CRNA Satisfaction for Creative Adrenaline-Junkies?

davis213 · Oct 18, 2012

I am currently a critical care nurse working in a large Neuro/Trauma ICU. I'm a huge nerd that loves to know WHY about EVERYTHING, and loves to be involved in the decision-making about my patient. I'm a nurse through-and-through--I love educating the families and helping them to understand what is going on with their loved one and make sense of this hell that they are experiencing. But I'm also very controlling of my patient--my rooms must be setup in he same way each day so I can find my stuff in a crisis, and I like my patients clean and well-positioned in their beds. I'm very protective of my patient in that the procedures and orders carried out on him/her must be appropriate in type and in timing--if there is any question about it, it will be cancelled or rescheduled. So, I'm a bit bull-headed, too, with a low tolerance for bureaucracy--if I need something for my patient, no is not an answer I will accept. I'm starting to feel like I'm outgrowing the ICU--I'm losing some skills, desiring more knowledge and influence over plan of care and delivery of care for my patients, and reaching my limit for tolerating blame for scheduling or communications issues that are out of my control--so I'm looking into advancing my career. I am applying to CRNA school, but I have a few fears that my personality and desire for knowledge and control might not be a good fit.
I like the role of the CRNA in that you perform a lot of advanced procedures--intubations, line insertions, and blocks. You're in charge of the hemodynamic and pulmonary issues that arise, which can be a little touchy at times, requiring you to change your plans often and think head 20 steps in case the case goes from lap to open or the surgeon knicks an artery. You're involved in surgery--something that is often done to help improve the patient's quality of life rather than harm them (as I often feel like I am tending the vegetable garden in the ICU.) But I'm concerned that I'm going to miss out on the critical thinking about all of the medical issues that the patient is undergoing and how they all affect one another and the patient's quality of life and how to get them back to a good quality of life (and the creative ideas and solutions that go along with that)...but I sure won't miss the readmissions because they didn't listen to our advice. I fear that life in the OR might be more monotonous in an assembly-line kind of way, and I'm so much of an adrenaline-junkie that I fear I might eventually get bored. I'm concerned, too, that it will be a constant struggle of being belittled by the MDA, with their constant oversight and opinions about my practice (not to mention the fact that they're able to bill for 4 separate procedures at once since they're overseeing 4 separate CRNAs that are doing a majority of the work). I don't want to feel limited in my practice in not being allowed to do certain cases such as open hearts due to my lack of knowledge in comparison to an MDA.
So, my question for those practicing CRNAs out there is, do you identify with any of these concerns/fears? Do you miss the ICU for those reasons I'm afraid I might miss it? Would you do it all over again?

You are the best nurse I have seen

Be_Moore · Oct 19, 2012

Well, I'm an SRNA, not a CRNA, but since no one else has responded...

Anesthesia doesn't really seem like the adrenaline game, definitely much more of a thinking game. It's been described as 99%/1%. 99% routine and 1% sheer terror when something goes wrong. It's probably realistically more like 99.9% / 0.1%.

That being said, there are places you can up the ante, so to speak. Working a community hospital in the middle of nowhere where you are the only anesthesia provider in house (no MDA to belittle you, which to be fair, only happens in hospitals with poor cultures). There you could definitely be exposed to some serious business, getting the page in the middle of the night to help intubate the trauma in the ED and rush him to surgery to stabilize before they fly the patient out to a bigger hospital. Of course, you're also just as likely to get woken up to place an epidural in a pregnant lady or to not get paged at all.

Have you ever thought about Acute Care Nurse Practitioner with a focus on ICU? They place lines, intubate, all that nonsense, but still live in the ICU. They admit, round, transfer, discharge, etc. They are sort of like the PA's for Intensivists.

foraneman · Oct 20, 2012

Your CRNA practice can be as routine and mundane or as challenging and stimulating as you desire. Your choice of employment setting AND your personal initiative within that setting determine it. I have worked in a world renowned academic trauma specialty anesthesia department with arguably one of the most CRNA friendly and respecting collegiate Anesthesia Care Team practices possible, where the CRNA yielded great autonomy and decision making in every aspect of the anesthesia care of the most critically ill patient's imaginable. I have also worked in another well know academic department of anesthesia which had an oppressive Anesthesia Care Team practice where the anesthesiologist expected to be consulted before a CRNA administered pharmacology to lower a patient's blood pressure, or administered a unit of blood.

