Nov
11

What does the Shadow Know?

By

GarretWhat does the Shadow Know?

Recently I had the chance to interview and conduct a day long orientation to a potential candidate to a Nurse Anesthetist Residency Program.  Good candidates are hard to find ala May West.  Some of you may know the reference.

There are SRNA programs out there that like young blond inexperienced candidates for their programs thinking that they can mold them into subservient technicians that could fit into their semi-national workforce.  Not so here at our facility.  Ideally, we are looking for experienced ICU nurses that can think, have the experience to give them some wisdom and those with leadership skills to direct and manage future anesthesia cases.  Do I ask for too much.  I would hope not certainly in the 21st Century with Health Care evolving into something none of us had anticipated nor expected.

The medical world is in total flux and non of us in “the Business” of health care know how the future will play out.  What is central in my thinking is patient care and what is best for our clients.  Who are our clients as anesthesia providers?  Certainly our patients come first but that is not all.  Our clients include the surgeons and nurses that work in the peri-operative arena as well as the families and visitors that come to our “peri-operative home”.  We serve them all but primarily it is the direct patient care in the operating room that defines our practice as safe and efficient Nurse Anesthetists.

This brings me back to the Shadow.  What do our candidates bring to the table.  What is it that we want for a base line level to go into nurse anesthesia training?  These are huge questions.  I get candidates that have one to two years of ICU experience and have been awesome and I get some with ten years of ICU experience that have faded and not up to the rigors or challenges academically or clinically for anesthesia training.  In a previously very popular post with the commentaries, Fire In The Belly, I talked about what I thought was the most important thing to look for in a candidate to nurse anesthesia school.  My thinking has not changed much.

If I were to give you the potential applicant the ideal credentials, here they are in my personal view.  I would look for an ICU nurse that has between 3 to 7 years of experience working is a SURGICAL setting not medicine.  Pediatric experience is a PLUS not a minus while NICU is a very special category all by itself.  If you have been an ICU nurse for several years and have not stood for the CCRN I have to ask why.  Is it that you do not have motivation to excel?  So the CCRN credential is important.  When was the last time you were enrolled in an academic program.  Have you forgotten how to study?  If it has been “years” since you have taken a rigorous scientific course take one and demonstrate excellence.  I look for driven motivated people that know what they want and are willing to make the sacrifices that it takes to get into a nurse anesthesia program and excel.  Are you willing to move to complete your goals?  These are questions only you can answer.

What I am motivated to do is to encourage the best and the brightest nurses to pursue a course of study in the field of nurse anesthesia.  It is not for every one certainly but the rewards are tremendous for you and our patients.

Here is a letter from Garret.  He is a wonderful example of what I consider an ideal candidate for our program. Maybe he would not fit into everyone’s program but he meets all of the criteria I have found to produce fabulous results.  This is not an endorsement that he will be accepted into our program only my opinion.

 

David,

As discussed I am writing this letter as a reflection related to my shadow experience with you in October 2014.  I had to put some thoughts together on paper for this response.

In order to provide you a better picture of where I am in the process of becoming a Nurse Anesthetist let me inform you as to how I got to meet you.  I am certain this process started when I was in junior high school.  Unfortunately like approximately 40% of American parents my mother and father divorced when I was young and eventually we left our hometown in east Pennsylvania and moved to Maryland.  While there we lived with my mother’s aunt until her job stabilized; she was a Nurse Anesthetist in Baltimore.

While living with her I had many enjoyments and challenges, going to work with her from time to time proved to be new and ever stimulating adventures.  I remember sitting in emergency and operating rooms watching patients come in with, various illnesses, gun shot wounds, stabbings, and all sorts of complex injuries.  I got a chance to meet other nurse anesthetists, physician anesthesiologists, and all sorts of surgeons.  I was always star struck, as these people were rock stars to me.  My aunt was typically calm during most of these circumstances and then like magic the patients were calm or sedated and having surgery.  She seemed like to captain of a ship so busy yet so in control of a large complicated circumstance involving the life of another person.  Every time I saw this I loved the complexity, the science she discussed, and our conversations related to what I saw.

