Independent CRNA Practice vs. Team Care Model Vs. Anesthesia Supervision

Your graduation is coming up in a few months and you are looking for your first job. A lot of questions are popping in your mind mainly to do with salary, schedule and location of your new job. All seems to be in place yet there is something you didn't think would be as important in making you happy in your new career. Working supervised or as an independent CRNA.

Now I am not here to put down one anesthesia work model for another so lets put egos aside and really think through this. People have different priorities be it family, money, social life or schedule. However, if we were to think of our profession alone, how should new graduates read that fine print in that job offer that is offering ridiculous amount of money but something just isn't right.

Working in a supervised CRNA practice can mean a lot of things. It can start anywhere from "we have anesthesiologist here as a consult or emergency supervision purposes" or "No, you as CRNAs are not allowed to push your own induction drugs". Motive behind why certain places enforce supervision to a certain degree are usually to do with how CRNAs are presented to the hospital board members by the leading anesthesia group members. These kinds of jobs are more prevalent in bigger cities ruled by anesthesia groups. So, what should you look for before accepting a job?

Working under Anesthesiologist Supervision (and Team Care Model)

1. Experience matters. This is not only true working with an anesthesiologist but also a senior CRNA. There are so many different ways of doing anesthesia but in dire situations, it is always good to have someone with more experience than you. So, as a new graduate CRNA (or an anesthesiologist) Knowledge sharing is a plus and it can be a good thing to work with someone. However, there is a very fine line where this can halt learning and turn you into a charting monkey. You cannot learn by not doing. Practical experience can only be gained by actually performing. Looking at someone else doing a regional block or putting in a central line won't mean anything until you get hands-on experience with it. Here is what you should pay attention to. It is a positive sign if you hear that anesthesiologist and CRNAs work together without restrictions and practical, hands-on teaching is promoted for all anesthesia providers. And you might want to rethink about places where you as CRNA don't do push induction drugs, call anesthesiologist for extubation and you cannot do peripheral or neuraxial blocks.
2. 2) Interpersonal Relationship- I have been through rotation where CRNAs are looked as second class citizens and treated with disrespect and constant abuse. It is important to know your limitations but equally important to know your value. If you are being trained to perform as an independent provider then you should protect that right and not disrespect yourself by working in such place. Ask the CRNAs or RNs about how anesthesiologists and CRNAs get along. Do you get lunch breaks when you have floats and how are people relieved at the end of the day. This is especially important as some places CRNAs will be the last ones to leave at the end of their day. Extremely important! Also, clarify on the things that you are and aren't allowed to do before starting.

CRNA-Only Practice

1. Now unless you are the sole provider for a facility, the pluses and minuses mentioned above still apply. Some CRNA-only practices run really efficiently with a comfortable working environment. Yet you can experience mistreatment if your group is being run by a poor leader. So be cognicent of that.
2. Are you a leader: Now we all think making it thru a CRNA school is difficult and you have to be assertive in order to make it. However, when you are really on your own its a different game. You have to be a good leader who can organize a group of people to safely provide care to patients. Surgeons can be tough to deal with but at times you will have to stand your ground and not get run over. This is especially true if you are in a private practice where every case that you cancel makes you look bad. And to make matters even worse, you work for the surgeon's patient so they can be very pushy to make you do something you don't feel like is the right thing to do. There is a fine line between keeping good relationships between your team members and being a safe anesthesia provider.

These are a few of the many pros and cons to working in team care model and CRNA-only practice. It is up to you to decide what you are comfortable with. Your schooling was supposed to make you be comfortable enough to practice independently as you are not Anesthesia Assistants (Aas). So, don't underestimate your skill level and be brave and open to learn everyday to improve yourself. Your career's future depends on you! I highly suggest against working in places where you are not valued and limited from fully practicing your scope.

P.S. Sorry about the looong delay in posts. Personal life has been challenging over the past four months and I just started the doctorate program!! Most on that later.

Feel free to add on comments, suggestions, feelings. And please “Like” “Follow” and “Subscribe”.

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.

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!

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!

Be sure to "Like it"on facebook. 

Quarter 4

Hi all, its been a while since we have talked. I had one week off and it went by really fast. A trip to the Grand Canyon made it a great break! Its just wonderful. Then again, I have been so out of shape, I couldn't do much there and stayed there only for 4 hours. This quarter has started off a little chill compared to all others (especially 3rd) but may be crap hasn't hit the fan yet. We ll see. I have a couple of presentations coming up along with other things to pile on. Its also time to figure out living arrangements for clinicals and seems like its going to be a big change moving for rotations. But at the end, I am glad to have one more down.

3 Quarter DONE!

Three down one more to go before rotations start! Just came out of the testing center after Principle of Anesthesia Final exam and feel pretty decent about it. Pharm was close but got what I needed. The feeling of being done with 3 quarters still doesn't feel real. Especially when I STRONGLY felt that I was not going to make it through this one. On top of that, today had to be the day I over slept!! Slept at 1:30 a and didn't even hear the alarm at 4. So, couldn't review anything like I normally do. I will suggest for anyone who wants to do this...get used to sleep less. It will be greatly helpful for exams.  

So me passing this quarter. what does this mean for all my readers?! 

I continue this blog! :) 

And for that...I am soon to share something you all will like so keep posted. 

Daily life of SRNA

Hi all,
I have been asked by many prospective SRNA on how daily life schedule is as a SRNA. So, I decided to write a little run down of questions that everyone wonders about school. I have my parents and sisters helping me with homely stuff so, I have not much to worry about at home yet (until I head to clinicals).

1) What is your sleep schedule like?
I am one of those who loves to sleep. First two quarters I got up right away and was ready to go on with my day. However, this quarter is a different story. I am always trying to stretch it out. My weekdays have classes starting at 8 everyday and I live 20 minutes away. So, I get up between 5-6 am. And as far as going to sleep, I try to aim for midnight but that is hardly the case. For me it usually ends up being 4 hours of sleep, that is either 1-5 or 2-6. I usually catch up a bit on weekends by sleeping in a little but even weekends are short on time.

2) How many hours do you study a day?
Leaving the daily slacking, low motivation hours, and eating etc. It ends up being about 8-10 hours of study time for me besides class time. And of course, that varies a bit everyday when  I have longer class days or lab.

3) How do you try and stay focused?
I have my days where I really don't want to study but when I think of 10 people who came as far as interviewing and didn't get accepted, I feel lucky and buckle down! Still for me, internet is the biggest distraction. I have all the notes on my laptop so I will always start browsing while studying at times. To help me with this, I use this google chrome widget called strict pomodoro to set study timer. This thing really helped me by blocking me from going on things like facebook, yahoo, twitter etc.

4) How hard is it for families?
Like I mentioned previously, I get a lot of help from my family. I think it would be harder having kids and trying to do this, but then, I have like 10 classmates who do just fine with young kids. You just have to make them understand that you are doing this for them and time goes by real fast.

I hope this helps answer some question
To listen to more of my responses be sure to subscribe for my interview, Be sure to click >>
How To Be A Nurse Anesthetist

P.S: Be sure to "Like" and subscribe!