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?

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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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 :)

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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Ready for it to be over!

Did you know Reglan if pushed too fast, causes delirium? I didn't till last week. Simple things that I did without thinking much as a nurse are all making sense. Why certain medications give the effects and side effects that they do, makes them a whole lot interesting! For me second quarter has been fun but I can't deny it being more exhausting than first. So, I am definitely looking forward for it to be over in 2 weeks!

Tomorrow I go for my airway practical! Seems harmless but honestly, its pretty scary when your instructor is watching everything you do, looking for things to ding you on AND adding multiple twisted questions to throw you off. Setting up the cart with all the necessary tools in 2-3 minutes, adequately breathing patient throughout, problem solving and intubate without dripping sweat on the fake patients...don't know if I am ready. I do think I have done my part of practicing in lab consistently so lets see what happens. I will keep you guys updated.

Be sure to share your experiences and thoughts!