CRNA Board Preparation

When you are in the CRNA program and the "finish line" appears closer than ever, another stress starts to creep on. BOARDS! All your mentors, family and professors can keep telling you that "you are going to do just fine" (and yes you will do fine) but it is difficult to stay calm. Good preparation and planning is the key to success. So how do you prepare? Here are some tips that helped me get through.

1) Timing

Getting your appointment for your exam is a difficult decision to make. "I didn't get time to study during clinicals", "I am not ready" etc are all the questions that may deter you from taking that step. Nevertheless, you NEED to do it. People tend to do better with deadlines and that little sense of nervousness will help you study better. If you go in without a set date for the exam you will more likely procrastinate (I did :) ). Also, regardless of the date you are taking the exam, there is always a topic that can be prepared better. That should not be the reason to delay your exam since we all have topic that are difficult to understand. So, make that appointment and don't change it because you feel unprepared. 

2) Studying 

It is ideal to study throughout the program however, we all know it is unrealistic. Some clinical sites have difficult rotations, exhaustion, and family matters can all play a role in limiting your study hours. It is important to set realistic study hour goals based on clinical sites. For example, 8 hour days may allow you 2 hours of studying whereas 12 hour clinical days allow you only 1. Use them appropriately. 

3) Topics

I know everyone's learning styles and habits are unique to themselves. So, know yourself. Don't follow the group. Choosing topic to study may work better if you have something to relate to. Discuss a topic with your clinical preceptor, relate it with your case, or study about your case a day prior. Studying and relating it to real-life situation is a great way to retain information. 

4) Review Course

There are so many review courses out there that may make it almost overwhelming to choose from. Every one of them have positives and negatives that again relate to your personal learning habits. I learn better from lectures and visual information so Valley review course worked better. However, if you are interested in how the boards are set-up, then Prodigy or Apex (or others) may be ideal. 

5) Relax

Most important one for the last. Relaxation and sleep are often forgotten as a CRNA student but are key to your success. I was so exhausted after two weeks of post graduation studying that I was having a great deal of trouble retaining information. You don't want to go in tired. Eat well before the exam and drink enough water. I had to change the environment I studied in to keep it stimulating. 

At the end, remember you made it through the difficult part that is the school and this is really the easiest portion of CRNA program. Feel free to comment or email any specific questions you may have. Wish you all good luck! 

It's that time to take the SEE again?

Yes, It is. SELF-Evaluation examination (SEE) consists of 160 questions in professional and legal aspects (13%), anatomy/physiology/pathophysiology (29%), Pharmacology (25%), Basic principles (14%), and Advanced principles of anesthesia (19%). Here is the breakdown of the content area from nbcrna:

These categories are scaled score that ranges from 300-600 points. As you can see, anatomy and pharmacology yields the highest percent, which means more questions are in these categories. Many people focused more on these two categories. Not many people realized that even though other categories are low yield in terms of number of questions, the percent of correct answers makes a big difference on your scaled score. In contrast, if you miss more questions, your scaled score will drop significantly. So when you study, make sure you cover the categories.

Results: Statistically speaking, SEE exam taken the 2^nd year yields lower score compared to previous year. One main reason is that most 1^st year takers are more fresh from the didactic standpoint. 

Generally speaking, scoring above 400 or higher is a good indicator for passing the NCE. The question that I always hear” what’s the national average?” Well, here it is. According to the table above, total cumulative score of 400 yields at 58.5%. That means you scored 58.5% percent better than everyone else in the country. That percent seems a little too high if it really correlates with the NCE. Valley anesthesia stated that Over 90% of 1^st time takers passes the NCE exam. If it is really over 90%, cumulative score in the SEE exam should be lower than 400 points as an indicator for passing the board. Of course, you want to score the highest for confidence purposes. 

Study tips:

Use the content area as your guide. You may use valley memory master, prodigy or APEX, Core concepts and many others to tackle these subjects. Happy studying!!!

