At the AANA annual meeting in Boston this past month, the NBCRNA reviled a program for the Continued Professional Certification (CPC) for CRNA’s as opposed to a biannual Recertification process. During the conference the topic of Recertification for nurse anesthetists became the major talking point after hours.  Currently, Rectification for nurse anesthetists requires 40 hours of Continuing Education Units (CEU”S) every two years as well as a work requirement that amounts to about one quarter time in the operating room.  The intent of the NBCRNA in initiating a CPC is to ensure that the CRNA credential continues to represent a commitment to excellence and public safety.

What will the Recertification process look like in the future for Nurse Anesthetists is a real question.  The NBCRNA has the sole authority over the process of Certificaiton and Recertificaiton for CRNA’s and has maintained their independence up until now.  Here is a short blurb from their web site:

The NBCRNA is not part of the AANA as so many seem to think.  The certification autority is not part of the function of the AANA.  Here is a recent letter from the NBCRNA “letting us know” about their progress toward Continued Professional Certification:

Continued Professional Certification (CPC)

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

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

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

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

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

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

To the CRNA community from the NBCRNA

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

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

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

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

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

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

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

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

It is a little early to be talking about the Fall season but already the calls for Shadow days has picked up.  Traditionally, the Fall is the time when most prospective candidates that are seeking positions in the nurse anesthesia programs are looking to hone their interview skills and catch that all important Shadow experience.  I have written about this before but feel that the Shadow exposure is really invaluable for those wanting to enter the profession as a nurse anesthetist.  So, what are some of the things that could be learned through this contact with a CRNA in an operating room.  Thats a big topic so lets keep it simple for now.

The Shadow experience is a two way street.  You get out of it only as much as you can bring.  Put another way; what I would teach or explain to a nursing student would be different from the discussion that I would have with a Nurse Practitioner wanting to go back to school to become a nurse anesthetist.  I had the chance last week to precept someone in the OR with a pHd in pharmacology.  Our discussion went back and forth and undoubtedly I learned more than he did during the day.

Most people have no idea of what General Anesthesia is all about.  When I ask someone coming into the OR with me what they think the goals of a general anesthetic would be, the common answers are, “Sedation and no pain”.  I have to guide them into a better understanding.  I ask, “Is a sedated patient awake?”, and the answer usually takes a bit to tease out.  So obviously sedation is not part of a general anesthetic but hypnosis is (medical term for sleep).  It helps to think in proper terms.

In my taxonomy of general anesthesia I have a list which goes like this: 1) amnesia 2) anxiolysis 3) analgesia 4) hypnosis 5) plus minus muscle relaxation – patient does not move regardless 6) lastly, blunting of the sympathetic response.  In the most basic terms General anesthesia produces a patient that does not move and does not remember the procedure.  There could be some debate on this which is good.  So, the Shadow person has an opportunity to observe this process irrespective of the surgical procedure which is a whole learning experience in itself.

Thats enough out of me.  Here is a letter from a recent Shadow person with a couple of my comments which follow.

Dear David,

Thanks again for the shadow experience last Friday. This was just the beginning of my research regarding a CRNA career and finding the right school to provide an excellent education. I thoroughly enjoyed the time I spent observing patient care under anesthesia in the operating room with you and the ease with which you practice. The passion you have for your chosen profession is admirable—very few find that type of satisfaction in life.

After my shadow experience with you, I still have an extremely strong desire to pursue a CRNA career. As I discussed with you during our day together last week, I have always been an ICU nurse for a very particular and important reason. I promised myself to only work in a hospital environment where I am able to thoroughly understand and appropriately monitor my patients. The intensive care unit offers an environment of constant supervision providing a nurse with the proper tools to predict and prevent rapid deterioration in a patient’s status, similar to the culture of the operating room. As observed with you in the OR, I know that CRNAs have a job that offers not only critical thinking & increased autonomy but also an environment that pledges safety for the patient in need of a surgical intervention. The limited knowledge I have surrounding anesthesia was a bit intimidating during my shadow experience but this only makes me more determined to get back into school.

