Archive for Student Life


Calling All Candidates

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David_Steve_ORThis past week I had the privilege to participate in candidate interviews for our Nurse Anesthesia Program here at the University of Southern California housed in the Keck School of Medicine program. Beginning this process started with reading through long dossiers from each of the candidates including transcript records and personal statements. After reading 35 or so of these collections, the process of evaluating each of them individually began. This whole process was inconsequential without meeting these wonderful people and putting a face and personality to the paper facade that I had been poring over for so long. Now for the hard part that has been put before us, the personal interviews.

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There, I Said It Tells All

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The longer I am exposed to the great anesthesia practitioners the more respect I have for what we do in the OR. I feel so privileged to be where I am today with the opportunity to do anesthesia and to teach – I am really blown away every day. One of my former clinical instructors and true mentors has confided in me concerns about what it takes to do well as an incoming anesthesia student and I wanted to share their concerns with you. If you want to know the truth it may hurt but it will set you free. Thank you so much “There, I Said It”. You rock TISI! For those of you that want to be CRNA’s take heed and follow the advice of a pro and you will be well prepared for clinical residency.

Why I think year ICU experience isn’t enough by “There, I Said It”.

I am a Nurse Anesthetist and a Clinical Instructor of Anesthesiology at a large metropolitan teaching institution.

I have been a clinical instructor for some years, and have seen many students come and go. We have so many applicants to our program, and each time the interviewing process becomes more and more difficult, as each applicant appears to be cream of the crop. The difficult decisions as to who will be accepted into the program come from a comprehensive process that involves input from many individuals of varying levels of practice; from student nurse anesthetists to department chairs.

According to the AANA, requirements for admission to an accredited program of nurse anesthesia include a minimum of 1 year of acute care experience, such as in ICU or ER. Herein lies my beef. Applicants or students who think 1 year of acute care experience is enough to perform at an acceptable level, in my view, are sorely mistaken. I feel this requirement should be changed. Can one truly master the art of ICU or ER nursing in 1 year?? Is a year enough time to glean an adequate level of skills or experience in adult critical care or ER nursing? After one year, can you throw up epi, levophed, dobutamine, dopamine, nitro, etc. and truly be comfortable with what you are doing?? Do you think you’ll be able to insert a swan and know what in the hell you’re doing? How much code experience occurs over 1 year? Is a year time enough to mature the development of interpersonal relationships with other members of the health care team much less the patient? Ask yourself these questions and I bet your answer will be no, no and no!

The students who have slithered through the interview process with what looks good on paper but have never been realized in practice have a hell of a time in residency. The clinical instructor has to work overtime to protect the patient from the student. I daresay there are those individuals that just have met the minimal requirements and are truly stellar students. However, these are few and far between.

I suggest the minimal requirement in an acute care setting be increased to at least 3 years. Applicants, if you barely have the minimal requirements for admission, ask yourself if you truly have enough experience to entertain delivering anesthesia care to an elderly individual with an aortic aneurysm, a child with epiglottitis, or an individual with multiple gunshot wounds to the chest and abdomen.


There, I Said It

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Graduation Plans

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Dear All,

Your graduation is approaching rapidly. If you have not done so already, get together as a class soon and get some ideas going for a graduation celebration. Each of you will need to pitch in and assign yourself to a committee.

If you need to do a fundraiser, I highly recommend the USC Anesthesia sweatshirt, t-shirt, and hat sales from last year’s class. Thanks to the 2005 grads, you have a nest egg to start up a project such as this. Besides, there a number of people asking for these items, both local and international!!!

Let me know what you think.


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

Bob Dylan

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Correspondence can bring many things. Recently there has been a lot of mail, much of it from friends and family with discussions of life, projects and goals. I even had a request for money recently from a needy soul that could not be turned down. What I wanted to share today was a series of communications from this last week that has occupied my mind for several days. Maybe after reading these you too will pause and consider what a gift we have been given to serve and learn from our patients. Their contribution to us is tremendous and must never be forgotten. This is a sacred trust that I am appreciating with a new understanding. Thank you Jim for that. It starts with a letter from Jo. I find her vignette interesting and instructive but what comes later is beyond instructive. Let’s see what you think.