D

Apex Anesthesia Review Course

I have recently been approached to give my opinion on a new SRNA board review website Apex Anesthesia Review (www.apexanesthesia.com) that is available now. Before I begin, in a  recent comment, it was mentioned that they feel "A Student CRNA blog" introduces a lot of new "products". I am not sure if they were saying its a good thing or bad. The information presented about the mentioned courses are  mainly introduction to the products without any promotion or rejection of their effectiveness. Everyone has different learning styles so the idea of me discussing these is to allow an insight into the courses that can help you all determine if they meet your learning needs or not. Regardless, I wanted to start off by saying that the products that I discuss on my blog do not provide me with any monetary compensation. In fact, I look for terms that allow me to keep a neutral, unbiased stand towards the product. Thanks to the developers of Apex Anesthesia Review Course, Kevin Baker CRNA and Daniel Frasca CRNA, DNAP, I have had the opportunity to personally browse their website courses and get an insight on how it works.

Apex Anesthesia Review is an online SRNA review course that provides students with a comprehensive review including multiple tutorials and question banks on topics tested on NBCRNA board exam. The topics are divided into 9 units along with review exams and national certification practice exams. Student subscriptions allow unlimited access to all these courses from your computers and tablets. Smartphones may also be used to access review exams and full length practice board exams. Student course progress is tracked and communicated between all compatible platform allowing easy transition from computer to ipad. The courses are created with in-depth details of the anesthesia topics and are supported by necessary diagrams and illustrations. Questions have been formatted similar to the NBCRNA boards such as multiple selection, drag and drop, illustration questions, and calculations. Apex courses are stored in the cloud and are updated without the need for students to get software update.

Pricing is based on a subscription model and a group rates are available for groups larger than 10. Students are also able to contact the CRNAs who created this program for personalized help if needed. According to the developers, they currently have a 100% pass rate. However, if a student fails, they provide help to create a customized plan and also provide a full refund if the student can't pass the boards after 3 attempts.
Browsing through Apex website, there were some things that I think SRNAs will definitely benefit from and some I had to think over a bit. Initially,from a student's perspective, I was worried about it not being available offline. However, I ended up favoring this change once I compared it with downloadable review programs. It allows students to access courses from almost anywhere and on any device since there is no program to download. All you do is login and pick up where you left off. Another tool that I really like is the "index" section which provides a straight forward, to the point list of very specific topics that are easily accessible with just a click.

Overall, Apex anesthesia seems to be a well organized and to-the-point review course website for SRNAs (and CRNAs in the near future). Hopefully my  brief introduction to the website provides all anesthesia folks with enough information to see if Apex anesthesia is the way for you to study for your boards and earn those four letters behind your name...C.R.N.A.

Feel free to help out fellow SRNAs by commenting below if you would like to share your personal experience with the Apex course. Also, you can contact this developers at this link if you have any more specific questions. http://www.apexanesthesia.com/contact_apex/

If this has been helpful, please be sure to "Like" us on Facebook! 

Thanks again for reading!

Part 1: Trauma Case Management

Hi all,
Hopefully everyone is having a great start to 2015. It has been a long time since I have had the opportunity to blog. A lot of good and bad has happened in my personal and professional life over these 4 months. I have finally learned how to utilize all the good from these experiences and make myself better for the future.
I still enjoy working independently and would never settle for anything less professionally. However, there have been some situations that made me realize that there are times when you just need an extra pair of hands and a fresh, fully-caffeinated brain.
This is especially true when you get a middle of the night call for a bad trauma case that is too unstable to be transported to a larger facility. That is when your mind needs to be fresh and running full force. I got caught off guard in similar scenario recently that really tested my knowledge of managing these complex cases. Even though, the trauma committee seemed impressed on the whole OR team's performance, there are always things that can be learned from such cases. So, I wanted to talk about what we need to consider dealing with these cases.

