Sep
30

Recent Comments and Reply

By

The first thing that needs to be done is to congratulate the graduating class of 2010 Keck School of Medicine nurse anesthesia graduates from the University of Southern California.  What a great class.  Good luck to all of you.

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.

Categories : Anesthesia

Comments

  1. Keith says:

    Can you please answer this question for me? I’m Keith, 36 and living in Los Angeles. I’m studying for my RN license now and ultimately want to become a CRNA.

    The problem I have is this: I live alone and must work at least a part time job in order to survive. Is there such thing as a part time CRNA program and if so where do I go to find one?

    Thank you,

    Keith

  2. Jennifer says:

    I have been reading your blog and following a lot of your advice on preparation for an NA program. I was wondering if you could provide any tips on a successful goal statement for gaining admission into a nurse anesthesia program. I am finally ready to submit my applications this year and I don’t know where to start with the application letter / goal statement. I appreciate any tips you could provide.

    Thanks,
    Jennifer

  3. crneprep says:

    I would appreciate if you could email your thoughts on submission letters. SOrry I just posted in this forum, but don’t know where my post is. The NA is something that many students of mine are interested in. Email me at info@torontoschoolofnursing.com or torontoschoolofnursing.com

  4. I recently came across your site and have been reading along.I am interested in NA…please give me more details about it…

  5. Toni Braxton says:

    A site that helps you with chandler chiropractic | chandler chiropractor | chiropractic chandler | chiropractor chandler . Provides information for customers and all website visitors. A wonderful resource.

  6. David says:

    Toni,

    It depends. Generally yes. Get a call to the program for further information.

    DG

  7. Hello just wanted to give you a quick heads up. The words in your
    post seem to be running off the screen in Chrome. I’m not sure if this is a format issue or something to do with web browser compatibility but I figured I’d post to let you know.
    The design look great though! Hope you get the problem solved soon.
    Cheers

  8. David says:

    thanks

Feedburner

Enter your email address:

Delivered by FeedBurner

website security