Hey David, here is a funny story,

As student nurse anesthetists we are fortunate to have some common sense especially since we have some critical care background and have actually touched patients. Anesthesia physician residents often do not have this luxury. They get thrown into an operating room because they have graduated form medical school and are expected to perform. While SRNAs are guided on how do things should be done in the operating room for a long time.

Recently I heard a story about a M.D. resident that was interesting. The surgical case involved a patient scheduled for a total knee replacement with an epidural catheter and an Laryngeal Mask Airway (LMA). A Nurse Anesthetist enters the OR to send the physician on a break. The patient is breathing 38 breaths per minute and chewing on the endotracheal tube. The physician states, “Oh that’s new this must have just started”. Propofol is then slammed intravenously and B/P drops precipitously and then the low blood pressure is then chased with ephedrine trying to bring the blood pressure back up.

There is a lesson to be learned here. You can’t blame the physician resident because many times when they are new in their training they do not have sufficient oversight. The patient obviously needed something other than slamming propofol – possibly a dose of narcotic and not hypnosis. The epidural was infusing but did the patient get a loading dose up front? These things may all effect how the patient was tolerating the surgery. What I have seen clinically is that when epidurals catheters are working well you need far less opioids and less volatile agent as the MAC is lowered. These patients usually wake up very comfortable.

The morale of the story is to feel good about the education that we receive as nurse anesthetists and feel proud to be apart of this prestigious profession of Nurse Anesthesia. Remember that 65% of all rural anesthesia is given by Certified Registered Nurse Anesthetists (CRNA’s). Some day you might be taking care of me or my loved one and I want the best and most competent anesthetist on the job.


At first I glanced over this note from Jo and scribble a few notes to myself while reviewing the many interactions that I have had with residents. Jo is a dear friend of mine – however I find that her reasoning incomplete. At least there is more here that is bothering me that I can not mine fully. She states correctly that patients with epidural catheters require lower MAC and less opioids then proceeds to disparage the hypnotic and suggest that the patient needs additional opioids? I began thinking that the idea of giving more opioid for a light patient is the wrong choice and her criticism of the resident could take a different slant. For me the propofol is not a wrong option but the lack of vigilance by the resident deserves comment. So ran my thoughts. To confirm my suspicions I ran off a note to a friend, we’ll call him ‘John’, a long time anesthetist back East. I was dealing with the trees and not the forest. My thoughts continued at that time this way:


I was not there in the OR and all of this is second hand information but an interesting discussion about CRNA SRNA and Resident relations mainly. We all have our prejudices I guess. For me the physicians do just fine and receive extensive training. At times in the beginning of their training there may be things that happen that are not the best practice. Who is to say that Student Nurse Anesthetists do better really? Personally I do not find it profitable to compare providers but to look for a best practice regardless of the practitioner. John, I thought you might get a kick out of this story and look forward to your comments on the scenario. Hope all is well with you and that your scheduled surgery goes well. I am wishing you all the best from Los Angeles.


The response I received back has been lingering in my mind for the past few days. When I started the web site my goal was to try to put together something with content that would be both instructive and entertaining while showing what it is like to be a nurse anesthetist student. John goes beyond my expectations.

Hi, David

I have many thoughts tumbling through my head at this stage of my career. As to the story your friend related, I find your take on it to be the more reasoned. Yes, the average SRNA is probably much more oriented to the care of the patient, by virtue of the nursing background. This stereotypical SRNA is also more clinically astute because s/he’s been on the front lines, watching actual patients get better or get worse and die, so s/he has earned to look at everything, make no assumptions, and always to keep that “sixth sense” activated whenever s/he is responsible for a patient. Those hard-earned lessons from the ICU on a 12-hour night shift do stand the SRNA in good stead.

And it’s probably true that the average MD trainee at whatever stage of her/his training is probably less experienced and clinically seasoned; more educated in basic sciences than the average RN (notice I said “more” educated which doesn’t necessarily equate to “better” educated). But a friend of mine long ago put it this way: “Good nurses know a lot about medicine while good doctors know a lot about nursing”. When I look back to the people who had the most influence on my developing anesthesia career (and it’s STILL developing) I find nurses who took it upon themselves to be very educated (and very WELL educated) and physicians who had that common sense and humanitarianism that is stereotypically viewed as the hallmark of nursing. What each had in common was a curiosity that motivated their learning, a humility that taught them that their learning would never end, and an empathy for the suffering patient who was at once her/his sacred responsibility and greatest teacher. The other thing they had in common was my enduring respect; you see, I’ve seen callous CRNAs and empathetic and truly altruistic physicians. We must be careful not to be guilty of that error which we decry in others: judging an individual by the letters behind the name and not the character attached to the person.

