Latest Comments by JoeCRNA

JoeCRNA 1,015 Views

Joined: Dec 2, '06; Posts: 19 (26% Liked) ; Likes: 5

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    In Tee

    There are a variety of practice settings available. I encourage you to check out the AANA website, they provide great resources and LINKS to some really excellent CRNA specific information.

  • 0
    In Tee

    Quote from ILoveIceCream
    Is it common for CRNAs to provide anesthesia for thoracic cases?
    It all depends on the practice. In my current practice I do thoracic cases such as lobectomies and wedge resections that require double lumen endotracheal tubes that allow you to isolate a lung to ventilate while dropping the other for surgical intervention. We do not do thoracic open heart cases such as CABG or valve replacements that would typically involve use of a TEE. However, there are CRNAs that do specialize in that type of anesthesia, known as cardiac anesthesia.

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    In Tee
    ILoveIceCream likes this.

    TEE can be performed intraop by CRNAs, especially those who provide anesthesia for thoracic cases.

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    Excellent, glad to have been shocked and proven wrong. Now where is the awe? What is the practice like.......

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    I would be shocked if PVH uses CRNAs, Such a desirable place to live is likely to be dominated by anesthesiologists.

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    I tend to do things quite similarly; however, I use a little ketamine 10-20 mg (typically 10mg) in addition to some versed and occasionally propofol for premedication. I have found this combination has minimal respiratory depression and is tolerated well by patients.

    I have not done much with the paramedian approach, but have been talking to colleagues and reading more about it. It is my intent to give it a try the next time an opportunity presents itself.

    With regards to age limits for spinals, I don't really see an issue so long as the patient can tolerate the procedure, and a small gauge pencil point is used. What specifically are your colleagues concerned about? PDPH? Have you ever worried about the age of a Parturient undergoing a c/s...

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    Qwiigley likes this.

    Quote from Qwiigley
    Hello All! It's time for me to re-visit my practice (habit) of my doses and drugs of choice for laboring epidurals when a c-sec has been called.
    Currently I use 5-10 mL of 2% lidocaine (with or without epi) with 5-10 mL of nesacaine to speed it up. I do get some hypotension, but usually managable with LR and rarely need ephedrine. I like to use less drugs with a pregnant women until the cord is clamped. Then I give her Zofran, Decadron, ephedrine if necessary and Duramorph 3mg with 5 mL of NS in the epidural for pain mgmt. Toradol 30mg Iv/30 IM if not contraindicated. As a side note, Our docs take about 60 min open to close for a section. Slow, but that's what it takes.
    I'd like to hear what other people are using so I can update or try new things. We all want "best" practice. What say you?
    I most frequently use 10-20cc 2% lido with epi, a little bicarb for speed, and 100 mcg of fentanyl to improve the quality of the block. If hypotension presents itself, I tend to reach for neo first and then ephedrine, if not responsive to the neo. I like the reduction in HR associated with the neo and can't remember the last time i had to switch to ephedrine.
    After baby is out, I use decadron and zofran for pts with a hx of motionsickness or ponv. In the last year, I have reduced my duramorph dose from 2.5-3mg to 2-2.5mg depending on height, less than 60-61" gets 2mg > than gets 2.5. I switched and have found less pruritis and no change in pt comfort level.
    Our OB's vary widely in their skill level and as a result they have an unfortunate department policy of no toradol. Our sections can range from 30min-150min, depending on who is holding the knife. As a result of this variation, my elective sections frequently get epidurals with certain surgeons. If I have to top off in the OR, I switch to 2% lido sans epi.

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    Quote from CRNA2007
    What I was taught was if the tattoo was older than 6 months it was fine, but I was also told that they have new acrylic dyes for tattoos, and that you are not suppose to give an epidural or spinal through them.

    Some advice for a new CRNA, being a licensed advanced practitioner "I was taught..." is not a good enough rationale for anything. The standard of care, the evidence shows, etc. are rationales. We are not minions to our teachers (whether they be MDA, CRNA, or whoever), we are well trained, independently licensed, well read, mindful professionals, who act on behalf of our patients best interests.

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    Quote from NREMT-P/RN
    Well, well, well.

    Hey there berry -

    "Cowboy" NREMT-P/RN here. I'm sure that you did not mean to be "demeaning" - it just slipped out.

    I generally avoid the "my _____ is _____ than your _____" contests because NO ONE WINS!

    But, I will CLEAR up some of the conclusions you jumped to --- for your BENEFIT, of course. (You never know, the next paramedic type person you don't "mean to demean" may not be so secure!)

    I remain resolute in the fact that I CAN manage ANY airway. Period. You took the leap to conclude that by "manage" that means dropping the ET tube. Sure, an ETT is one way to "manage" an airway (and I generally prefer it). However, I have other options if the patient needs 'em. Managing the airway only means that I maintain a route for ventilation and optimal oxygenation of a patient - reducing/elimination of the aspiration risk is included in the package! Simple. I have a number of methods available for achieving airway management!