Preoperative
When the patient comes from emergency room in an unstable condition, it is sometimes difficult to assimilate all the information that is being reported off to you (if you get a report at all). There are some key details that should never be overlooked and are definitely important to know in order to manage a trauma.

• How much fluid has the patient received?- This can get out of hand very quickly in even well managed trauma cases. The transition from administering crystalloids to blood can easily get delayed further compromising patient outcome. A poorly resuscitated patient will also be poorly responsive to vasopressors. If blood transfusions have been started it is important to note if they were type and cross matched to avoid compatibility related reaction.
• Does the patient have adequate venous access? A trauma patient going to the OR should have at least 2 IV lines (if not a central line) regardless of how severe the trauma is. Things can change quickly so preparation is key.
• Is there an arterial line? This is especially helpful if the patient is expected to have massive transfusions. ABGs and continuous hemodynamic monitoring will be needed.
• What were the recent lab values? Electrolytes and blood count should be evaluated. 
• Radiology reports: Cervical spine stability must be maintained with a  C collar especially if radiology reports were not cleared. Placement of ETT should also be confirmed.
• Degree of trauma: Talk to the surgical team to get their view on how severe the trauma is. It might seem common sense but sometimes even the most important information tends to get lost in translation.

Preoperative Setup

• Hotline with blood tubing, arterial line setup, vasopressors such as phenylepherine drip, ephedrine and vasopressin (1u/ml), level 1 rapid infusor, bair hugger, central line kit with CVP monitoring set up.

Intraoperative
It can be a daunting task to prioritize things for a trauma case. Everything seems important and it may be difficult to organize appropriately in such a high stress time. Fluid and blood administration takes high priority for me (generally, depends on the case). If the patient is very unstable it may not be appropriate to hold off on making incision. However, if the patient is hemodynamically stable it may be wise to get properly set up with vasopressor drips, bair hugger, arterial line etc. Patient may lose significant amount of blood on incision depending on the degree of trauma. Resuscitation may be difficult especially if the patient is already fluid depleted.
Another important factor to consider is temperature. Hypothermia can severely increase trauma related mortality and is unfortunately, ends up being last thing on the to-do list. Use of hotline, air humidivent, and bair hugger should all be incorporated soon after patient arrive to the OR.
Massive transfusion is bound to cause severe electrolyte imbalances that could lead to possibly fatal outcomes such as arrhythmias, and vasodilation. Therefore, correcting abnormal laboratory values such as potassium, calcium, magnesium, and arterial blood gases should not be delayed. Hyperkalemia is often noted with massive transfusion so EKG changes should be noted carefully.


I have been researching this topic to ensure that I don't miss anything but even remembering all the details and writing it for the blog is a long tiring process. So, I will continue on this topic in Part 2 to follow.

An Insight into CRNA Career

Hi everyone,

It’s been a while since I blogged but it has been even longer since graduation. Today it’s a year mark since graduation and it has been a great one. There have been so many things I learned and improved. I agree completely with what my preceptors told me during clinicals that “real learning begins when you are on your own”. That leads me to the topic for today, independence in the profession of Nurse Anesthesia.

If you are just considering applying for CRNA School, you might think topic about jobs is a little too far for your interest. However, I think the biggest shock for me not knowing much about the profession was realizing that there is such a vast range of independence allowed in this profession based on where you work. I am not talking about doing certain types of cases but the scope of practice you will be “allowed” as a Nurse Anesthetist. It may be a little difficult to grasp since as RNs we are all expected to be efficient in everything (and often more) than our defined scope of practice. The scope of practice for Nurse Anesthetists has unfortunately been distorted by American Society of Anesthesiologists (ASA).  So for us this means that even though skills such as placing central lines, administering neuraxial anesthesia or regional analgesia are under our scope of practice, we have to sort through multiples jobs to find a place that “allows” us practice with such independence. I have realized that the real depressing issue is that we have allowed that to happen.