Additionally, I am in search of a culture of people that desire to acquire more understanding and knowledge within their specialty. During my day of observation, I was very impressed with the CRNA clinical instructor’s enthusiasm for teaching as well staying informed on the latest information regarding Nurse Anesthesia practice. Bedside nursing does not demand RNs to seek more knowledge. The status quo is fine and honorable for many nurses. I often find myself frustrated with the lack of complete knowledge I hold as a Bachelor prepared Registered Nurse. I seek the more intimate and comprehensive knowledge surrounding a patient’s pathophysiology and medical diagnosis.

As observed, you understood the patient’s medical history in order to proficiently administer and monitor the person under anesthesia. It is also noted, that there are many anesthesia cases that involve much more complex disease processes and patient care interventions (brun cases). All of this is very exciting and extremely frightening but I cannot imagine life without a challenge. CRNAs are trouble- shooters by nature—both technically and mentally. I would be honored to become a part of this autonomous and enthusiastic nursing profession.

Thanks again for taking a complete stranger under your wing for a day at such late notice. Your flexibility was greatly appreciated. At your recommendation, I have officially signed myself up for the CCRN examination and will be sitting for the test in the very near future. I hope you have a wonderful Summer/Fall and that your wife makes it back to the USA safely.

Sincerely,

Libby Patton

There you have it.  I do have to comment about Libby’s idea of autonomy.  I work in an Anesthesia Team practice with Anesthesiology and happen to enjoy the back and forth exchange of ideas.  Team is always good.  So where does the idea of autonomy come in?  No one in the operating room is totally autonomous.  All of us from the nurses aids that help bring the patient and the surgical scrub technician as well as the assistant and attending surgeon all work towards a common end.  Nursing has a big roll to play as does our surgical colleagues.  Anesthesia has its own team as well and we all work together.  I will say it again, no one is an island.

I think what Libby was impressed with is the level of practice that CRNA’s have achieved.  While there are some States and areas where CRNA’s truly are autonomous that is not what is happening in my practice setting and I do not try to engender that idea.  I really don’t want to get any more political than that, period.

Enjoy, and as always, keep the goal in sight.

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

Excellent salary base and benefit package, which includes:

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

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

Please forward your resume to:

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

The AACN American Association of Critical Care Nurses issued the following press release this past week:

WASHINGTON, D.C., October 5, 2010 – Today, the American Association of Colleges of Nursing (AACN) applauds the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation for their visionary report on the Future of the Nursing: Leading Change, Advancing Health, which includes among its recommendations removing regulatory barriers to nursing practice, raising the education level of the nursing workforce, enhancing nursing’s leadership role in healthcare redesign, and strengthening data collection efforts.

The IOM is calling for policymakers, educators, and leaders across the profession to take collective action to reform education, strengthen nursing roles, and amplify nursing’s voice in transforming the healthcare system. “The IOM’s focus on the future of nursing comes at a time when healthcare reform presents new challenges and opportunities for the nursing workforce,” said AACN President Kathleen Potempa. “AACN stands ready to work with the Robert Wood Johnson Foundation and other stakeholders to ensure the report’s recommendations are implemented to enhance patient safety and the quality of care available to our nation’s diverse patient population.”

The four key messages that structure the recommendations in the Future of Nursing report include:

* Nurses should practice to the full extent of their education and training.

* Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

* Nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States.

* Effective workforce planning and policy making require better data collection and an improved information infrastructure.

Specific action steps requiring a collaborative response include:

* Increasing the number of nurses with baccalaureate degrees from 50% to 80% by 2020 and encouraging nurses with associate degrees and diplomas to enter baccalaureate programs within five years of graduation.

* Doubling the number of nurses with a doctorate by 2020.

* Addressing the faculty shortage by creating salary and benefits packages that are market competitive.

* Moving to have at least 10% of baccalaureate program graduates enter master’s or doctoral degree programs within five years of graduation. * Removing scope of practice barriers that inhibit Advanced Practice Registered Nurses (APRNs) from practicing to the full extent of their education and training and serving in primary care roles.

