Jul
03

More Shadow Days

By

Recently I have been very busy with the new students operating room rotations.  We are now coming to the place I really look forward to in the development of the SRNA’s clinical skills and awareness.  This new class has been in the OR’s now for a little over 6 months and are starting to really shine.  Now is the time to back off as clinical instructors and let the little fledglings fly a bit and see what its like to take care of patients with less direction and more watchful care from the instructors.  I have been really pleased to see how far the students have come in their skills and judgment of basic anesthesia care.  My greatest pleasure now is in seeing the developing SRNA’s taking the reigns and allowing me to back off to more of a watchful position.  Off course I am always there to rescue or to discuss different management systems for the cases we do.  All in all I think that as instructors of clinical anesthesia we are very hands on.  Now is the time to back off a bit.

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

Categories : General

Comments

  1. Jeff says:

    Fantastic post. I look forward to your next one.

    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?

    Thanks.

  2. David says:

    Jeff,

    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. 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:

    1) We often give midazolam (versed) in the preoperative area to reduce anxiety and produce amnesia. Goal number 1 is anxiolysis and amnesia. We do not want our patients to worry or to remember the experience of surgery.

    2) With induction of anesthesia we often use opiods such as fentanyl to facilitate tracheal intubation and begin producing analgesia. During the 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.

    3) In general anesthesia cases do you want your patient to be awake? No. We often use propofol to induce hypnosis and maintain hypnosis 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 – 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.

    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.

    These are the goals 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. 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.

  3. Uma bhaskara says:

    Hi David,

    I have been looking out for a shadow oppurtunity with Nurse Anesthetic but I found to be nearly an impossible task. I don’t know if I am posting my message in the correct blog , but I did so because of desperation.I am a RN working in Glendale CA and interested in applying for CRNA program at USC.
    Hoping for a reply
    thanks
    Uma

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