pediatric practice

Pediatric Critical Care Columnist · Jul 22, 2004

Point #1... Children are not small adults. Their anatomy is quite different, as is their physiology. For example, their airways are much smaller, narrower toward the carina and softer than adults. It is possible to obstruct a child's airway simply by extending the neck. Minute amounts of secretions can obstruct an airway as well, either natural or artificial. Barotrauma and volutrauma are both too easily caused by inexperienced but well-meaning staff when hand-ventilating tiny, immature lungs. Many commonly used drugs affect children much differently than they do adults, often meaning a huge decrease or increase in the amount required to obtain the desired affect. No simple formula for this exists, though. And their responses to illness are very different; they compensate for alterations in cardiac output by increasing heart rate, and a drop in BP is a very ominous sign.

Point #2... Developmental levels are important guiding principles in dealing with children. They have great fears of being separated from the parent, and sometimes no amount of reassurance will make a difference. You can't reason with them until they're about 6 years old, and they don't respond all that well to bribery, because they're not stupid and catch on quickly that there's always a price to be paid for the treat! Older kids are capable of holding very extensive grudges. Most kids don't telegraph the onset of projectile vomiting except to the most perceptive of us. They also will cry long and loud without even being touched, will become very uncooperative with most procedures and can be counted on to do the unexpected. Using Mom to demonstrate how harmless the BP cuff/thermometer/monitor leads can be will help. If you can keep Mom around until the little darling is asleep, life is much easier!

Point #3... Needles aren't what causes them the most pain and upset. It's having tape removed!

I love kids and the challenges they offer, and would never want to work anywhere else. Spend some time with a few and see how you interact with them when they're well, and that will help you decide.

loisane · Jul 23, 2004

Can someone tell me the differences between working in a general practice and a dedicated pediatric practice? The info I am looking for is just the kind of day to day differences, and not the specific dosages or medications.
Thanks

User69, I imagine you a SRNA considering a first CRNA job as a new grad (not a RN considering a change in bedside nursing unit employment).

If that is the case, I think you would do more for yourself with a general type practice job at first. Then after a year or two, specialize in peds or whatever. The first year after graduation from nurse anesthesia school is very important. IMHO, even if you had excellent clinical experiences in school, you still need that transition time to fine tune your own personal practice patterns. If you spend that time in a specialization area, you will have lost valuable ground in your other skills. If you specialize after a year or two, you will always have that initial experience to fall back on, if you decide to practice in another area later down the road.

If you are an experienced CRNA, then of course none of that applies. If that is the case, and you are looking for practical insight into what a dedicated peds practice is like, I am afraid I am no help, since I haven't had that experience.

Hope you get some anesthesia specific responses.

loisane crna

jwk · Jul 23, 2004

Point #2... Developmental levels are important guiding principles in dealing with children. They have great fears of being separated from the parent, and sometimes no amount of reassurance will make a difference. You can't reason with them until they're about 6 years old, and they don't respond all that well to bribery, because they're not stupid and catch on quickly that there's always a price to be paid for the treat! If you can keep Mom around until the little darling is asleep, life is much easier!

I'll respectfully disagree about keeping parents around during induction of anesthesia. I've done it both ways, with and without parents. I think the key is adequate premedication. Having the parents in the OR is more for the parents peace of mind, not the kids.

Athlein1 · Jul 24, 2004

Something to consider, too...

The current trend toward the preferential hiring of fellowship-trained, board-certified pediatric anesthesiologists will continue. Demand for CRNAs to work in dedicated pediatric-only practices will likely continue to decrease. Physician anesthesiologists who are drawn to peds seem less money- or practice-focused than others who specialize (i.e cardiac anesthesiologists), and they often cover the PICU, too, which is an added benefit for the hospital. That means they'll work harder and longer for less pay in exchange for the benefit of working with kids. Two of the children's hospitals I have talked to have either phased out CRNAs in the anesthesia department or are using them only for LMACs in special procedures and routine M&T/T&As.

jwk · Jul 24, 2004

Something to consider, too...
The current trend toward the preferential hiring of fellowship-trained, board-certified pediatric anesthesiologists will continue. Demand for CRNAs to work in dedicated pediatric-only practices will likely continue to decrease. Physician anesthesiologists who are drawn to peds seem less money- or practice-focused than others who specialize (i.e cardiac anesthesiologists), and they often cover the PICU, too, which is an added benefit for the hospital. That means they'll work harder and longer for less pay in exchange for the benefit of working with kids. Two of the children's hospitals I have talked to have either phased out CRNAs in the anesthesia department or are using them only for LMACs in special procedures and routine M&T/T&As.

Funny how things are different in different areas. The two pediatric hospitals here depend heavily on their CRNA / AA staff for all types of procedures, including open hearts, neuro, craniofacial reconstructions, spinal instrumentation, etc.

Athlein1 · Jul 25, 2004

Yes, it's true that CHOA does use CRNAs in a variety of complex cases, but, they are supported and directed by those board-certified, fellowship-trained anesthesiologists.

Also, the Children's Hospital in Fort Worth and Miami Children's are actively advertising for pediatric CRNAs in the AANA journal.

user69 · Jul 25, 2004

Thanks for all of the great info

jwk · Jul 25, 2004

Yes, it's true that CHOA does use CRNAs in a variety of complex cases, but, they are supported and directed by those board-certified, fellowship-trained anesthesiologists.
Also, the Children's Hospital in Fort Worth and Miami Children's are actively advertising for pediatric CRNAs in the AANA journal.

True, but I think it's the anesthetists doing the vast majority of the cases - I don't think the docs do too many, although there are more anesthesia residents at Egleston.

I think you've got to have a little different personality to do kids all the time. Of course, I guess you could say that about most sub-specialty areas.