I consider myself lucky to have attended a school that had clinical sites all over the nation. This allowed me to experience vast array of settings that CRNAs practice in today. These included completely supervised CRNAs practices, MDA/CRNA groups without supervision and CRNA only practices. I get goose bumps thinking about places like a clinical site that I attended where CRNAs are highly supervised by MDAs and often treated as second class to anesthesiologists. That is mostly not the norm and I have seen practices where the relationship is harmonious. My goal with this is to have you consider that if you are looking forward to a completely independent unsupervised CRNA career, you might have to sacrifice a few “must haves” on your list until we have a stronger professional organization that restricts these limitations. These may include you having to move into a rural area, work in setting where you have to take significant call days, and possibly lesser pay. So, before you make that decision of attending a school, be sure you know what clinical experience they offer. In addition, have a clear insight of the things that are important to you in your CRNA career. I HIGHLY recommend focusing your clinical time to prepare yourselves for an independent practice. It might even be worthwhile to make those tough sacrifices to better yourself as an independent practitioner during the early years of your career.  Before I get off the soap box, I do want to mention that I work in a rural area in a CRNA/MDA model with 100% independence and practice every skill I learned during school and I wouldn’t give up this freedom for anything.

When Endoscopy Cases aren’t Quick

It has been three months since I started working as a CRNA and “I m loving it!” However, good days, bad days, so-so days are there just like any other profession. Being able to practice independently has allowed me to finally use the drugs how I learned they were meant to be used. Going out of the box is a little unnerving even though I have been practicing in my scope of practice and using well researched techniques. General anesthesia is a little more forgiving in my attempts to ensure best use of anesthetic agents and adjunct pharmacology. On the other hand, Monitored-Anesthesia Care (MAC) doesn’t allow that luxury. I remember as a student I used to be think, pushing propofol for a five minute case is not bad at all.  That all changed during clinicals when I realized that my five minutes are not five minutes for the surgeons and their understanding of MAC is simply that it is a general anesthesia without the “tube”. So, now that I am in a place where endoscopy cases can last anywhere from 30 minutes to hour and a half long, I have been challenged more than once intraoperatively. Whenever a MAC anesthetic is used, it is important to acknowledge the fine line that exists between maintaining an unassisted airway and adequate sedation. So no surprise that for the first day I was re-introduced to endoscopy, either my patients were too awake and fighting or too sedated and apneic. And starting off with an embarrassing case where the patient gags, coughs, desaturate doesn’t help your reputation as the new guy. Luckily for me, I am at a place where anesthesia providers (I will leave it at that) are known to use physical restraints to hold patients during endoscopy cases. 

After trying out a few things, here are a few tips to bring back smooth, calm endoscopy day. (Like we all know every patient is different and there are thousands of ways to"skin a cat".)

       1)     To numb them or not? Entry of EGD scope can sometimes be traumatic and lead to the patient gagging and coughing. So I was always curious to see if numbing their oropharynx with hurricane sprays or lidocaine mists would make it less stimulating. I started off with using a 2% lidocaine gel in the back of their throat and asking them to gargle. That was too much or too thick to gargle so I soon converted to using a mist of 4% lido from the LTA kits. Now I haven’t personally tasted it but noticing patients’ facial expressions, I could tell that both tasted NASTY! And that taste would last a while making them cough as I rolled them to endoscopy suites. A bit counterproductive. Another issue with numbing was its timing. It was easy to administer it either too early or too late. Surgeon didn’t come in the room right away and it was gone! Using it also caused the patient to salivate more thus increasing their risk of aspiration. Now I don’t use numbing agents at all and just request the surgeons to go slow with the initial entry while I give the patient a jaw thrust. So far I have had positive outcomes with this technique.

