ended up pretty messy and did not finish until 6:45 just 15 minutes before I was scheduled to leave. Oh joy – I can go home now.

All in all for the 24 hour schedule I did 6 cases, a couple of them fairly long. I did get an hour nap Saturday afternoon around 4 o’clock so it was not too bad. Looking at the coming schedule I will be doing another overnighter next week and the following week another 24 hour shift on the weekend. Thankfully it is not a holiday weekend and maybe the natives will not be too restless.

16 Hours in the OR

This past week on Friday evening through Saturday morning I spent in the County Hospital operating room providing anesthesia to the never ending trauma cases that come in over a weekend. Maybe it’s just me but the natives are too restless it seems – especially when you combine alcohol and illicit drugs to the mix.

The last two cases were really special. One a stab wound to the face and the second a gun shot wound to a very drunk mans leg. The stab wound case was technically difficult to secure the women’s airway due to so much bleeding from her cheek and tongue laceration. Really it was more of a HUGE laceration. Her domestic partner, I believe, thought that she was stealing all of his cocaine or crystal meth or what ever and thought to teach her a little lesson. The stab wound went through her cheek and tongue to the other side of the face. You can imagine that there was a lot of blood in her airway. The lady was pretty hysterical and we just induced her (put her to sleep) quickly while she was sitting up on the gurney. After unconsciousness the attending anesthesiologist and I laid her down quickly while the surgeon held some pressure to her cheek. Two suction catheters going and ten seconds later she was intubated and her airway was secure. After that it was simple. I am really glad that the attending anesthesia staff was there to help out. Now that is not something you see everyday. The surgery was fairly straight forward and we left her intubated overnight to make sure the bleeding was under control and her airway was secure.

The next guy had the rudeness to try for another six pack at closing time at the local drive through liquor store at 01:50 in the morning. Evidently there was an altercation of some sort, who knows what really happened here because the guy was so drunk and combative. He came to us in the OR at about 3:30 in the morning just after we had finished up with the younger lady and the stab wound to the face. I could not even close my eyes for a couple of minutes. This guy was really out there jumping all over the place. We could hardly keep him on the gurney let alone transfer him to the OR table. After 10 milligrams of midazolam he saw it our way and we were able to get him to the operating room table and start the case. He ended up with facsiotomies of his calves and some vascular reconstruction. All this for another beer. Seems like to me he had had enough but who would have thunk it.

All in all doing a clinical rotation in a large county hospital and being able to take weekend call time shifts is a great clinical experience. There are things here that you see and do here that are not available at other times. The lack of sleep is not something that I cherish but I would not trade the chance to do this rotation. I will be at this facility for another three months and will be taking overnight call once a week in addition to the regular days during the week that I am there.

The routine week day cases are fairly standard type cases. The obstetric floor is covered by the student nurse anesthetists as well and we see a fairly large population of caesarean sections, tubal ligations, and labor epidural placement management type things. So the mix of cases here is really nice. Right now I will catch up on some sleep and then hit the books for an exam that is coming this Monday.

Being a nurse anesthesia student has its ups and downs. The stress is pretty intense and there is a lot that is demanded of you both academically and clinically. I love it when you are trying to get a difficult case started and the staff starts asking you questions about the case and all of the pharmacology and pathophysiology involved just when you are trying to get the endotracheal tube placed. If you thought that chewing gum and rubbing your tummy at the same time was difficult come join us for an afternoon or maybe hang out and spend the night at the County Hospital during a holiday weekend. Now that would be an education worth remembering.