PresG33

I worked at a level 3 trauma hospital, but we did tons of super complicated cardiac and vascular, RNs in the unit ran ECMO, and we also took complicated medical patients. All of this was with tons of autonomy. Trauma level only applies to trauma cases which are, in terms of ICU management, only a small sliver of the other comorbidities you can see. Being at a level 1 center also can mean that much of the management is done by residents and fellows and very little autonomy is passed on to nursing. All of these are important variables that go beyond a simple level 1 vs. level 3 discussion. Best to get info from floor nurses in both units and make a decision based on that.

Every ICU in America is full of nurses who at one point wanted to go to CRNA school and decided not to for whatever reason. They had kids, didn’t want to move, was too expensive, wanted to do a masters instead of doctorate. Whatever the reason, the desire to put up with the huge money/time/effort commitment just wasn’t there. I commuted 2+ hours a day, had my wife and kids alone while I was at school or clinicals, and took out more loans than I could ever imagine. But it led to me having a great job that I honestly love and pays well. If it is important to you to feel the same, then it won’t matter if it’s a doctorate or masters. If it isn’t worth it, then that’s fine too. But just don’t be one of those nurses serving 7 to life in the unit wishing they had gone to school and regretting it. Make your decision based on the next 20 years, not the one extra year.

There’s plenty of people who worked in the ICU for 5 years and just kinda slid by and did whatever the ICU docs said and then got into CRNA school. And there’s plenty of people that busted their butts for 1-2 years, took super sick patients, practiced relatively autonomously, and tried to understand the physiology of their patients and the treatments. Bottom line is that the quality of the experience is much more important than the time. Take your work seriously and learn as much as you can and just a few years is fine. And how you are as a didactic and clinical student in CRNA school will be much more important for your success as a CRNA. I for one am just glad that we as a profession have held onto the critical care experience requirement at all when so many others (NP, PA, AA) have not/never did. Even the minimal requirement we have allows us to put out much more qualified CRNAs.

I was married with two kid, house, etc. when I went to CRNA school. People would always ask how I could afford to go to school. I would say “how can I afford NOT to go to school??”. I meant this both financially (even with maxed out loans, by decreasing your expenditures after school and making a great salary you can have a great financial future. Much better than as a RN) and also personally. If I had to continue to serve 2 to life in the ICU with no chance of parole I would have been miserable. Now I like my job, feel challenged and rewarded by it, and enjoy going to work (most days). The struggle of loans and, most importantly, decreasing lifestyle, to save money is well worth it. I would recommend listening to the White Coat Investor podcast as it delves into lots of these types of financial and lifestyle issues. Good luck.

1) spend lots of time with friends and family and remind them that your ability to spend time in school will be minimal. Try to build up some goodwill now for the inevitable decrease in your ability to spend lots of time on these relationships. 2) work overtime to save some money. This will remove some of the huge stressor of no income for several years in school. Loans pay for tuition but silly little costs like case tracking software, ALS/PALS, computer exams your school requires add up to thousands of dollars in unforeseen costs. Having even a few extra shifts worth of savings can make the difference between stressing over this or just writing the checks (do people still write checks?) 3) Take a month off before school. Travel, sit at home and watch TV, meal prep a month of lunches and freeze them so you don’t eat like crap at school, exercise... just chill and try to form some beneficial personal habits for the long haul ahead. 4) If and only if the previous things are done, spend some time learning autonomic receptors front to back. Alpha and beta, what each one does, where they are located, etc. And not “alpha 1 works on blood vessels”; memorize the several different sites of each receptor, and the biochemical pathways and second messengers that each one uses. Don’t worry about medications. Just learn the receptors in depth and you will be ready to absorb additional information related to them later. good luck. Remember that being a CRNA is literally the best job and it will all be worth it.