In the second setting, which came along after years of practice in the first followed by more years of independent practice as a sole provider, there were 40 Anesthesia Assistants and 5 CRNAs. The ACT was clearly designed to fulfill the required-by-law direct supervision of AAs by anesthesiologists. Whether I continued employment in the department was not a worry of mine. I could take it or leave it and I was not going to allow myself to be "belittled" or micro managed if they wanted me to stay, which they did. On my second day I was 'floating' with the AA who was assigned to post-ops and carried the code/trauma/intubation pager. So I got my tour of the large inner city Level 1 Trauma Center as we did post ops (where I found a patient who had two broken tibias with external fixation, no BM for 7 days and abdominal pain, with a bed pan lying on her lap in great expectation...first 'let me help you treat this pt correctly' moment, not 8 am yet). Before the day was half over, how my CRNA practice would be defined for the remainder of my next two years there was made clear, by me, with two more events.

The pager went off and we were called to the trauma OR for a patient coming from the ER as an emergency. I do not recall the mechanism of injury, only that it was either a chest or abdomen and the patient was clearly in hypovolemic shock. There was myself and two AAs in the room and the patient was intubated. While they were connecting the monitors and taking care of the usual transition to the OR/anesthesia machine stuff I took note of the need for better IV access the situation demanded and grabbed a Cordis Introducer, quickly prepped the groin knowing in minutes the drapes would prevent access to a large volume line site below the injury location, and inserted it into the femoral vein, tossed in a stitch, done in 2-3 min. I hear "What are you doing!!?" and look up to see sheer terror in the eyes of one of the AAs. "I put in a femoral Cordis." He desperately exclaims "We don't do that here!" "You don't use femoral Cordises here? Why not?", was my reply. "No, no. WE don't put them in! Only the attending can do that!" he gasped, looking around as if he feared that at any moment every anesthesiologist in the building would burst through the doors to drag us all out and arrest us. "Well THIS is gonna be interesting" I said to myself, my mask hiding the smile on my face. Attending comes in, drapes go up, myself and my AA tour guide go off to our nest assignment leaving the nerve wracked AA and attending with the case.

A few hours later we answer a page for a head injury pt in the neuro ICU who has extubated himself. Due to swelling he has limited jaw opening and neck extension and it is clear he is not going to make it sans endotracheal tube, so we will reintubate. Must call the attending first. "OK, you call the attending and I will get everything ready so that we can get on with it when she walks in", says I. She arrives, tosses me an understandable "who the hell are you" glance as she scours my badge with a scowl. Not much is said as it is made clear that I am welcome to hush up while she and the AA handle things. The AA attempts the intubation a number of times unsucessfully. The attending calls down to the OR for the fiberoptic scope. As we wait I introduce myself to the attending and ask he if she would like me to take a look while we wait. The patient is stable and being bagged. "Nope". Another minute or two go by. "One of us might as well look. Who knows? A different blade or perspective and this could be over...couldn't hurt", I offer in a friendly, light tone. "No. We will wait for the fiberoptic." comes the 'I do the thinking' toned response.

I roll my eyes and go sit in a chair in the corner of the room. "I may not stay until dinnertime" I point out to myself in inner dialogue. At the same time I am also in my "Well THIS is gonna be interesting" mode. Fiberoptic is brought up by an anesthesia tech. Wrong one, too short...not the tech, the fiberoptic. A Trauma surgery attending is now in the room and the anesthesia attending says to her let's prep for a trach. Now everyone is running about doing just that. "And THIS is exactly how and when bad shite is unnecessarily created" my inner alarm bell screams. So I get up and nonchalantly walk back to the head of the bed as gowns are hurriedly being put on and the betadine is hitting skin. "Seriously, let's have a second person take one more look before we cut this guys throat" I suggest, not with any suggestion of a mere friendly opinion. "No." comes the reply, without even a glance my way. Well, I think to myself, 'I didn't really care if I ever ate the cafeteria food here anyway', and I place my bare hand on the betadine prepped neck..a few gasps, and before the trauma surgeon can say a word I say to the attending "We cannot do a bedside trach on a patient who has only had the least experienced anesthesia person in the room attempt an intubation with the wrong laryngoscope blade. While they reprep let me look. If I cannot intubate this patient then I will immediately quit." Sounds bold, but the blade used was a MacIntosh, notoriously difficult for a limited jaw/neck mobility situation, and the patient simply was not one I would peg as a difficult intubation based on lots of experience intubation trauma patients....and at that point I had had it and really would have quit. "Fine, it's on you"..whatever that was supposed to mean, was the reply. Patient quickly intubated on first try, Miller blade.

