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! 

Precordial Stethoscope: Quick Thoughts

Anesthesia is an ever-changing field where new technology, practices and research helps us make our practice safer and more efficient. That always raises the questions of when it is time (if ever) to exchange techniques that were used in the early years of anesthesia with new ones. Precordial stethoscope has been a key tool for anesthesia providers that can be used for continuous intraoperative assessment helping diagnose number of possible pulmonary and cardiac complications. However, improvement of anesthesia technology has made me question if its really a necessary assessment tool nowadays. Use of ETCo2 monitor, pulse oximetry, esophageal stethoscope and ventilator alarms etc can help providers diagnose changes in patient status as well. So, is it worth incorporating precordial stethoscope? Following is a list of key points on how I feel we can use them to improve our practice along with some tips on its appropriate use.

Types of Cases: I can't deny that having an extra monitor as such can ever be bad for any type of case. However, certain cases or patient population definitely support its use more so than others. I have used precordial stethoscopes primarly during pediatric cases mainly for continuous pulmonary assessment. Pediatric patients are at increased risk of events such as laryngospasm especially during induction and emergence. There is also a higher chance of right main stem intubation commonly in cases such as intraoral cases where head is manipulated. Therefore, I place precordial stethoscope over the left chest wall and hear for absent breath sounds. Anesthesia providers can also benefit from a precordial in patients with reactive airway disease, smokers and other pulmonary conditions.

Surgical Positions: Some cases require patient or bed to positioned in a way that can limited to sometimes, no access to patient airway. This can result in transforming, generally easily manageable situations, into complicated emergent ones mainly due to the delay in diagnosing and treating the problem. Airway disconnect, inadvertent extubations, changes in heart tones can be easily assessed with the use of precordial stethoscopes especially in such positions. Beach chair position is a commonly used position for shoulder repairs , craniotomies etc that places patients at risk of complications such as venous embolism.

 Feel free to share your thoughts on it. Do providers you know still use it? If so, how often and during what types of cases?

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

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.

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.

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! :)

Graduation!

Hi all,

Its finally here! The long, exhausting journey through CRNA school is over...(well if you don't count the boards). I thank you all for following me through this process and I hope to continue updating you all on what I learn from whats to come. Hopefully, this has helped you. Thanks again! :)

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 :)

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. 

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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Spinal Anesthesia

Lately, I have forced myself to overcome my fear of leaving the somewhat comfortable zone of general anesthesia and head to other types of anesthesia such as neuraxial. I have had a chance to work in OB for a couple of days now and feel better about administering spinals and epidurals even with such limited experience.

Yesterday, I had a 15 and a half hour day in the OB department. Yes, it was really long! Part of it was sitting in the surgeon lounge waiting for the doctor to come or patient to be prepped, but still...it was too long! Regardless, I had plenty of opportunities to try out spinal anesthesia for C-section.

Here is a quick run-down on how I was taught and other necessary tidbits.

• A my clinical site, a tech preps your spinal site usually and sets up the tray for you. I managed to do a few myself. The first thing before doing anything is to make sure the patient is connected to the monitors. A baseline set is needed as you will have to keep a close eye on vitals immediately after injecting spinal anesthesia. Be sure to adequately preload the patient with fluids to prevent hypotension and nausea/vomiting related to that. 
• Basic things needed: Duramorph, Spinal Kit (we use Pencan 25g), sterile gloves. 
• The next step is to ensure proper positioning. Inform nurse that the patient needs to be in a "Mad cat" position and it helps demonstrating this to the patient. Ask the patient to drop shoulders forward and push lower back outwards. Another thing that I missed was ensure the patient was not leaning to a side. I was a working with an obese patient and it was hard to tell but I was aiming my spinal needle off centered because she was leaning slightly to one side. It was easy once my preceptor made me realize that.
• Before prep it is good to identify the landmark for L3-L4 interspace. For some reason if you did not get an opportunity to find the landmarks prior to them prepping the site. Use the drape to feel for iliac crest to keep everything sterile. It is also important to follow the spine with one's fingers to make sure it is not off midline as one would notice with scoliosis. 
• Be sure to collect everything before donning sterile glove. I used duramorph so, I had to open and place the unsterile syringe standing upwards on the table so I could draw up having my sterile gloves on without touching. 
• After getting everything ready, palpate for the insertion site again and mark with a little indentation using your thumb nail. 
• Open the glass vials in the spinal kit one at a time to keep things simple. 
• #1: Lidocaine 1 % for infiltration=  3ml
• Infiltrate the insertion site, create a skin wheal and injected at the site. Skin wheal helps identify the site you choose.
• # 2: Bupivacaine 0.75% = 1.6ml and inject 250mcg Duramorph (0.5ml for me). Be sure everything is meant for spinals and is preservative free!
• By the time your spinal meds are drawn up, local infiltration gets a chance to work
• Insert the introducer straight in. Deviate as necessary to avoid bone. 
• Insert the Pencan spinal needle. Feel for pop 1, keep going and then feel for pop # 2.
• After second pop, remove stylet and check for CSF.
• Connect the syringe with medicine and check for clear CSF and aspirate to check for swirl
• Then slowly but steadily inject the medication and pull all the needles out together!
• immediately rest the patient back.
• I have been told that 1.6 can work for everyone under 6 feet as you can make it go higher or lower based on patient's bed positioning.
• And assess level to be a T4.
• If it is too low, trend the patient for sometime and reassess. If patient starts having numbness or tingling to the fingers. Straighten the bed to avoid further increase in spinal. Vice versa.
• Let patient know that it IS OK to feel pressure and touch!
• But NOT OK for pain.

This is it for now...I will keep adding to this as I learn more. Please let me know your experiences and what else I should add.   Be sure to Comment, "Like" ,Subscribe and "Follow"  for more useful info! Thanks!

Month and a Half Later

I know its been forever since I have come by to update you guys. I have missed writing...besides doing other fun things but free time has been very hard to come by these days! 10-12 hours workdays 5 days a week followed by homework over the weekend...exhausting! On the other hand, with a few ups and downs, its going alright till now. I have done a lot more cases including a couple of days of OB where I got to put in a few spinals...kind of nervous doing that but they went fine. My preceptors have been great! I have had an opportunity to see many different techniques including total intravenous techniques where patient's wake up and get extubated in less than 2 minutes after surgery and ask how the surgery went. That was pretty cool to see! Homework is something that kills me! I hate writing care plans with info that means nothing more than written words because we never actually use the plans I write in real life. All that I had learned is slowly fading away and I am trying hard to keep up with reading so I don't lose every bit I learned just last year. Thats all I have for now. I will be back a lot sooner than last time. So, talk to you soon.

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