Fast forward through high school in Montgomery County Maryland, ten years of training (graduated top of avionics class), working, and traveling the world for the US Navy (5 years in uniform and 5 not), attending CSU Fresno (BSN Nursing 2006, Academic Deans Medalist for Department of Health and Human Services), completing a two year externship in Pediatric Critical Care (early acceptance based upon academic performance) as well as Burn and Trauma Nursing (Community Regional Hospital Fresno, CA), ten years of working in the Pediatric ICU, promoting to Pediatric Critical Care Transport  and Charge Nurse (Summer 2010), sprinkle in some adult post-op in patient care at a surgery center and here we are today.  I started talking to Dr. Gold in 2011 about how to become a candidate for selection into the Masters of Nurse Anesthesia program at USC.  Most of our conversations have been her advice for choosing required coursework and my decision to not pursue medical school in order to practice anesthesia.  She provided me with a solid course guideline in order to prepare me for the application process.  Admittedly I was following an academic track geared up for my own development in critical care and medical school in order to take an MCAT; a lot of math, chemistry, and physics, you know the drill.  I enjoy those sorts of courses and plan to continue some related education after the master’s degree.  That training and coursework has me a stronger critical care nurse and has provided a stronger foundation to my practice.  In order to further research my decision to pursue nurse anesthesia I have recently, through a close friend, contacted Dr. Jane Fitch, President of American Society of Anesthesiologists, whom used to be a practicing nurse anesthetist.  I wanted to get some advice on choosing a school in which to train and know why she decided to go back to medical school after so much training and academics in order to become a physician anesthesiologist.

A year ago I realized my window of academic opportunity was near based upon my family circumstances with one of our children nearing her college graduation at Davis, the other entering junior high, and my financial plans getting set for being a full time master’s student.  I again contacted Dr. Gold and reviewed my academic record to ensure I was on track.  We met in February 2013 and discussed not only my academic record but also the ability for me to sit in on one of the SRNA lectures.  After some emailing and date confirmations I was able to sit in on a OB lecture this past June with Dr. Jabbour.  For me this was the entrance to the Disneyland of an experience.  I could not sleep thinking about this and had to make sure all was perfect on my end (outfit, shoes, background knowledge search, timeliness, etc).  Since I had been to Dr. Gold’s office before getting there was not much of a challenge, but I was nervous as I waited for the students and Dr. Jabbour to arrive; this was a backstage pass for sure that I am extremely grateful for.

That day was exciting.  Dr. Jabbour and the other students made me feel welcome and I was able to ask a few questions to the students.  My biggest concern and still remains to a slight degree is my clinical background; PICU.  As I was researching the Master’s Degree of Nurse Anesthesia most of the requirements across the country contained adult critical care work experience, and some emphasized more specific areas within that were preferred.  At the end of the lecture I was able to speak to a student, a young lady, that was a PICU nurse prior to becoming an SRNA.  She expressed a great deal of comfort with much of the material throughout the program based upon her past work as a PICU nurse.  She further explained that everyone in the class comes from various specialized areas and their strengths are obviously a result thereof.  Not everyone was from some high profile, high acuity trauma and / or cardiac adult critical care area as I had previously imagined.  Between that information and the awesome lecture presentation my pursuit of this career was even further energized and more intrigued for applicable related knowledge.

After the lecture I was able to meet Dr. Norris at the program office.  She discussed with me some feedback of my experience and eventually recommended some related texts to obtain and read as a foundation to anesthesia practice.  Dr. Jabbour joined us and I was able to thank them both for the experience and their time.  I ordered the book from my phone on Amazon before I got back to my car (Stoelting and Miller).  As I was leaving we discussed what was available for me in terms of shadowing CRNA’s.  I explained that there was not a practice available at my facility and that we had only MD anesthesiologists; of which very few are supportive of CRNA’s.  We eventually decided to set up a shadow experience at LAC/ USC and that is how I got to meet you and Kari Cole.

