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.

CRNA School...are you Ready to Apply?

You now feel ready to take that big step towards progressing your nursing career. You have always wanted to be a CRNA or have recently started researching this field. What do you need to know in order to figure out if it is the optimum time for you to apply? Here are some things you must address before applying.

1) Are you really ready? Nurse anesthesia program is a highly demanding program that requires total commitment and dedication. And this process begins way before the school actually starts. It begins when you decide to apply. Everyone else applying along with you is your competition. If you GPA is not where you feel comfortable applying, don't apply. Work to be at your best academic and professional standing before applying. Not only that, even before making that decision to start applying for school, thoroughly assess your readiness to be able to make all the necessary sacrifices. Are you willing to move for school? Are you financially ready? Have you researched enough to determine that it is for you? Are you willing to quit work for school if needed? Do you have the requirements (GRE, CCRN etc) met? All these questions should be thought out prior to you submitting that application.

2) Is your family ready? If you go in single like I did, you may think I can skip this step. However, I would suggest you still give it a thought. You friends, parents, siblings or whoever is important to you may not understand the significant change they are going to see when you are actually in the program. It is important to discuss the changes they can expect to see in you during school. Less time at home with the family, eating out, no vacation time, emotional turmoils, traveling for clinical rotations, along with many others are common issues observed in Student Nurse Anesthetists. Your family or significant other has to be on the same page as you before you apply because even if you may not agree, your family will be sacrificing a whole lot more than you to get you through a CRNA school. Do they know you won't be able to work? Are they going to survive without your income? Can they tolerate time away from you if needed? Are they willing to move with you if needed? These are all important discussions to have before you decide its time.

3) Is this profession really for you? Great pay and "chill" job is what I kept hearing about this profession before I applied. As I got to know more about it, like every other profession this isn't for everyone. You are doing yourself and your future patients a disservice if you are doing it just for money. It is a very stressful and at times, unpredictable profession. This may not be for you, if you are the one who likes to talk to your patient and enjoy following up with patient progress throughout their hospitalization.CRNA profession has an ever going battle for their role in the anesthesia world against anesthesia assistants and anesthesiologist. This can limit the availability of job that you envisioned when you decided to be a CRNA. Like me, you may have to move to a rural area in order to find your dream job. So, you may have to continue sacrificing longer than just the duration of the your schooling. Be sure you find a CRNA (specifically a CRNA) to shadow to get an idea of how their day goes. This can give you some idea on what to expect.


Look forward for additional CRNA school related considerations. Hope this was helpful. Be sure to Like, Subscribe and Follow.

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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It is Official!

Hi all,

It is official! I am done with school and done with boards. Officially a CRNA! This was some tough journey and I am so glad it is over. My board preparation was not as efficient as I would have hoped because of some family troubles but it paid off. I had attended Valley Anesthesia review course and had invested in Prodigy program as well. I was asked to take the boards as soon as possible by my future employer so the time I had was limited. I wasn't able to stick to Prodigy's study guides and basically used it to practice "drag and drop", multiple options and "hot spot" questions. My main review source was Valley Anesthesia material. I reviewed the "sweat" book and memory master once each. I didn't feel too good about the exam however, most of the 100 questions I was tested on were from familiar topics. I strongly suggest reviewing Valley anesthesia material multiple times especially memory master.Hope this helps. I will be continuing this blog and be working on writing review questions and material. Thank you all for being with me! :)

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 :)

Valley Anesthesia Review

What a busy weekend!! Just came back from attending Valley anesthesia and my mind is full of information. Three days to learn important anesthesia topics was a tough job. However, I was highly impressed with how the information was presented. Sometimes it felt like topics were discussed really quick and it was too much to handle. It was nice that they allowed us to voice record so I can re-listen it. I am kind of disappointed that my weekend sleep-in time was lost but I would be really glad if this helps be do good on the SEE and the boards. It was a little expensive I thought (at $750 + Hotel + Flight cost) but if it works, its better than paying for boards twice. When you sign up for the review course, they send a review book (sweat book) for you to study through prior to coming to the actual course. I be honest that I didn't even get a chance to open it before the actual course review. I highly suggest you try to do that! It was nice seeing all of my SRNA friends after a while and the new ones I met. So, good luck to everyone on the exams and let me know how you feel this review helped.

Boards and Job Search?

Quarter 3 has come to an end and as only two more remain, thoughts about being ready for SEE and boards are making me a little nervous. Reviews using Prodigy anesthesia have made me realize how much I have forgotten from the didactic portion of my school (almost all of it!). Slow and steady study review has begun. Homework is also more focused towards studying for boards which is a big relief! Careplans are still on the to-do list (basically since the first quarter). It looks like all this is going to end like it started...stressful! I am ready for it to be over though. I realized how close I am to finishing when I heard my classmates talking about job hunting. My thoughts about job hunting are scattered all over the place.I am not sure where I want to work, what I need to look for in a place I want to work and everything else that matters. To feel like I did something about it, I updated my CV today to be ready for the time I be needing a job. Then I think am I doing this too early? I haven't even thought about the SEE or more importantly the boards. Would I be able to pass them, would I make it through the last two quarters? I guess we will see. 