* Enhancing new nurse retention by implementing transition-into-practice nurse residency programs.

* Embedding leadership development into nursing education programs and increasing the emphasis on interdisciplinary education.

* Ensuring that nurses engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.

“Implementing these recommendations will propel the nursing profession forward and better position nurses to become full partners in reforming our healthcare delivery system,” added Dr. Potempa. “AACN is committed to leveraging our influence, data resources, and extensive network of nurse educators to advance these recommendations to better meet the health needs of the nation.” The new report is the product of a study convened under the auspices of the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, and is the result of the committee’s review of scientific literature on the nursing profession and a series of public forums to gather insights and evidence from a range of experts.  The expert committee leading this work was chaired by Dr. Donna Shalala, president of the University of Miami, and included among its members Dr. Michael Bleich, dean of the Oregon Health & Science University School of Nursing. AACN was pleased to provide testimony, consultation, and assistance with data requests to the IOM Committee while the report was in development.

The American Association of Colleges of Nursing (AACN) is the nationalvoice for university and four-year college education programs innursing. Representing more than 650 member schools of nursing at publicand private institutions nationwide, AACN’s educational, research,governmental advocacy, data collection, publications, and other programswork to establish quality standards for bachelor’s- and graduate-degreenursing education, assist deans and directors to implement thosestandards, influence the nursing profession to improve health care, andpromote public support of baccalaureate and graduate nursing education,research, and practice.

CONTACT: Robert Rosseter, 202-463-6930 rrosseter@aacn.nche.edu <mailto:rrosseter@aacn.nche.edu>

The AANA put out a news bulletin following the publication by the Institute of Medicine (IOM) visionary report on the Future of the Nursing: Leading Change, Advancing Health.  What follows is their News Report published October 5, 2010:

Park Ridge, Ill.—Landmark findings from the Institute of Medicine (IOM) assert that expanding the role of nurses in the U.S. healthcare system will help meet the growing demand for medical services. The IOM report urges policymakers to remove policy barriers that hinder nurses—particularly advanced practice registered nurses such as Certified Registered Nurse Anesthetists (CRNAs)—from practicing to the full extent of their education and training.

The report, titled “The Future of Nursing: Leading Change, Advancing Health,” was released in the wake of two definitive studies recently published in leading peer-reviewed health journals that confirmed the safety and cost-effectiveness of nurse anesthetists.

“The new report from the Institute of Medicine is further evidence that all nurses, including advanced practice registered nurses, play an integral role in the U.S. health system,” said Paul Santoro, CRNA, president of the American Association of Nurse Anesthetists (AANA). “Millions of previously uninsured Americans are about to enter the system, and millions more baby boomers are coming eligible for the Medicare program. In conjunction with the recent RTI study that called for the repeal of the supervision rule, the IOM report shows it is long overdue that these highly qualified professionals be allowed to practice to the full extent of their capabilities, ensuring all Americans access to safe, affordable healthcare.”

The RTI study, titled “No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians,” was published in the August 2010 issue of Health Affairs, the nation’s preeminent health policy journal. This study, which examined nearly 500,000 individual cases in 14 states that removed the federal physician supervision requirement for nurse anesthetists between 2001 and 2005, revealed that patient outcomes did not differ between the states that do not require physician supervision and states that do. Further, the study confirmed that there are no differences in patient outcomes when anesthesia services are provided by CRNAs, physician anesthesiologists, or CRNAs supervised by physicians.

In addition, the Lewin Group published a study titled “Cost Effectiveness Analysis of Anesthesia Providers” in the May/June issue of The Journal of Nursing Economic$. This study considered the different anesthesia delivery models in use in the United States today, including CRNAs acting solo, physician anesthesiologists acting solo, and various models in which a single anesthesiologist directs or supervises one to six CRNAs. The results show that CRNAs acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model. Alternatively, the model in which one anesthesiologist supervises one CRNA is the least cost-efficient model.