SHADOW DAY

6 Oct 2014

After contacting Kari Cole and finalizing a date I decided to arrive in town a day early.  I stayed at the Marriott in downtown Pasadena.  The night before my shadow day I could not help but to think about what I kinds of cases I might get exposed too, what sort of questions will I be asked, how will my first impression come across, do I have my question list cleaned up, am I going to make myself look bad, etc.  I thought about every one of these things all the way across the bridge from the parking garage as I waited for Mrs. Cole and Mr. Godden at the security entrance.  I really wanted my hands to not sweat as I reached out to shake their hands.

David and Kari appeared from the side door near the entrance and Kari greeted me with a smile while David appeared in assessment mode, but welcoming.  I liked that.  After a few minutes Kari explained to me that I would be spending my morning with David and I hoped he would be accepting of my level of excitement and inquiry.  I knew there was something about him that smelled experienced yet government like. The more we began to talk the more we had in common.

After a stop at the Keurig machine he explained to me that we would be going to the fast track OR area to see some patients that he was preparing to do their anesthesia cases.  We started out by looking at their charts, recent lab data, reviewing any pertinent information with the bedside nurse, performing a physical assessment, and then waiting to speak to the physician performing the procedures.  Our first patient was a 76-year-old man having eye surgery for cataract removal.  He had some previous labs that were abnormal and his initial assessment did not support him being generally healthy, but David’s conclusion was that his clinical condition was satisfactory for his anesthesia plan.  It was this case that I learned about the narcotic Alfentanil; I had never heard of this before. We discussed this medication and some of its pharmacokinetic data as it related to traditional fentanyl that I was accustomed to using in my ICU.  We discussed this patient’s tolerance and level of comfort related to the medication’s David was using as well as the procedure itself.  As I asked a few questions David pointed out the importance as well as some vital aspects of his safety checks within his equipment.  I wanted to take apart the anesthesia machine in order to understand how it worked but as it was a shadow day, no time for that.  A ticket to that show would have to wait.  The most interesting concepts to me within this case was not only David’s competency but his logical approach to what his patient needed and tolerated during the case, what the physicians needed in terms of space and comfort, and me finding out the anesthesia table did indeed have a sort-of closed circuit system with regard to the respiratory circuit.

During the next cataract removal case David was considering a change in his original plan based upon the amount of deviance from the patients baseline vital signs and the patient’s tolerance to the procedure.  He called to confer with the chief anesthesiologist to conference in on his decision and they quickly decided to use more midazolam in order to provide the patient additional comfort.  In both of these previous cases David asked the patients if they were anxious or worried prior to entering the operating room.  Based upon their answers and his assessment he administered a small dose of midazolam as an anxiolytic prior to surgery.  As I sat in during the second case David continued to allow me ask questions and often elaborated into them displaying a much deeper understanding of medications and physiology that I not only admired like a teenager at my first rock concert, but that I truly craved as a lifelong skill; I did not want our discussions to end.  My top take away here were some text recommendations and David’s description of the stages of anesthesia; anxiolysis, amnesia, analgesia, hypnosis, plus / minus muscled relaxation, and blunting the autonomic response.  I was glad to find out there are a subset of nurses that believe in having a small working library within their possession.   I honestly thought I was of very few that had looked upon my bookshelf as an alter worth every dime invested and much more.  I am currently ordering a text called, “Watchful Care” by M. Bankert.

As an observation, I also noticed the amount of passwords and associated computer based systems David had to use in order to complete his documentation.  Unfortunately I believe this circumstance to be true in a lot of medical facilities.

