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?

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/

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Thanks again for reading!

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.