CRNAs are anesthesia professionals with 7-8 years of education and training related to their specialty,  including a four-year bachelor’s in nursing, at least one year of experience as a registered nurse in an acute care setting, and a master’s degree from a 24-36 month nurse anesthesia educational program.  In addition, CRNAs must fulfill continuing education requirements every two years in order to remain certified to practice. By the year 2025, a doctorate of nursing anesthesia practice will be required for entry into the profession.

The IOM report was the work of the IOM’s committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, which consists of doctors, nurses, academicians, and other healthcare representatives.

The Health Affairs study referenced above is available at www.aana.com/optoutstudy.

The Nursing Economic$ study referenced above is available at www.aana.com/lewinstudy.aspx.

Here is a link to the IOM press release: http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12956

Here is a link to a brief of the IOM report:
http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Report%20Brief%20v2.pdf

The IOM report can be purchased at: http://www.nap.edu/catalog.php?record_id=12956

We all received news today from Sean CRNA (left) that he passed his Board Exams this past week.  How wonderful is that!  After all of the hard work blood sweat and tears to finally reach the Board Exam and pass.  Awesome.  Sean was a very talented student excelling in clinical rotations.  Good luck dude.

Its been a bit since I last sat down to write for the Nurse Anesthetist Org blog.  In the intervening time there have been several comments that some of you have been so gracious to send in.  There have been a few questions too.  Here I will attempt to answer some of the questions that have come in about Nurse Anesthesia.  First, I wanted to start out with a question about general anesthesia asked by Jeff in a comment from the last post.  He asks,

“Any chance you’ll let us in on how accurate the author of last note was regarding the components of anesthesia? And perhaps fill us in on the missing 6th component?”

What Jeff is referring to is what a “Shadow” person wrote as he remembers it concerning the goals of general anesthesia that I tried to impress upon him.  As far as the accuracy of his memory is concerned I make no comment.  The validity of what I teach has often been called into question.  But no matter, you make up your mind.

One of the things that I try to do when having a candidate for any anesthesia program in the OR with me is to try to get them to think about what the goals of general anesthesia are. Spend a couple of minutes to think about it yourself. What would your goals be for someone undergoing general anesthesia?

What I have come up with is a short list of goals as teaching points. This is my creation based on years of experience and extensive study. Feel free to use these ideas but give credit to me for elucidating them.

Here are my teaching point goals of general anesthesia for the learner:

1) We often give midazolam (versed) in the preoperative area to reduce anxiety and produce amnesia. Goal number 1 for a patient undergoing general anesthesia is anxiolysis and amnesia. We do not want our patients to worry or to remember the experience of surgery.  For patients that can not or do not wish medication the hand holding techniques are wonderful.  This is particularly the case in obstetric anesthesia.  The practice of the “Therapeutic Use of Self” is a nursing technique that is extremely powerful and is often neglected.

2) With induction of general anesthesia we often use opiods such as fentanyl to facilitate tracheal intubation and begin producing analgesia. During the surgical case more opiods are some times used or other agents such as nerve blocks to produce analgesia. Goal number 2 is analgesia. We do not want our patients in pain.  Reduction of pain in surgical patients is a major goal whatever the method.

3) In general anesthesia cases, do you want your patient to be awake? I would say that in my practice the answer is no. Propofol is often used to induce hypnosis.  The maintenance of hypnosis during the surgical case may be accomplished with a propofol infusion and volatile inhaled agents. Goal number 3 is hypnosis throughout the case. We want our patients to be asleep during surgery and not to experience recall of any intra-operative events.

4) During surgery it is expected to have our patients still and not moving around with surgical stimulation. We want a quiet surgical field so the surgeons can do their best work. So, we do not want patients to move but do we need muscle relaxation or muscle paralysis? There are certain procedures that require a degree of muscle relaxation such as reduction of a femur fracture or large intra-abdominal surgeries. For these surgeries we use muscle relaxation medications to facilitate the surgical procedure. Goal number 4 is a plus minus – maybe yes maybe no – do we need muscle relaxation. We do not need muscle relaxation so that our patients do not move. A quiet still patient is taken care of with a balanced use of general anesthetics. Muscle relaxation is a different story and is used when it is a surgical necessity.  This is my opinion and practice.