One point I will make: in my opinion the strength of your schooling is mainly attributable to you being an active learner. There are SRNAs at “weaker” programs that are very good because they take an active role in their learning and make the most out of their situation; and there are SRNAs from “top” programs that are not strong because they sit back and expect knowledge to just seep into their brains via osmosis rather than active transport (nerd alert). This is why within a class of SRNAs you will have some “rock stars” and some that are less prepared. Same schooling, but likely different aptitudes, experience, and attitudes. In my opinion, the best question to ask isn’t “which schools are good?”, it is “what can I do to make sure I am a rock star SRNA no matter where I go?” and start honing those active learning skills now while you are in the ICU. Beyond that, I would say that any CRNA school interview you go on is a two way interview, you can get an idea of the support and systems in place and that may be what drives your decision on the right school for you as opposed to what are likely biased opinions (mine included) on the internet. Good luck!!

Leaving just to manage IABPs is not necessary for CRNA school or in practice. Whenever they put a balloon pump into a heart I’m doing it is managed by perfusion. We are generally to busy to do anything with the balloon because if the pt is getting one they are sick and we are starting drips and trying to optimize things on our end. If you want to go to CVICU for other reasons that is fine, I have always felt that recovering a fresh heart is the thing I did in the ICU that was most similar to what I do in the OR now. Having that experience was incredibly helpful when I did my heart rotation and helps me now that I do cardiac surgery. That being said, maybe 20% of my CRNA class had CVICU experience and the 80% graduated just like we did... so it is definitely not necessary.

I worked in a CVICU and am now a CRNA who primarily does hearts. A few tips: - There are lots of nurses that know WHAT to do but not WHY. They know that adding milrinone will make the cardiac index go up and they might need to put on some norepi, but don’t really know why. The best RNs will understand the mechanisms of drugs and will be able to proactively see side effects of them and treat them before they become a problem. Always know the WHY! And to know this you need to read outside of what you are told at work. - As a RN I was taught the first 3 solutions to a heart that wasn’t doing well were volume, volume, volume. I can tell you now that this is misguided. Crystalloid neither carries oxygen nor clots, which are the two things a post op heart needs. Optimize preload, but don’t forget about heart rate (pace), contractility, SVR, and enough afterload to optimize cardiac function. - And my pet peeve: listen to the CRNA or other anesthesia provider’s report when they drop off the heart. They have spent the last 3-8 hours giving the patient different types of medications and have learned how the patient reacts. I have some RNs who listen intently and I can clue them in on things to make their life easier (“Inferior wall looked sluggish on echo, he will prob need volume, and he reacts better to norepi than phenylephrine”). Some RNs literally just want to know what they need to fill out their report sheet (Is and Os, what drips, what lines, nothing else). I think that they then struggle trying to “figure out” what the patient does best with when they could have learned that in 3 mins talking to me. That being said, some anesthesia providers give crappy reports and then you’re on your own! I aways loved hearts and love them even more as a CRNA. In my opinion, recovering a post-op heart is the closest thing in nursing to being a CRNA taking care of sick patients in the OR. Have fun and try to learn everything you can. If you love recovering hearts, chances are you will love being a CRNA and think about that path the future!! Good luck.

If possible, dont make the decision on where to work at your first job based on commuting time or salary.... make it based on case mix and autonomy. You will have plenty on time in your career to make location and money based decisions, but the first 2 years out of school are imperative to making you a great CRNA for the next 30 years. I took a little less money and had to drive an hour each way to my first job but it was at a major academic center where CRNAs did all types of cases. The experience I got there made it so I got comfortable going anywhere and managing sick patients.

I had two kids during school (one was born during school). It was OK. It forces me to plan ahead and prioritize my time in a way that made my studying more efficient than my classmates. When I got my syllabus for the semester I would start working on papers/projects that weren't due for months so I could get ahead. I listened to recorded lectures during my commute. My wife actually liked the schedule better than when I was in the ICU (every weekend/holiday off during school and was able to put my kids to bed every night as opposed to working 12 hr rotating shifts/holidays/weekends in the ICU). It isn't the most fun thing in the world but I think my kids' lives will be much better in the long term with me being a CRNA as opposed to not going to school. The schedule/financial difference is huge and having a Dad that loves his job is probably better than being over stressed, under appreciated and unhappy as an ICU RN.