As to your friend’s assessment of what was needed, we all know that anesthesia is a complex specialty. From first principles, the patient should never have been allowed to come to such a state, under the care of an anesthesia provider, that the patient was chewing the tube and breathing 38 breaths per minute. The rescue of the patient from that unacceptable state can take many forms, some better than others. The bolus of propofol was a “fast” answer. Fast is important, but one must be careful not to overshoot lest one have to engage in the “dueling drugs” scenario as your friend described chasing blood pressures all over the place. You made another astute observation: “I wasn’t there…” This is a very mature approach to analyzing anecdotes about cases; you know that not everything that happens can be reduced to marks on an anesthesia record, and that even the most careful observer is biased to some extent.

I have a feeling that neither you nor your friend would have gotten yourself into the situation of needing to rescue the patient from inadequate anesthesia. In a couple of jobs I’ve had in the past, we’ve had trainees rotating through the anesthesia department. Now, I’m always careful about generalizations, and the following observation is given with the very large caveat that generalizations are poor tools to explain things. That said, I noticed that there were in general two “styles” exhibited by anesthesia trainees. One style was more “high tech” and the other more “high touch”.

One manifestation of this was the manner in which the trainee monitored the patient. Some stood with their backs to the patient and watched a bank of monitors. These tended to miss things that a more experienced onlooker would see evolving before they manifested themselves on the monitors. These were the “high tech” ones. Many were very intelligent — far more so than I — and usually more educated as well. As a generalization, these were doctors. Others gave their primary attention to the patient, and looked to monitors as a secondary information source, to validate their clinical impression of the evolving anesthetic. Most of their time was spent seated or standing in close proximity to the patient, their backs to the monitors. Sure, this has elements of a false dichotomy, but by and large, these latter were nurses. They didn’t treat numbers, they treated patients. And they usually “picked up” things before the “things” became “problems”.

Sometimes the “high touch” crowd couldn’t even characterize what it was that was about to go wrong. Usually the “high tech” ones could recite the “book learning” about what had just gone wrong. If you haven’t found this out already, in anesthesia it is frequently the case that we are too smart too late. You’ll also know the daily reality of something I once read: Most great discoveries are presaged not by the exclamation “Eureka!” but by “Gee. That’s strange….”

The only good thing that came out of Jo’s experience is that you are talking and thinking about it and learning from it. The occurrence of inadequate anesthesia in this patient — the failure of our specialty, the patient’s trust betrayed — became, if you will, a “chance experiment” in the laboratory that is your learning. No Institutional Review Board would ever have approved of the situation into which this patient had been allowed to deteriorate, even for the pragmatic good of your learning. But it happened. Remember, “stercus contingit”. You have been handed a learning opportunity, purchased at a very high price by your patient. Learn from it, get all you can out of it. And, as you progress in your career and teach others, remember the debt you owe to that patient, in whose care an error was made, allowing you to learn from the remediation — and yes, even the “cover up” — of the error.

Here is where I have a huge problem with many physicians with whom I’ve worked. There’s an attitude of entitlement. “I earned this degree. I got out of training with six figures of student debt. I am owed”. No. Wrong, wrong, wrong. They are who they are, they know what they know, and they have what they have, because of an unending string of patients who held still for their first clumsy attempts at the laying on of hands, who suffered at their mistakes as they repeated lab tests and painful procedures, who died at their imperfect hands — at all of our imperfect hands. David, I submit to you that this is a debt that can NEVER be repaid; the currency to satisfy such a debt has never been minted, nor could it be.

