Dec
29

New Academic Year Thoughts

By

DGThe academic year is well underway and thoughts now turn to the candidates that will be filing applications for graduate nurse anesthetists programs.  For those that are thinking about or are applying this year here are a few tips from someone fresh in the mix.

Dear David,

Words cannot express the gratitude that I have for the invaluable shadow experience you presented me and all the words of encouragement you provided me.  Forgive my redundancy, but thank you, thank you, thank you, thank you and thank you some more.  My journey to become a CRNA started when I was just in my third semester of nursing school.  During my clinical as a nursing student in the OR I approached a CRNA and his SRNA apprentice.  I asked them “What do I need to do to be a CRNA?”  To my surprise they kindly offered me their contact information and an opportunity to shadow if I was interested enough.  From that day forward the “fire in my belly,” as you put it, was lit.  I dedicated myself to pull the best grades possible, get acute care experience and do anything I could to build towards getting accepted into the CRNA program at USC.

Flash forward three years later and I am there standing at the entrance of the clinic tower waiting for a chance to experience first hand what it is to be a CRNA.  I was greeted by a staff CRNA who brought me up the OR elevator and escorted me straight to the pre-op holding area where you were working up your first case of the day.  We went over the goals of general anesthesia:  1.amnesia 2.anxiolysis 3.analgesia 4. hypnosis (which you mentioned as the medical term for sleep) 5. plus-minus muscle relaxation 6. hemodynamic stability (blunting the sympathetic response editor).  Essentially, the goals for general anesthesia are to create a pleasant experience for both the patient and the OR team.  Overall, the idea is the patient does not remember anything, feel anything or move during the operation.  The overriding function of a CRNA is to deliver safe, comprehensive and individually tailored care.

You also asked me why CRNA?  My reason for getting into anesthesia stems from my undeniable desire to strive for the best.  Anesthesia is the pinnacle of nursing and remains progressively as one of the most interesting areas in medicine.  This is truly where medical knowledge guides nursing judgement and function.  Interestingly, nurses were historically the first anesthetists.

Our first case was a patient with cervical cancer that needed cervical brachytherapy.  The procedure was to insert a cervical intracavitary brachytherapy device.  Brachytherapy is aimed to deliver high doses of radiation into specific areas of the body while not compromising surrounding tissue.  The plan was to put the patient under general anesthesia and avoid intubation.  In the pre-op holding area the patient’s airway and anatomy was assessed to measure for the oral airway, tube fitment and past medical history.  In the operating room, I was impressed by your set up.  Everything from drug kits (lido, zofran, propofol, fentanyl, rocs, decadron, etc) to your ET tube/laryngoscope setup were squared off and ready to use at any time.  I remember you designated a “clean side” and a “dirty side” for all your tools/drugs.  Naturally, the “clean side” was the side that had all the tubes/instruments” and the “dirty side” had your drugs/random stuff after they had touched the patient.  The first case went from being a simple one to a more complicated one. The initial idea was to use an LMA and not to use an ET tube.  At the start of the procedure the pt was given sevoflurane through inhalation for the induction and everything was going as planned.  The patient was asleep and was able to hold her airway fine. Just the patient was being preped, the pt started to cough and it seemed as if the patient could aspirate.  Within a moments notice the patient needed an ET tube.  Within arms reach the anesthetist was able to grab the ET tube from the setup and rapidly intubate the patient.  The lesson learned from this case for me essentially was that planning for any eventuality and having all the necessary equipment ready for use at any time could be the difference between life or death for your patient (or at least a complication editor). Good practice begins with careful preparation and a methodical drawn out plan.

Our next case was a patient with infertility problems.  She needed to be scoped laparoscopically in order to assess for the validity of her reproductive system.  The entire procedure was performed through the umbilicus.  The unique aspect about this procedure that stuck out to me was the use of CO2 to blow up the abdomen like a balloon.  The reason for pressurizing the stomach was to facilitate the passage of the scope and allow for space within abdomen to visualize adjacent structures.  As the surgeons blew up the abdomen with CO2 you asked me what were the possible complications of filling the abdomen with C02.  I knew that it had to do with something along the lines of pressure of organs and ischemia, but I was partly right.  As you pointed out, a main complication would be a vasovagal response.  The neurogenic bodily response would be bradycardia, which could be life threatening to a patient under anesthesia.  As soon as our discussion of potential complications was over the patients heart rate began to drop from 60 to 50 to 40 within moments the heart rate had dropped.  If left untreated, perfusion and oxygenation could be compromised.  Thankfully, you acted quickly and administered a dose of atropine.  Within seconds the heart rate rose to 80 and remained that way until the end of the procedure.  The rest of the surgery went smoothly, the patient was extubated and brought to the post-op holding area.  The lessoned learned here was that being in tune with the entire procedure not just the anesthesia aspect of it is vital.  Knowing what surgery is occurring, following it throughout and planning for potential complications within the OR is key to anesthesia practice.

I noticed that it was difficult for me to follow the surgery in its entirety because I was so focused on the anesthesia, partly because I was so interested in it.  I received a valuable lesson from this procedure, you have to be in this sort of melodic harmony with the OR team in order to plan, assess and deliver safe care.   Our day ended with a short meeting in the anesthesia lunch room.  You provided me with useful literature, your website and twitter account (@SRNA_Cafe), all of which I have begun to rummage through lately.  Again, thanks for all the tips David and hopefully I will see you soon.

Ronald

 

So there you have it from new eyes.  Now I have to tell you it was not all that dramatic.  Potential complications of any “small” general anesthetic can really be costly in terms of patient morbidity so vigilance is key at all times.  I think the lesson here is that there are no “its just a small” fill in the blanks procedure.  Preparation and awareness is key.

For all the the candidates that have the same intense desire to become a nurse anesthetist as Ron has, I wish you all good luck and the recommendation that you really stay focused.  I highly recommend reading Paul Marino’s, “The ICU Book” available from amazon as a prerequisite for candidacy to any nurse anesthesia program.  I really can not recommend this little gem of a book more highly for anyone interested in perusing a career in nurse anesthesia.  Read it throughly before applying to any program.  Just a tip.

Categories : General, Student Life

Comments

  1. Garrett Kitt says:

    Ronald, I could not agree with you more. I had an amazing shadow experience. It’s posted on here as well.

    I just got my copy of Merino’s book. I tore off the plastic tonight and gave it a quick scan. As a quick overview, this text is looks really nice. The pictures are clean and just in the quick non-linear reads I hit this evening, it appears to provide some strong foundational concepts. I am not sure it is “the one,” but I am the applicant; let’s be clear about that. If someone who is doing what you want to do, and doing it well, tells you to do something as a means to get where he is, I will listen and do.

    Thank you David.

    Garrett

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