5) In general surgery cases the patients are asleep (hypnosis) and they do not remember (amnesia) and they cannot tell you what they are feeling so do they have pain? In my view if a patient is asleep and does not remember and cannot tell you what they are feeling – then by definition they do not have pain. What they do have is sympathetic stimulation. Now obviously this is an extensive subject but the short course is to see elevations in heart rate and blood pressure as a sympathetic response. What we want during a surgical case is for the patient to be stable hemodynamically with normal heart rates and blood pressures. There are multiple pharmacologic agents and techniques to do this, which is not the subject here. So goal number 5 is to blunt the sympathetic response. We want stable patients.

6) The best monitor in the operating room is a trained Vigilant anesthesia provider.  The sixth and most important goal during general anesthesia is to maintain vigilance as an anesthesia provider.  Nothing else in the OR will take the place of this.  Nothing will be as well attuned to expected and unexpected changes in the patients condition as the person providing the anesthetic.  No one in the lounge, no one in the hallway, no ECG monitor, no pulse oximetry monitor or capnography monitor will be as quick or as skillful in detecting and caring for patient needs as the trained and skilled anesthesia provider in the room.  If you want to discuss this call me any time.

These are the goals of general anesthesia that I have come up with. The list is manly used as a gestalt or way of thinking about what a student needs to learn about general anesthesia. The techniques to produce a good anesthetic have been described as “An Art”. The art of anesthesia is a combination of medical and pharmacologic knowledge with technical skills and expert patient care experience. In my view as a nurse anesthetist, I refine my craft every day both in the operating room and as a clinical instructor of fledgling anesthesia providers.  There you have it Jeff.  I hope that answers your question.  As far as accuracy is concerned Jeff, these are my definitions and ideas and is certainly not the only way to describe the general anesthetic.

Anne writes in a comment:

Hi.. I am a filipino nurse assigned in the OR for 6months now..
Since I am assigned there, I have become interested with anesthesia and thought of becoming a nurse anesthetist.
I am actually gathering some requirements in order to study BSN again in australia.
Is there anyone who could help me find my own path in becoming a nurse anesthetist?
I don’t know where I should start and when.. I’m not even sure if my experience
In OR is enough already or if I really still need some experience in ICU.. I’m glad I’ve
Found this site. Thank you.

Well Anne you have come to one of the places where these questions are asked and attempted to be answered.  Unfortunately, the only country that I know of where nurse anesthetists have a flourishing practice is where nurse anesthesia started and that is here in the good old United States.  The practice of nurse anesthesia in the Philippines has undergone changes in the past several years but as I understand it the practice is fairly limited.  My suggestion to you right now is to complete the BSN degree in Australia.  That is a totally doable goal and one that will benefit you no matter what other path in nursing you take.  Good luck and study hard.  Thank you Anne for stopping by and keep us informed about your progress.

Just as a reminder – all content – pictures and media is the sole property of nurseanesthetist.org web site and nothing is to be used copied or distributed without the expressed written consent of the webmaster – that would be me.  I found a picture that I took and displayed in the web site here published in a local magazine recently.  They never asked for my permission and was published without my consent.  Weird.

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

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

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

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

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

David,

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

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

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

Thanks

Here is another one that worked out well.

David,

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

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

Respectfully,
Joe Romero

Finally the last for now.

Dear David,

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

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

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

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

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

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

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

Wes Easter RN, BSN, CCRN

Its one thing to have a book understanding of concepts and basic science theory about anesthesia; it is another matter to deliver anesthesia care for a live breathing patient.  I guess that is what makes what we do so much fun.  The clinical rotations now are in addition to continued class room work.  I want to discuss more about what its like to start clinical rotations but first.