Yes. Ca can "buy you some time" by maintaining the difference between RMP and threshold, but it will not keep badness from happening. This is true of most "treatments" like bicarb, hyperventilation, insulin/glucose, albuterol, etc which only shift K instead of getting rid of it.

In hyperK, the resting membrane potential rises, which brings it closer to the threshold potential. This means that a much smaller stimulus is needed to trigger an action potential, which can lead to arrhythmias. Ca raises the threshold potential without raising the resting membrane potential. This restores the difference between resting and threshold potentials and makes it harder to trigger an AP.

The main reason to apply cricoid pressure is to be able to check that box on documentation and hopefully not get sued if there's an aspiration. The cricoid pressure itself has been shown to decrease glottic exposure during laryngoscopy (means longer time until plastic is through the cords and the airway is protected), as well as potentially increasing rates of regurgitation. Also several MRI studies have shown that it does not reliably obstruct the esophagus (and this is when it is applied at the right place with the proper force, which it rarely is in practice).

I think leaving a job in less than a year is semi suspect. I'm assuming you want to go to CRNA school b/c that's the forum you posted in, so the optics of that type of move is important when admissions committees are looking through hundreds of resumes and trying to weed some out. Small things like that might make a difference. That being said I think going to a CVICU will give you the best experience for school. Best option: get the CVICU job and work the small ICU job per diem for another year. That way you get your experience and it at least looks like you kept the other job for longer than 6 months. Other best option is to get a job at CVICU effective one year after you started the other job so that you will have left the small ICU at one year.

At my large sites the attending a pushed induction drugs, were stingy with giving us central lines and blocks, and I did a few really cool big cases and a bunch of normal cases. At my CRNA/Indy rotations I did all my own inductions, did a ton of blocks/central lines, epidurals, etc, and did a few really cool big cases and a bunch of normal cases. I went to a small program (14 in my class) and it was the best decision I ever made

Your stats get you an interview, your interview gets you accepted. Start practicing answering interview questions now and be prepared to defend any weak spots in your stats. For you this may be that experience is on the lower side. I was accepted before I hit 2 yrs and I think it was because I acknowledged the issue and gave examples of how I had really tried to maximize my learning in the ICU (volunteer for sick patients, take extra training, constantly evaluate the "why" behind interventions, etc).

Save a lot. Spend less. Also you can usually get Grad Plus loans that cover most living expenses. As far as family time, I spend more time with the family now than I did as an ICU nurse. Now I'm home to put the kids down every night, Home every weekend, Home every holiday. When I was in the unit none of those were true. Biggest mistake I've seen is not to address the difficulty with your significant other BEFORE school starts. I prepared my wife for the worst so now she constantly says that school isn't as hard on the family as we thought it would be.

I thought of doing ACNP before I ended up going to CRNA school. ACNP have some rough hours (whole week of nights, etc). There is also a lot of scut work for ACNPs (doing H+Ps, drawn out family meetings, etc). The NPs on my unit never left work on time and were usually pushing a computer around documenting stuff. But the biggest thing that made me want to go CRNA is that when I am in the OR, I make the plan of what to do and then put the plan into action. As a NP, if you want to give someone a vasopressor, you have to be told about the hypotension by the nurse, order the pressor in the computer, pharmacy has to approve it, the nurse has to go to the pyxis and pull it, the nurse puts it on the pump and gives it. In the OR, I see hypotension, I pick up my vasopressor, decide how much to give, and I give it. There is no one else in my decision loop to worry about and I solve the problems on my own. This compresses the "assess, intervene, reassess" loop and allows faster treatment. That being said, there are times where I am in a long case and have the patient stable that it gets a little monotonous, but I use that time to plan for a smooth emergence and get set up for my next case.