I recently had a physician make some comments to me in passing. I think he meant to encourage me; I’m not sure. He commented on my skill at regional anesthesia, especially in the massively obese parturient with whom we’d just dealt successfully. I described how I’d evolved in my skill to a peak several years ago, and how I’ve had to refine my skills as my senses and strengths change. I used to palpate everything, and my sense of touch was my paramount one. As I age, my tactile sensation has diminished, and I rely more on vision. And even that is failing as I approach my seventh decade of life. But I continue and I do my job well and carefully. He expressed surprise when I told him how old I am — that surprises everyone because I’m blessed with a youthful appearance. Then he told me that he doesn’t intend to work past the age of sixty, not at all while I intend to work until it would no longer be safe for my patients for me to continue to do so. I’ll know when that is, and a carefully selected group of people with whom I work will validate that judgment. Only then will I pursue a lesser career, and I will leave with reluctance and with regret for that huge unpaid debt, with gratitude for every patient who has taught me what I know. For now, CRNA doesn’t describe so much what I do as who I am.

PS: My surgery has been put off until the 22 of this month. Several things have to be in place for it to take place, one of which is some sort of fibrin glue to be used in the repair. I am blessed to have tissue that doesn’t act its age, and a “sports medicine” orthopedist who normally limits his practice to athletic injuries in genuine athletes. He’s agreed to apply his skills for an old man who fell on the ice, whose “athletic” prowess is confined to paddling canoes and kayaks to photogenic places, or slogging along on a mountain bike or cross-country skis to places that aren’t crowded, and whose major competition is against entropy — and gravity. His method includes aggressive rehabilitation. It will return me to my “playing field” sooner, and ease the overwork my absence will impose on my partner and our already thinly-stretched locums. That’s important to me.

Thanks for your kind good wishes. I’ll keep you posted. In the meantime, work is busy, and that’s great therapy.

Categories : Anesthesia, Student Life
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Three Cheers for Berny

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David Avitar ArrowheadLife is so good sometimes. Today I received a great letter from my dear friend Berny. Between finishing up finals this semester and the rigors of clinical rotations, receiving this letter from Berny is a great treat. Sometimes you have to see where you have come from to appreciate where you are now. The workload lately has been tremendous this second year of nurse anesthesia training and this is one of the little rewards along the way that I wanted to pass along.


How is life treating you? How are your holidays? Well, I just wanted to write you to update you. I got accepted to Buffalo, New York. New York was my number one pick! I just want to thank you for helping me out with all your advice and encouragement. You have helped me a lot, more than you’ll ever know! Thank you for taking the time to write the awesome recommendations you wrote me! Anesthesia school has been my goal for so long! I’m finally going to make it happen! David, I can’t THANK YOU enough! I hope life is treating you and your wife well!

Happy Holidays!


Berny is a friend of mine from UCLA that I have been encouraging to pursue a career in nurse anesthesia. We worked together in the cardio-thoracic ICU for a couple of years before I jumped ship and trapped off to school at USC – the cross town rival.

Congratulations Bernadette on your acceptance to the University of Buffalo and their great nurse anesthesia program. You will love it there I am sure. Josette, another contributor here at has is a student at Buffalo and will show you the ropes at Buffalo. Good luck and continue to study hard. It is all so worth it.

I am so happy for Bernadette. Good for her. You see if Berny and I can get into school after lots of hard work and preparation, those with enough determination and desire will succeed. Again, congratulations to Berny on being accepted into anesthesia school at the University of Buffalo.

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Valley Anesthesia Review

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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.

Valley Anesthesia Review

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.”

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Anesthesia for Aortic Aneurysm Repair

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David Avitar ArrowheadThis 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.

Surgical Team in the Heart RoomThis 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.

Categories : Anesthesia, Student Life
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FrazerMy 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.

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Aortic Valve Replacement for severe AS

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David Avitar ArrowheadThe 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.

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An Anesthesia Machine Ooooops

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David Avitar ArrowheadIn 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,

We never get to talk too much so I just wanted to share one of my never ending idiot-girl stories in hopes that you learn from me.

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.

So there I am with an apneic, un-preoxygenated patient and no immediate means to ventilate. Don’t go there, I am embarrassed and have learned the hard way. Fortunately, my patient is fine (I can’t even begin to imagine the worst case scenario)……..why do we have to learn the hard way?

Never ever ever skip or forget 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 Arrowhead Regional Medical Center
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 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.

Categories : Anesthesia, Student Life
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