Here is a little digression.

There are basically two types of Nurse Anesthesia programs out there.  There are those that “Front Load” with all of the didactic and class room work up front and then put the clinical rotations at the end.  These programs are usually longer because the clinical applications and specialty rotations take at least 18 months of solid work.  Then there are programs that start some clinical rotations immediately combining class room study and clinical rotations.  The USC approach is to give at least one semester of didactic then start the clinical rotations.  What we have been doing for the past two years now is to expose the new students to the operating room environment through the use of “Shadow” experiences and now “Simulation” during the first semester to ease the transition to the Clinical sites.  This seems to be working really well.

Simulation work is the frontier for learning new skills and crisis training.  There are some programs that have really jumped on the Simulation Bandwagon.  The University of Pittsburgh Nurse Anesthesia program has one of the largest Simulation Laboratories in the country.  I was fortunate to visit their fabulous institution during my search for a program for myself.  Pittsburgh or just plain “PIT” is an awesome program.  Fortunately, we have one of the former clinical professors from Pit now as part of our department.  One of his passions is to get the LAC + USC simulation room up and functional.  We have all the equipment but the whole simulation package here is improving with Lou’s help.  Last month we had an all day event with the first year students in the simulation room.  We all learned a lot about what it takes to make it “real”.  One of the “patients” died during the simulation.  It was real “Art”.

Samuel Merritt University has a simulation center as well.  A couple of our faculty here went up to visit their facility to see how they are progressing in their simulation work.  You can read about Sam’s Health Science Simulation Center here.  Samuel Merritt University is one of the great Nurse Anesthesia programs here in California.  They are our San Francisco cousins, sort of.

First Year Nurse Anesthesia Students in the OR

Combining physiology and pharmacology in a hands on application is what the practice of anesthesia is all about.  I have heard it said that anesthesia is an Art and a Science.  For the first year student nurse anesthetists here at LAC + USC in their first clinical rotation it’s more like Effort and Guidance.  The Art comes later maybe way later.

For me as a clinical instructor, watching the growth of the students over the first several months during their clinical trials is like watching your first born learn to crawl then stand.  Crawl mostly, the standing is a little shaky right now.  The first walking steps with minimal if any assistance will come later in the second year of clinical rotations, hopefully.

Airway management is on every one’s mind and developing the needed skills to maintain an airway is something that takes time effort and practice.  Eventually the skills in assessment improve to the point where surprise is a rare occurrence.  For the First Year SRNA’s, just Hand Mask Ventilation can be a challenge, depending on the patient.  I think its important to note that the students are never left in a position where there is any risk to a patient.  A fully trained licensed CRNA or anesthesiologist is with the patient at all times during the first year of nurse anesthesia training at our institution.

Here is a former USC student during anesthesia training.  He was late to a very early mandatory student meeting.  He was setting up his room when he should have been in conference.  We work them hard.

After passing his board exams recently, Geoff is now part of the USC anesthesia team.  We are glad to have him.

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

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

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

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

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

The best months to set up a “Shadow” day to follow a nurse anesthetist is now – between the months of September and January.  These are the months when our first year students are busy in the classroom and the clinical staff in the operating rooms are free to turn their attention to potential candidates entering the program of nurse anesthesia.  We do allow candidates to shadow all year long but the days are more restrictive.

Recently a persistent young man was able to come by and was shown around our dearly loved County Hospital.  It was a busy day.  Maybe that is for the best because it gave a realistic picture of whats its like to have a clinical practice in a large public hospital.  My kinda place.  What follows is the beginning of a screenplay I am sure.  The names have been changed to protect the innocent but the gist of the story is all factual.

Enjoy and let me know what you think.

Red Blanket?…What’s a Red Blanket?