Surgeon thanks the attending. "Well IS gonna be interesting" I think, mask again hiding my smile. Attending turns to me and says "well I gotta go back downstairs, don't forget to write this up in the chart." "Not me", I reply, "I couldn't begin to explain in writing what just went on in here, and I guarantee you would prefer it if I did not." And out the door I went. The events of the day of course spread quickly within the department. Not one to wait for others to form the outcome of important things and then tell me about it, I took the dept MDA Chief aside in the hall a bit later and, ignoring the entire ICU incident since I figured "I DARE someone to criticize me on that", I asked, "Hey, what's this I hear about CRNAs no being allowed to insert central lines here?" Well, it's not that they are not allowed. No one has ever asked to before. Technically the AAs and CRNAs have privileges to do so, but only the AAs who do the hearts ever do them.", he replied. "I put a femoral Cordis in a trauma this morning, so you can add me to the list." "I bet THAT raised a few eyebrows." he chuckled, and that was that. From then on I treated the patients, without delay, as needed, and informed the attendings as soon as reasonably possible. Patient needs blood but not urgently? Sure, I'll give you a call if that is the sort of thing you want me to bother you with. But no, I will not delay urgent care trying to find you. Within a month or two it became clear each attending had their own version of the ACT, which became even another version specific to me...a 'what are you calling me for, get on with it version'.

My point: If as a CRNA you are feeling marginalized, lacking respect, unappreciated, unchallenged, bored, etc., you generally have willingly placed yourself in that position and in the end have no one to blame but yourself. Even in the WORST of practice settings you play a part....though the fact that you are IN one of those settings is usually the first thing you can and should change.

From everything you have said, I think that you would find being a CRNA a very rewarding career which, for you, would likely be a specialized one of your own making based on the challenges of the position you seek, rather than the paycheck from, say, an outpatient eye clinic. The only other career move that comes to mind which it sounds like you might enjoy is a critical care Nurse Practitioner in a setting where the NPs are used similar to residents in the ICU. These do exist.

allnurses Guide · Oct 20, 2012

Save the hassle all around and avoid ACT practices.

foraneman · Oct 22, 2012

Save the hassle all around and avoid ACT practices.

I agree...unless you want to work in a large university academic center setting doing the most challenging of cases across many disciplines, using the most cutting edge technology, and be able to teach students, participate in research, etc. Then you are rather stuck with one form/severity of ACT or another.

allnurses Guide · Oct 22, 2012

I agree...unless you want to work in a large university academic center setting doing the most challenging of cases across many disciplines, using the most cutting edge technology, and be able to teach students, participate in research, etc. Then you are rather stuck with one form/severity of ACT or another.

Hmm...I teach students as do many other CRNAs without being in a large academic center. I don't miss doing "ultra big sexy cases" which if the university academic center is associated with an anesthesiology residency the residents are going to more than likely being doing those cases anyways. There are plenty of hospitals where you can do hearts, heads, and vascular cases independently as a CRNA, and not be associated with an ACT. I can conduct my own research where I am if I so choose without having to be sponsored by an MDA which is the case at many university hospital centers. Cutting edge research is debatable and all depends on the hospital.

ACTs are a farce and do nothing to increase the access to patient care or the quality of patient care.

lizzzzzzz · Oct 24, 2012

Thanks for the input, everyone!

For those of you who asked, I have seriously considered the ACNP Intensivist role (it was actually on my planned career path when I went to school) but as I've worked at the bedside I've realized that in a lot of cases, this tends to be more of an eternally-intern role, and an evolving role at that. There is so very little standardization of some CNP prerequisite knowledge that I have seen many physicians refuse to trust CNPs to effectively manage their patients and therefore limit their responsibilities significantly. It seems to be a similar situation as with ACTs, although it seems that many ACTs are more trusting of CRNAs than say, a surgeon and the CNPs on his service, due to the rigor of CRNA training and more standardization of the role. There just seems to be more need to "prove oneself" as a CNP and still not be respected, as there is as a CRNA. But I could be way off base with that, too.

Basically, like anyone else, want to work at a place where I get the respect I deserve for the care I provide and deal with as little bureaucracy as possible. Because I would react very similarly to foraneman in the situations he described, except I would probably would not have handled myself nearly as well, nor been able to tube that guy successfully, ha.

To those of you that have found the "good ACTs," how did you screen them to find one that would fit you? The ACT that allowed you an appropriate amount of autonomy for your skill level and provided you with opportunity to build your skills and challenge you?

ssrhythm · Nov 10, 2012

Wow, there is a lot to address there, so I won't try to go item by item. I graduated in May, and I'm the only FT CRNA at my hospital working with three Anesthesiologists. I work independently, side-by-side with the MDs. I make my own decisions, but we are all there for each other to discuss difficult situations and scenarios. I'm equally respected my the surgeons and OR staff. The only difference in practice between me and the MDs is the title on my badge and the pay. It is an ideal situation, but I had to hold out for the job and fight for it. You can find employment that will satisfy you...I can assure you of that. It sounds like you will be a great CRNA, but understand this...all of your personality traits that will help you tremendously as a CRNA will likely drive you nuts as an SRNA. When you get into school, just realize that you will be doing things the way your CRNA for the day wants you to. You will have to reign it in an swallow it for 2.7 years. It is just part of it, but you can handle it. As far as adrenaline and boredom...I can not imagine having to return to the routine of the ICU. You will get plenty of adrenaline rushes as a CRNA, and I'm already learning that the fewer I get, the better. I feel the rush during ever case, no matter how routine, because I know what can and will eventually go wrong. My rush is doing everything in my power to assure that nothing does go wrong and that everything stays routine. Knowing that it is up to me to ensure this for every patient who trusts me with their life...that's adrenaline enough for me. Good luck with your decision.