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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US- Guided Femoral Nerve Block

Hi everyone,

Hope everyone is having great holidays!! It's been busy at the new site I have been for the past month. Even though I only do about 4 cases a day unlike 7-8 at the last site, there is still a lot of running around. In all this busy work, I have had some great opportunities to learn how to place femoral nerve blocks using ultrasound (US). Still no where near being an expert at using the US, I have learned to get through it using a few resources like NYSORA website and RKU compact app. The site I am uses a lot of these continuous fem blocks (in conjuction with spinals and TIVA) for post op knee surgeries. So I decided to write a little bit about how I have been taught to place one. I also attached a video for the visual. 

Preoperative :

1) Ensure correct patient and the location of surgery. Check for allergies

2) Check consent. Only absolute contraindication for regional block is patient refusal

3) Equipment: Continuous FNB Tray (2-4mm stimulating needle), dermabond if available, EKG pad for nerve stimulator, sterile gloves. Medications to include Versed and Fentanyl, monitors ( spo2), Ropivacaine 0.5% = 30ml (or similar alternative), another RN or CRNA for assistance. Emergency equipment

4) Inform patient about the procedure. 

Procedure: 

5) Connect monitors, give versed and fentanyl as appropriate. Expose groin/ inguinal area on correct side

6) Don sterile gloves after opening Kit.

7) Prep site with chloroprep as place drape. Prepare local 1% Lidocaine and open femoral Catheter and place it on the sterile portion of drape for easy access.

8) Drop end of the extension cord for assistant to connect and flush stimulating needle with local anesthetic. Do the same to connect nerve stimulator at turn on at 2mA

9) Set up US probe by adding lubricant in the sterile sleeve provided and covering the unsterile probe with sterile sleeve with the help of assisting RN.

10) Place remaining sterile lube at site and orient self to US. Make sure the probe side on your end and on the US screen are matching to avoid confusion.
11) Identify anatomy in the inguinal region. Vein, artery, nerve (medial to lateral). Vein is more compressible when pressure is applied with the probe. Also, identify the two fascias, fascia lata and fascia iliaca that present as white lines under US. Two distinctive "pops" must be observed as these fascias are penetrated.
12) Once structures have been identified, nerve stimulating needle is inserted at 2 mA and patellar "snap" is identified. The bevel of the needle should be facing towards the patients head to ease guiding the catheter. A medial sartorius twitch may by corrected by repositioning the stimulating needle more lateral. Negative aspiration for blood is confirmed as needle is moved. Patellar "snap" should be present up to 0.5 mA of voltage. If still present under 0.2 mA then the needle should be withdrawn slightly as it may be too close to the nerve bundle.

13) When patellar "snap" has been identified and a good view of the needle is seen on the US, 5 cc increments of local anesthetic are injected with periodic checks for negative aspiration.
14) Correct placement of local anesthetic can also be confirmed with the US. Once injected, the needle should be held stable and injecting catheter should be disconnected so that the catheter can be threaded.
15) Correct marking for the catheter may vary but is generally placed at the 15 mark. The catheter cap is applied and it can then be secured with a tegaderm dressing.

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New Challenges at Home

Hello all,
Its been nice moving back home for clinicals this quarter. No more paying rent while I have a house, no more daily fast food stops, no more worries for at least 3 more months...one would think. Even though all thats been great, moving to a new clinical site does bring a lot of worries and challenges. New people, new place, new ways of doing anesthesia. So, I am not surprised that I had a stumbling first week. The last site I was at, I didn't get a chance to extubate my patients in the room, which is like saying I only did 50% of anesthesia. Coming to a site that does extubation in the room has been some task. Lowering the anesthesia by approximating when the surgery is going to end to allow patient to wake up with the last suture in is one heck of a challenge. On top of that, new charting, preop and post op routines and CRNA preferences have been hard to remember. While I was hardly ever tested at my previous site, my first week here consisted of multiple questions on medication dosages, regional anatomy and EKGs...some of which I didn't have a clue about. And therefore, here I sit on my chair at home, doing my homework early so I can brush up on these topics for Monday. Hopefully it will be helpful for later. Well...time to get back at it! Be back soon...hopefully

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End of Clinical Quarter II

Hi there dear readers,
I am happy to say that another break is here as I have finished my second clinical quarter. Now another place to move to for my next rotation. That brings in new fears, new challenges, new people...new everything. I really don't enjoy having to start everything all over again but am a little excited too. Even though, I am nervous, I do feel really lucky to have had my first experience at a wonderful site with a huge number of cases. Hopefully this continues and I can get really comfortable (especially with peds) before I graduate. Before that...a week and a half to enjoy at home after a long drive back.

Succeeding CRNA Interview!

Its that time huh?
You have a CRNA interview but are not sure on how you should proceed?
Even though I have discussed in my previous post what one might expect in an interview, it is hard to really pinpoint on what one might be asked exactly. So, I decided to write a post giving you some tips to consider on what YOU can do during your first (hopefully only) interview at a CRNA school to leave a good impression!