By Hugh Adair

I met David at the double doors of the hospital entrance on the second floor. 6:30 sharp. The introduction was brief and to the point. “We need to get you into scrubs,” he said. Scrubs…awesome. I couldn’t believe this was actually happening.  I was so excited. I came across David’s blog Nurse Anesthetist, several months ago as I was scouring the web trying to find as much information as I could about CRNA’s.  At 35, I decided the life of a television producer was no longer going to fit. For 13 years, I worked in post-production for network and cable television. As a husband and relatively new father of two (a 3 year old son and a 1 year old daughter) I realized the 15-hour day, 6-day workweek was not going to work, plus I yearned to do something rewarding. A strong desire to help others drew me to my decision to become a nurse. I had always been interested in medicine – surgery specifically. When I found out there were nurses that provided anesthesia to patients in surgery, it seemed like a perfect match. Nursing and Surgery. After reading through David’s blog about his life as a CRNA and the journey that got him there, I was even more intrigued. I wanted to speak with him and ask him questions.

One particular page that leaped out at me was an entry on the importance of a shadow day. A shadow day is when a prospective student follows a CRNA from case to case. As a shadow, you are observing right alongside the anesthetist as he or she is working. Having an opportunity to shadow a CRNA for the day would be a good test to see if this was something I was truly interested in pursuing. I reached out. I sent David an email explaining who I was and that I was interested in talking with him about being an anesthetist. I wanted to ask questions like, am I too old to do this? What are the career prospects and opportunities? I also asked if it would be possible to shadow him for the day. I sent the email. I never heard back. I was bummed.  I moved on. I searched the web looking for other possible shadow opportunities. I contacted local hospitals that employ CRNAs to see if they offer a shadow experience, I even asked an OB/GYN friend if she could help, she tried with no luck. Every request was a no. How was I to know if I would enjoy being a CRNA if I couldn’t get a chance to see what it was like? What if I were to invest all of my time, effort and tuition (not to mention the personal toll on my family) to go through nursing school, work for two to three years in ICU and then go back to school for 2 ½ additional years to finally become a CRNA – only to find out it was not for me? I needed confirmation.

Months had passed and I had almost forgotten that I had even sent an email. Then I got the word. David emailed me that his blog had been attacked by a virus and that he was sorry it took him so long to respond. He told me to call him anytime. I was ecstatic. I phoned immediately and left a message. After several rounds of phone tag over a couple of weeks (I didn’t want to hound the guy), we were able to connect. After our conversation that was kind of like a phone interview (I was quite nervous), David spoke the words that sounded like music to my ears. “Well, you need to come down and have a shadow day.” Really? Was this really what I was hearing? “How is your schedule?” he asked. The conversation ended and I met him two days later.

After a brief introduction to the incoming fall class of SRNAs and other faculty members, I was given a set of scrubs and we were off and running.

David was covering one of the operating rooms reserved for the E.R. Since these rooms are used specifically for the E.R., there were no scheduled procedures on the board.  By 7:00 am we were sent in to relieve two Resident Anesthesiologists who had been in surgery since 10:00 pm the night before. An 18-year-old male with multiple gunshot wounds to the pelvic region. When David took over, the Orthopedic team was finishing up their work and the OR staff were preparing for the Vascular team to begin their work of repairing this kid’s veins. After the exiting residents briefed David, he signed on and took over the case. David immediately begins assessing the patient, monitors and medications. David works at a rapid, yet controlled and calculated pace. Impressive. Very impressive. The patient is stable and very lucky to be alive as he lies on the table with an incision from his sternum to his lower abdomen, an incision from his inner groin to his knee and several incisions on his hip. The operating room buzzes with adrenalin. David continually monitors and adjusts his medications. He gives me a complete play-by-play of what he is doing and the reason why he is doing it. David even throws out a couple of test questions as any good teacher would. “This is an applied science,” he says. “Anyone can regurgitate information, that’s not good enough. You need to be able to practice it.” This is life or death. No room for errors.