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          2) How to induce. Being a new grad, it is easy to let yourself think that you are taking too long when the surgeon is waiting for you holding the scope. Truth it, it doesn’t matter. If I need time to do a safe anesthetic then I am taking that time. It is critical to take this time especially in endoscopy cases because a little too much and they go apneic and start desatting as the scope goes in. Slow induction is the key. I would give them just enough initially, for example, 50mg of propofol for a young healthy male, then continue in small squirts. Goal is to keep the patient anesthetized enough to tolerate the scope without going apneic.

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          3)Ketamine is awesome but…. I started using Ketamine for endoscopy solely because it does not depress respirations. However, one of its side effects includes excessive salvation. I thought using a small dose will limit its side effects but that is not true. I had a lot of patients laryngospasm on me as the saliva would collect in their oropharynx. Using 0.2 mg robinul about 3 minutes before the procedure starts greatly decreased this side effect resulting in a smoother anesthetic.

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           4)What I use now. In preop, I administer 1-2mg of Versed and 0.2 mg of Robinul if I am using ketamine or patient has a lot of secretions. Once in the room, I connect the monitors to get a baseline set of vitals and immediately give 25 mg of Ketamine. I follow it with propofol 200mg + 25mg of Ketamine at a slow rate. If it is a colonoscopy, I will also give 25-50mcg of fentanyl as insufflation generally causes pain and causes you to use more propofol. I will push a very small amount of propofol every other or third heartbeat (which I can hear from my monitor) for the remaining case. So far that has been working great for me. Let me know what works for you.

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Being a CRNA

Hi everyone,

Believe it or not a month has gone by since I started my new job as a CRNA. And it has been amazing! It's just a different feeling knowing you are on your own and have the independence of making your own anesthetic plans. I am at a place where both MDAs and CRNAs work independently. So I fly solo but have someone available to bounce ideas off of if needed. It's a small place but I have been doing all kinds of cases on pediatric, obstetric, and general population. I have also been doing regional anesthesia such as inter scalene and femoral nerve blocks using ultrasound. It's been great learning all the new stuff that I read and can apply to better my anesthetic plan without any interference. In addition to that I love my schedule! My usual work week is three days and a night on-call with post call day off.

I know it's been a while since I got to write for you guys but that will be changing shortly as I will have more time. New thing to look forward is a review book for boards so be sure to like, subscribe and comment.

Thanks for reading! 

Which Program to Choose? (Part 1)

Hello everyone,

Selecting a CRNA program to attend should be a process and not a one day decision. That is the key to remember in picking a program. If you are planning to attend a CRNA school, there are a number of things to keep in mind to ensure you get what you wanted from it. And for that, you must know what you aim to achieve. These are some of the topics to research before settling for a program.
 
1) "I want it easy"
During my schooling, everyday I thought my program was too tough! So I always questioned myself if attending an "easier" school would have been better. One would like to think yes, but would that help ensure a long, safe, CRNA career? Truth is, most likely not! First of all, I highly doubt there really is a CRNA school too easy! Some school may be more laid back about the rules, exams and teaching methods but overall you need to learn the same things in order to practice successfully. So, I say learn, research and understand that if its real tough to get through its most likely to make you good at what you be doing. Also if you are looking for an easy way out, this isn't for you. No pain no gain!

2) "Do I want to travel?"
This is something I would confess to as the primary reason for why I chose the school I went to. It was 20 minutes from home and so I be closer to family and friends etc. Didn't looked beyond that. Again research the school well! Make an appointment with the program director to see if it meets you need. You may think it is close to you but that might be just the didactic portion. Like my program, clinical rotations are all over the nation (which I knew BTW). That might not work for everyone. This might also be a problem when it comes to cost and safety. Do you really know where you be going before hand? Can you request site rotations? Do they pay for your housing and transport? and what kind of experience you be getting at those specific sites? MD directed or independent CRNA practices? Rural areas? These are all good questions to know. Regardless of where you plan to go, I highly suggest you go up there and assess the situation.