Our last case of the day was a case that had already started. David took me to an orthopedic case in which a 59-year-old man with schizophrenia had jumped out of an open window and suffered a right tibia-fibula fracture that required surgery in order to facilitate stabilization and healing.  This was a general anesthesia case and the case was nearing an end as we entered the room.  The CRNA there was also a United States military Vet and had been an instructor for David when he was an SRNA.  She gave us a report of the patient’s clinical condition and anesthesia circumstances.  She was very encouraging and engaging with me; she thought best I stay close to David in the small area as he assessed the patient for extubation and what was going on with the anesthetics, monitoring, etc.  I was so amazed at the level of control and respect both CRNA’s displayed for the case.  I wanted to know how he dosed the anesthetic gases and how he monitored it.  He inferred that that level of discussion was not entirely for today but to my amazement he showed me how he could monitor the expired concentration of an anesthetic gas.  That was really cool, along with the BIS, capnography, nitrous oxide / O2 measurements, EKG, respiratory monitoring, constant patient assessment, etc.; I was completely grabbed like the best first date ever.  During the case a new MDA had been participating in the patient’s anesthesia management.  She later joined us and discussed the case thus far, asking a few questions with David she then proceeded to discuss some post-operative plans.  She seemed professional, non-confrontational, and kind in her academic approach.  David expressed a sincere supportive attitude as he spoke to her.  He later told me it was important to remain open and kind; especially to new professionals and those in training.  He said it was a priority that they had good experiences and memories while visiting USC/ LAC Hospital.  I could not agree with him more; as my experiences and memories are just that.  In the post-operative area I was able to see Dr. Jabbour again.  She remembered me from her OB lecture and our brief discussion with Dr. Norris related to indomethacin administration to expecting mothers.

Afterward David escorted me to Kari Cole’s office in order to complete my shadow day.  Kari and I reviewed the key points of my shadow day and discussed some details of the Los Angeles area.  I was able to ask Mrs. Cole and Mr. Godden a few questions related to my candidacy as an applicant to the USC Program of Nurse Anesthesia.  They both provided me with great advice and told me to keep doing what I am doing.  We even had some dialogue and some shared opinions on the future of nursing education and a belief that our baseline as well as advanced practice deserves an academic and professional upgrade.  As a second career nurse this is something I have long believed but could not label.  Due to this experience my confidence as an applicant has grown as well as my confidence within my own abilities as a critical care nurse and knowledge seeker.  It is very exciting to know there are nurses fundamentally practicing and approaching their practice as I do through a continued academic mindset with professionalism and applicable knowledge as priorities.

I am especially grateful for my time with Mrs. Cole and Mr. Godden as well as the administration at the USC Department of Nurse Anesthesia for organizing this experience and meeting with me for advice as I go through my journey to become a nurse anesthetist.

Garrett Kitt, RN, BSN, CCRN

Charge Nurse

Critical Care Transport Nurse

Pediatric Intensive Care Unit

Children’s Hospital Central California

So there you have it.  Go get um Garret.  I will be here for you all the way.

DG

Categories : Anesthesia, Student Life

Comments

  1. Jim says:

    David,

    Just wanted to tell you that I stumbled on your blog this Christmas night from a simple Google search, and have been utterly enthralled!

    As a SICU RN, anesthesia is a dream of mine and your blog is invaluable to people like me who are desperate for resources to aid in preparing for school applications.

    I will be following here from now on. Keep up the good work, your page just got ‘bookmarked’ on my phone, and again, thank you for the resource!

    Jim

  2. David Roy says:

    You are welcome Jim. I do not do enough writing these days. Maybe your encouragement will get me going again. What I need is input from current ICU RN’s looking to get tips on how to get into a good SRNA program and from current students that can give feedback on how their journey is gong.

    If you have any specific ideas or comments I would be happy for you to email them to me and I will put them up on the site.

    DG

  3. Judy says:

    HI David,

    Thank you for taking the time to do this! Your letters have answered a lot of my questions. I am currently working in a small ICU, and it has been 1 year. I have always wanted to become a nurse anesthetist. My cousin who is an anesthesiologist in Europe, made me fall in love with anesthesia. I am worried about finances of course, I have a good GPA, but I am afraid that my ICU experience will not be accepted nor be enough to enter a CRNA program because it is small and the acuity level is not that of some major hospitals in my surrounding. Thank you in advance for any advice you may have.

    Warm Regards,
    Judy

  4. David Roy says:

    Judy Judy Judy,

    Old quote but still applies today.

    If you are unhappy with the quality of your ICU experience do something about it.

    Choose a teaching hospital that has a surgical trauma ICU or cardiothoracic ICU.

    Now maybe you cannot move or those are too far away for you. I understand that.

    BUT make it happen. See your future……Be your future.

    MAKE IT HAPPEN

    a very old saying I often think of, “When the Student is ready, the Master appears”

    The question you have to ask yourself is “Are you ready for the next door opening?”

    Kind regard

    David Godden

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