It’s 9:00 am. Time is flying by and I am loving every minute of this experience. David needs to be relieved from this case to take over the room next door. He briefs the Doctor taking over the case. Once finished, David grabs his MP3 player and we move next door. David plugs in his music player and begins prepping for what is coming down the pike. David’s preparation is articulate and precise. Remember, no room for fuck-ups. David checks, double checks and triple checks his medications.  Once satisfied and set-up we take a quick break for a burrito. “You eat when you can,” he says. During our brief breakfast David asks if I’m still interested in pursuing the career. “Very much,” I replied. David, under no uncertain terms, makes it very clear how hard a road it is to become a CRNA. Preparation seems to be a paramount prerequisite for anyone considering applying to the USC CRNA program. In addition to courses taken during nursing school, David recommends taking additional semesters of physics, upper division chemistry and an epidemiology course. Breakfast was brief. We head back upstairs.

A 17-year-old male came in the night before with a clean fracture to both the ulna and radius. David showed me the x-ray on the computer screen. “This could be very complicated,” said David. Hardware was probably going to be needed. The boy’s mother passes by the nursing station as they wheel the patient into the pre-op room. She is visibly shaken and scared for her son’s pending operation. Her English is broken. David speaks to her in Spanish. Her eyes fill with tears. David’s words comfort her. She tells David she will pray for God’s guiding hand over him and the operating staff. I get a little choked up myself. This is real. This is exactly why I want to do this.

I follow David into the room for the pre-operative interview. The patient seems alert and lucid. David asks him how he ended up in the ER. “Skateboarding.” he said. David runs through a battery of questions. “Have you had any kind of surgery before? Any known allergies? Was he born naturally or by caesarian?” The mother had a natural birth, but premature. This was important information. David was writing down his notes when a nurse came in and said they were sending up a RB from the 6th floor. “RB? What’s an RB?”  “Red Blanket,” said David. A Red Blanket is an emergency call for surgery. An RB is a life or death call that apparently supersedes any scheduled or lower acuity procedure. David apologizes to the fracture case and tells them he will be back later.

A 55-year old female was six days out from colorectal surgery. On rounds, a resident was examining the patient and asked her to cough. The patient coughed, her abdominal sutures break and her intestines herniate. Surgery is definitely needed.  After reviewing her chart, David preps his workspace. David works expediently, yet remains cool. The OR is prepping. He turns on his music. David has an eclectic taste in his tunes, mostly British pop. I wondered if his music choices held any significance or if it was just white noise while he worked. The patient arrives, distressed. As described, a small portion of her intestines are protruding out of her stomach. The patient’s gut is severely swollen (gas). She looks like she is nine months pregnant. David reassures her and givers her something to calm her down. The patient begins to relax. As the team transfers her to the table, the patient loses control of her bowels and makes quite a mess. A slight distraction. The nursing staff make quick work and move on. David introduces another medication and the patient quickly falls asleep. Once asleep, the patient is intubated and put on the ventilator. By the way, if I haven’t mentioned this in a while, this experience is incredible. I am mesmerized, like a kid in a candy store. But I digress. The attending surgeon arrives. He and the resident get to work. It seems the patient’s fascia was not strong enough to hold the sutures. Before long, the patient is made whole and the surgery is over. I follow David as he escorts the patient to recovery. Once in recovery, David gives the post-op nurse a run-down from the surgery and follow-up orders.  This case is finished.

David makes tracks to prepare for the 17-year old with the fracture. I follow. David stops and tells me I need to go eat. My day in the OR was over. I was bummed. I was hoping he would say, “Ok, let’s go”, but I was done. Then I realized that it must be tiring having someone looking over your shoulder for six hours.  I thanked him once again and changed out of my scrubs.

David escorted me to the door where I met him. He told me once I was actually in nursing school that I should call and do it again. He was very gracious. We shook hands and he went back inside. What an experience. Thank you David.

There you have it straight from the horses mouth.  I think Hugh should stick to writing screenplays what do you think.  Just kidding.

Just so its clear, what Hugh did not notice is the communication and team work in the anesthesia department at the Big House.  We work in a team setting with M.D. anesthesiology and CRNA’s.  This is one of the great benefits for our patients.  Without being political, two heads and four hands are often better than one.  Get it?

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

Now, lets eat!