1) Dress code
NO Hawaiian shirts! As clear as it seems, its not. You be surprised what our minds can force us into doing on such big days! This is from personal experience. Don't be the one going in for the interview and being the only one without a suit. Even though, a nice shirt and tie for guys might suffice, I highly suggest buying or renting a nice, professional suit for this. And Yes...even if it is hot outside! Ladies, it is very important to limit exposure. Again, as simple as it sounds, it still happens! CRNA school applicants have a higher set of standards to meet professionally as they are already professionals as nurses and this apply right from the get go.

2) Be Humble
Had 10 years of ICU experience, 5 of ER, 5 of cath lab? Share it in your resume and I can guarantee you they have read it. So, don't flaunt it. You never know it can play for you in the right amount or against you if you promote it too much. When I walked into my first class, I was told by my instructors "leave your nursing background out the door". If you were good at certain things and knew them inside out, it may be of value but keep it with you until you need it.

3) Know your Experience
This is an add on to the one above. I did say that you will have to change your mindset from being a nurse eventually, but you better know your experience. By that I mean, if you write in your application that you are a neuro nurse, you are putting yourself out there to be tested on anything neuro...yes...anything! 
I do want to make it clear that there will be a lot that you don't know, just be honest and don't make up stuff.

4) Dealing with bad GPA
So you applied disregarding your bad GPA to see what happens and to your surprise you got an interview call (like me). What do you do? Well, the truth is that they saw something in your resume that intrigued them enough to call you. So, DON'T take it lightly! Make your bad look good.
Here's an example
My GPA was a quite low in nursing school, like Bs and Cs (I know...I was shocked too!). That was recovered a to about 3.4 after I got a 4.0 in the BSN (yes...anyone can do that with a BSN!). Even without them mentioning it, I told them that my GPA was low initially but I have worked really hard to improve it so I could make myself eligible for CRNA school. Mention any other extra things like volunteering you did, awards, that your worked two jobs and still got grades etc. Don't beg or stay focused on it, but do give them your perspective.

5) Things to take with you
Most importantly, confidence (just enough...don't overdo!), enthusiasm, smile, along with a pen and notepad. All of them are important but taking a notepad and a good working pen is a must! It shows that you are prepared.
To leave an even better impression, use your notepad and have your questions written out before you go. Again, shows that you are prepared.
And if your questions were answered, look at your notepad at the end of the interview and mention that you had some questions but that they were addressed already.

6) A Good Lasting Impression
At the end of the interview, have the same confidence, energy and smile. Don't look disheartened if you didn't get a question correct. Instead, ask them if they decide not to select your as a candidate for the upcoming class, what can you do to improve yourself? This shows that you are not ready to give up!

A little personal side note: These are the things I made sure I did before my interview and was lucky enough to hear "See you next year" with a pat on my back from a member of the panel as I stood there in the cafeteria line. Its was a wonderful feeling and a sense of relief. Probably doesn't happen often but regardless, your goal is to work hard and not worry about what happens after...because your hard work will pay off!

Hope this helps!
Let me know how it goes.
Good Luck!

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Anesthesia related topics: Soon to come!

Here's a Reason

For all those who are dealing with exhaustion, sleeplessness, low on motivation or even sick like I am. So, if you are wondering if you should do it or not? Or if you should keep doing it or give it. Here's a reason to keep doing what you are doing and NOT quit! Look in the right section. 

Certification Review Course

Hi guys,

Just wanted to mention a very popular name in SRNAs, "Prodigy Anesthesia". He's a CRNA who provides review courses for SRNAs and helps them organize a plan for certification exam. I am posting a video and a website link with some info.

Here's a link to there free article archives

http://www.prodigyanesthesia.com/archives.htm

I am also posting this video that shows a demo on how this program works. In addition, there is also a free itunes application called "Paces mini" available. 

56 Days!

56 days to go to rotations!! So this quarter is fluffed up with stuff I honestly don't care about this time but its been going good so far. First exam tomorrow, so really hoping to get a good start. This weekend my class attended the AZANA seminars which was long but interesting. It sort of was a review of what I have learned so far in school. Along with that, I got a chance to hear my seniors present and give tips on different rotation sites. The one thing I my having to put off is reviewing stuff for the upcoming SEE aka self evaluation exam. Another issue thats been worrying me is getting a place to live at my rotation site. Its so hard to pick a place to live at a site where I have never been. Then again, I guess I should make sure I pass this quarter before worrying about rotations. We ll see.

Back to studying! Talk to you soon!

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The Ultimate Guide to CRNA Career

Hi all,
So, I am at the verge of finishing my 3rd quarter and am getting a tinge of excitement and nervousness brewing in me for rotations already. Actually I can't wait to really see all of my learned knowledge being applied!
Anyways, a month or so ago, I was interviewed by a now a fellow SRNA Andria about things to know about getting in to CRNA program. I was asked stuff like how was the interview like, how much experience I had before, what hardships to get it etc. Well, she has organized all that and a lot more from other resources for anyone who is interested in knowing more about the awesome CRNA profession. Here' the link to all that you need to know about getting into and surviving CRNA school. Hope it helps :)

Click here for: The Ultimate Guide To A CRNA Career