Mully · Dec 11, 2012

@foraneman, that is the best story I've read in a long, long time. I think I even gasped at one point. Nothing like a story of pushing a guy that's got nothing to lose into standing up for the right thing. I think you just sealed the deal on anesthesia school for me! lol

SRNA4U, BSN, DNP, RN, CRNA · Jan 17, 2013

I equally enjoyed Foraneman story as well. I think when I graduate, I would rather work in a large academic teaching hospital to get those type of cases you speak of. I know Baltimore Shock Trauma has a ton of openings for CRNAs in their trauma OR. I once told when there are large vacancies at teaching hospitals to beware since that usually means they treat their CRNAs like crap but sometimes if you want the experience, you have to suck it up and do what you need. I trained at Shock Trauma in the ICU before I deployed to Afghanistan and I was able to shadow some friends of mine who are Air Force CRNAs who teach in the CSTARS program there. That was my first time actually seeing the ACT model since in the military, our CRNAs work independently. I was shocked to see the anesthesiologist push the induction drugs and then he walked out the room while the CRNA intubated. For me, that would take out the all the fun of doing the induction. I have seen an anesthesia resident try to place an LMA in an patient that was not deep enough and the pt bit him when he stuck his finger in the pts mouth. Me and CRNA buddy just looked at each other and smiled.

Keep up the great work Foraneman

limaRN, BSN, RN · Jan 17, 2013

I am currently a critical care nurse working in a large Neuro/Trauma ICU. I'm a huge nerd that loves to know WHY about EVERYTHING, and loves to be involved in the decision-making about my patient. I'm a nurse through-and-through--I love educating the families and helping them to understand what is going on with their loved one and make sense of this hell that they are experiencing. But I'm also very controlling of my patient--my rooms must be setup in he same way each day so I can find my stuff in a crisis, and I like my patients clean and well-positioned in their beds. I'm very protective of my patient in that the procedures and orders carried out on him/her must be appropriate in type and in timing--if there is any question about it, it will be cancelled or rescheduled. So, I'm a bit bull-headed, too, with a low tolerance for bureaucracy--if I need something for my patient, no is not an answer I will accept. I'm starting to feel like I'm outgrowing the ICU--I'm losing some skills, desiring more knowledge and influence over plan of care and delivery of care for my patients, and reaching my limit for tolerating blame for scheduling or communications issues that are out of my control--so I'm looking into advancing my career. I am applying to CRNA school, but I have a few fears that my personality and desire for knowledge and control might not be a good fit.
I like the role of the CRNA in that you perform a lot of advanced procedures--intubations, line insertions, and blocks. You're in charge of the hemodynamic and pulmonary issues that arise, which can be a little touchy at times, requiring you to change your plans often and think head 20 steps in case the case goes from lap to open or the surgeon knicks an artery. You're involved in surgery--something that is often done to help improve the patient's quality of life rather than harm them (as I often feel like I am tending the vegetable garden in the ICU.) But I'm concerned that I'm going to miss out on the critical thinking about all of the medical issues that the patient is undergoing and how they all affect one another and the patient's quality of life and how to get them back to a good quality of life (and the creative ideas and solutions that go along with that)...but I sure won't miss the readmissions because they didn't listen to our advice. I fear that life in the OR might be more monotonous in an assembly-line kind of way, and I'm so much of an adrenaline-junkie that I fear I might eventually get bored. I'm concerned, too, that it will be a constant struggle of being belittled by the MDA, with their constant oversight and opinions about my practice (not to mention the fact that they're able to bill for 4 separate procedures at once since they're overseeing 4 separate CRNAs that are doing a majority of the work). I don't want to feel limited in my practice in not being allowed to do certain cases such as open hearts due to my lack of knowledge in comparison to an MDA.
So, my question for those practicing CRNAs out there is, do you identify with any of these concerns/fears? Do you miss the ICU for those reasons I'm afraid I might miss it? Would you do it all over again?

What makes you think you can't do open heart cases as a CRNA? Not every CRNA does but some do.