3) "How much money I be spending?"
Of course, nothing is done until you ask how much it costs. This a major determining factor for a lot of students decision. Private universities will cost a whole lot more than state. This might be a problem for students with families or someone who would rather not have 100,000 dollar loan. Again, ask your school if they for sure send to out of state clinical sites and if travel and housing is paid for by school. If they school is paying for your housing, is it in a safe area, in the hospital (I have seen call rooms being student housing)  

 (will be continued...Got to study for Boards :) )

Senoritis!

I cannot believe I am saying this already but I have 27 more shifts to go within the next 2 months and I will be officially done with CRNA school! Knowing this fact, I have a severe case of Senoritis. Switching between nights and days is a little tough and my cardiac experience at this last site hasn't been too kind. Now the stress is towards finishing the last bit of careplans left to do and to study, study and study!!
Prodigy and Valley are in the study plan but haven't been too consistent with it because of long shifts and alternating day and night shifts and of course, "senoritis". The nice thing, however is that time is moving closer to my graduation every minute and I cannot wait!!
Time is ticking :)

LMA Placement

I have heard that people have a love and hate relationship with laryngeal mask airways (LMA). Lately, I have been using a lot of LMAs and the more I use them, more I like them. There are a few tricks to remember while placing one to avoid causing trauma even though micro trauma is frequent. There a variety of LMAs that I have seen at the sites I have been. LMA Supreme is my favorite (2nd picture) and has been the easiest to insert for me. However, a problem that can occur with any one of these is catching of the tongue in the opening of LMA as you are inserting it. Some patient's have large oral opening that make it easier to insert but for smaller oral opening it is important to make sure you protect the tongue.

Insertion:

One technique to help with this is to use a 4x4 gauze and hold tongue upward out of the mouth and slide the LMA over it. It can be helpful but hasn't always worked for me. Another technique I have used lately is to go in slightly sideways while inserting. I have found this technique to work better if I use the LMA exactly like its packed, without deflating the cuff. Once you get past the tongue enough, turn it straight again and your patient was saved from getting a frenulectomy.

Cuff air:
This is another thing to experiment with while inserting LMAs. I always go back and forth between deflating the cuff completely or adding in more air before insertion. The problem I have with deflating cuff completely is that its tip will almost always tend to bend on its itself and be a reason for some major struggle. So, based on my experience with them, a little bit of air always makes it easier. Now I just inflate it enough where there are no wrinkles or dips in the cuff and its worked quite well.

Anesthesia depth:
This is what makes us different from any random person trying to shove a mask down people's mouth. Figuring out how deep you need to have the patient prior to inserting the LMA may need a lot of practice especially if you like your patient to start breathing spontaneously immediately after insertion. Well, I have noticed that there is a very fine line between you having the patient too deep that they won't breath or them biting your finger when you are trying to make sure LMA's tip doesn't bend or worse...bronchospasm. Style points for putting the LMA in without patient coughing or gagging and then them breathing. However, I think its safer to give enough to have them go apneic and support their breathing until necessary either manually or with PS <20 on the vent. So, do give them the needed propofol dose! Use of opioids can also ease insertion but their administration should be very well timed. This is especially true if you are using fentanyl. There have been times when I am just a little bit delayed in pushing that fentanyl and then had to deal with them being way too comfortable to breath. Give fentanyl first thing as the patient enters the room. Sometimes, if a young, healthy person, I will even give it with the versed in preop and then bring to the OR.

Extubation:
This is one step of using LMA that I haven't seen many variations of. Almost all of the CRNAs or MDAs I worked with remove this without deflating the cuff. This prevents secretions from falling off the cuff and possibly be a reason for laryngospasm or bronchospasm.

Thats been my experience so far with LMAs. Very nice tool to use but if ever question using it in a patient that might possibly be more at risk than benefit from LMA...just intubate!! Better be safe than sorry. Hope you all liked this post. Let me know your experiences or suggestions.


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