    As to the #'s game - I declined to play above (but, be careful as to your number estimates - it is clear that you plucked that # from some reference, it may not apply to me - or anyone else I know!). As to the conditions of practice, I will add this:

    My patients:

    * are never NPO, often have full bellies
    * have a wide variety of clinical presentations, many of which necessitate RSI and a few need crash airways. I even have to nasally place an ETT ever so often.
    * never present to me in a well lit comfortable room
    * have a wide variety of dental/oral issues. Dentures and removable appliances are in place, meth mouth is more common than I would like (tends to eliminate parts of the soft palate, lots of icky tissue)
    * frequently have c-spine precautions in place (a bit more restrictive)
    * in trauma patients, the derangement of the "normal anatomy" is only limited by your imagination

    Anyway, I hope that you get the point. You the "SRNA" and me the "Paramedic/RN" have different practice realities. But the one common reality we have to share is the:

    ABILITY TO MANAGE ANY AIRWAY. (Note I did not specify intubation!)

    I will agree that AIRWAY MISMANAGEMENT is a primary reason for litigation, but careful about the accusations of "cowboy mentality" that must be why so many "ER's have open lawsuits". How do you know this???

    A professional recognizes that other professionals have certain areas of expertise. A certain amount of courtesy is expected. To blanket "paramedics" as you did in your post could be considered offensive to some. However, to your credit you do admit to having backup by a CRNA or MD.

    Anyway, FYI - we do agree on the Diprovan issue. I hate the drug. It is generally not useful to my practice. I have better options for RSI induction and post intubation sedation. End of story. But, occasionally we do get a call to transfer a vented patient that has Diprovan running. I generally will have to supplement it (something about those jet engines, the vibration, stimulation brought on by extreme conditions) with additional medications just to keep the patient comfortable. Often, I just turn it off and use a more appropriate medication regimen.

    Practice SAFE!
    Sounds COWBOY to me...

  • 1
    jessi78 likes this.

    Having read your progress through school, I am sure that you did well on your exam and will soon be a full fledged member of a great profession.

    Like another poster, I too found out that I passed via the AANA credential verification page; however, my FedEx package did arrive later the same day.

    As a full member of the club, please remember that every CRNA is your brother or sister and that all p u b l i c remarks about one another should be positive, I am positive that this will not be an issue with you.

    The following is not directed to EmeraldNYL...
    Disparaging remarks about the intellect of a fellow CRNA does nothing but bring us all down. Certain "rocks" earned the same degree, passed the same certification, and call themselves CRNA, just the same as those who are intellectually superior to "rocks." Opinions are one thing but public denigration of a colleague is another.

    CRNAs are the tip of the spear with regards to the public and medical communities perception of Advanced Practice Nurses and as such, we should encourage each other to be the best practitioners, act as role models to fellow nurses, and set the standard for professionalism in healthcare.

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    Room air General is frequently synonymous with a Big MAC which is essentially General anesthesia with a natural airway and intravenous "sedation."

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    As a matter of practice, I do not place epidurals through tattoo ink.
    The verdict remains out and although the risk is probably small, why take a chance...especially with an elective procedure.

    However, there is typically an interspace that is not inked or there is clear skin close enough to an interspace that it can be stretched over the interspace and the needle and catheter subsequently placed through clear skin.

    I have placed many catheters right between the antennae of a butterfly or through the centers of many a letter.

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    Quote from dfk
    hey joe,
    i'm assuming you mean "retentive"...
    otherwise, OUCH!!!
    No, I actually meant retention as a double entendre.

    But, thanks for the assumption.

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    GilaRRT likes this.

    Re: ICU or ER
    permalink
    I personally came from an ER background and to this day find the skill set I learned in the ER to be invaluable. Rapid assessment, quick thinking, improvisation, a cool head under fire, being able to roll with the punches, prioritization, decision making are all assets learned in the trenches of the ER. and will serve any CRNA well.

    That being said, there is a definite advantage to the icu because the icu is the realm from which most CRNAs were born and therefore can most relate. Common traits among CRNAs are type A personalities and anal retention, two qualities well suited to an icu type environment as well as the OR.

    People tend to make a big deal about drips and lines in the icu; however, the pharmacology, physiology, and technical skills learned in anesthesia school take one to an entirely different level so as to negate any advantage of prior knowledge.

    Unfortunately, schools are showing less and less inclination to accept ER as acute care experience making icu the preferred route. IMHO, this is folly on the part of acceptance committees as the ER skill set is an asset in the OR. I thank my lucky stars everyday I go to work that I am no longer in the ER, but wouldn't trade those skills for all the icu gtts and lines in the world.

  • 0

    I personally came from an ER background and to this day find the skill set I learned in the ER to be invaluable. Rapid assessment, quick thinking, improvisation, a cool head under fire, being able to roll with the punches, prioritization, decision making are all assets learned in the trenches of the ER. and will serve any CRNA well.

    That being said, there is a definite advantage to the icu because the icu is the realm from which most CRNAs were born and therefore can most relate. Common traits among CRNAs are type A personalities and anal retention, two qualities well suited to an icu type environment as well as the OR.

    People tend to make a big deal about drips and lines in the icu; however, the pharmacology, physiology, and technical skills learned in anesthesia school take one to an entirely different level so as to negate any advantage of prior knowledge.

    Unfortunately, schools are showing less and less inclination to accept ER as acute care experience making icu the preferred route. IMHO, this is folly on the part of acceptance committees as the ER skill set is an asset in the OR. I thank my lucky stars everyday I go to work that I am no longer in the ER, but wouldn't trade those skills for all the icu gtts and lines in the world.


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