When I was in the ICU and when I am in the OR now (in CRNA school) I think "what is the worst thing that could happen to my patient right now?". For instance, in a simple laparoscopic abdominal surgery, I imagine that that surgeon punctures the aorta (or the patient codes, or the ET tube gets pulled out... whatever). I then mentally go through the step I would take. The key to this is not to just breeze through and say "oh I would start giving blood with the rapid infuser", mentally go through each step in priming the blood tubing, setting up the infuser, getting central access, etc. if you do this, when things go wrong it won't be "a situation I'be never encountered" because you will have already worked through the steps. It would be extremely unlikely for a surgeon to ever puncture and aorta like I gave as an example, but if they ever do I will have run that simulation in my head and will be a few steps ahead. Next shift you are recovering a heart, just say "what would I do if the patient went into tamponade?" Call for help, make sure chest tubes are draining, call surgeon, go up on epi drip, get chest cart to bedside in preparation to open, etc. Work through these situations and you will be better prepared for when it goes down for real.

Don't try to learn any specific anesthesia stuff. Make sure that your REALLY know the stuff that you use in the unit. Don't just know that norepi is a vasopressor or increases SVR and CO but know each specific receptor, onset and duration of action, etc. Know this for every sedation and vasoactive/cardiac drug you give in the unit. Also study the autonomic nervous system and receptors until you can recite every single one and the effect from memory. These are a common theme throughout school from day 1. Another thing that REALLY helped me was that I started using the ultrasound machine in our unit to put in peripheral IVs. It is actually a very tricky skill to learn to use a ultrasound and guide a needle while not looking at it. It is a skill that you use for a lot of different procedures and one that I saw many of my classmates really struggle to learn while I had an easy time because I had practiced it. Learning nerve blocks was easier because driving a needle under ultrasound was not new to me. Even if you can do 10-20 IVs under US before school it will make the learning curve much easier on you.

Nah. I had a 2.6 my first stint in college. 10 years later got all As in prereqs, 3.85 in accelerated BSN, really good GRE. Never was asked about the first bad GPA in interviews and was accepted to first school I applied to. I did address the first GPA in one sentence in my personal statement. Just something about maturing and realizing that my grades increased as I found subject that I was truly passion about. Be prepared to answer questions about it but if you have been solid since then you should be good.

My advice is to go to a school that sends you to multiple different sites as opposed to having a primary” clinical site. There are no perfect sites: completely independent sites may have lower acuity patients, you may do liver transplants at another site but under a ACT model. Some clinical sites have CRNAs do all OB, but docs do all nerve blocks, and it may be the opposite somewhere else. By having a variety of sites you get exposure to different areas of anesthesia and different ways of doing things. My school sends us to 5 or so different sites and by the end you are comfortable walking into any OR with any machine and any surgeon and giving anesthesia.

My opinion differs a bit. Large teaching facilities MAY focus their teaching more on residents/fellows and less on autonomous nursing. In some units, this means nurses must constantly check with Dr. before starting drips, etc. and I have heard (rare) units where the nurse must check before titrating vasopressors. I came from a smaller hospital, no residents, that did sick open hearts, ECMO, etc. Nursing was given a lot of independence and we would start drips, hang blood, etc. on our hearts if we thought it was what they needed (after the surgeons trusted you to make good decisions). Bottom line is that size and acuity don't matter if you're not making decisions. A unit that "does ECMO" sounds cool but it is very different if there is a perfusionist sitting on pump as opposed to nurse-run ECMO (we did this in my unit. Very cool!). The best unit is the one that teaches you to think like a provider and make autonomous treatment decisions, because that's what being a CRNA is all about. Try to talk to some nurses that work in the units you are interested in and try to learn about how they make treatment decisions.

Lenovo Thinkpad 13. Less than half the price of a Mac and more user friendly. Also, usually best to make sure you have Microsoft Office because a lot of the Mac programs for writing and slideshows are a pain to cross over to Word and PowerPoint which are the format of most of the material in school. Also, use the money you save on the computer to buy a really good recorder, record lectures, and listen to them while you're driving or working out... great way to add more study time to your day.

I read some anesthesia textbooks before school but it was a waste of time. I didn't have enough background to understand it. The best advice is to really focus on the "why" behind everything that is happening in the ICU. Why certain pressors are chosen in certain situations, etc. Also, for every drug you give, look up the drug class, dose, MOA, and onset/peak/elimination times. If you are at all unsure about parasympathetic vs. sympathetic and the different types of adrenergic receptors then those are a good thing to study.