piper77

Hi Nupe: First, let me say "i understand!" and can empathize with you...it is absolutely MISERABLE to feel stuck in a job that you hate, and feel as though you are stuck in and cannot leave. It sucks! A little about me so you know where I am coming from: dad of 3, RN for 25 years, SRNA for 2...so while I have not been practicing anesthesia long...I have a little insight into what you are talking about. I too wondered if this was the direction I wanted to go in, and the negative aspects you mentioned were precisely the ones that gave me pause. However, I actually think the advice you have received already - even from the non-anesthesia providers, is pretty good. Just like there are many ways to put or keep someone asleep..there are many cultures in healthcare organizations. Sounds like you may be involved in one that is rough to work with. In my 25 years in nursing, I spent much time researching organizational behavior and personal job satisfaction (weird work for a nurse, ain't it?).. You seem to be at a crossroads where a decision soon has to be made, one that is intensely personal. As with all personal decisions like this, it sometimes helps to get non-biased help in sorting though your feelings and options; I myself have used a career counselor (and paid quite a bit for it, too!) that was very, helpful. It was worth the time and effort to find someone that was a true counselor, and not a kid with a degree in HR who wanted to give me pat answers....I found somebody with a clinical degree and experience who helped me work through some of the issues facing me...for instance in your case - is it the work environment that you dislike, or the work? Do you enjoy being a clinician, constantly upgrading your skills in a demanding profession? Do you like your patients to be more awake than most of yours are :) . Or, is it merely the environment...the pressure to turn over cases...the arrogance of surgeons (and attending MDA's)..or even nursing staff? Is YOUR personality suited for this work environment? You know that, as people have already said, there is much latitude in the culture of OR environments. You will likely find others that are much "friendlier" to CRNA's. But it's probably wise to acknowledge that this era's economics will always put pressure on turnover times, and arrogance, stupidity and downright meanness have existed in every profession in every institution and organization I have ever worked in...and trust me, that is quite a few. So, my opinion...just my opinion....is that this is a GREAT time for you...a time for some deep soul searching (and some hard work)...so that you might sort out what is best for you and your family. You have invested much in your profession; why not invest a little more to find someone who can guide (not direct) you through this process to enable you to find a job that takes with you the career investments you have made and leaves behind that which makes you crazy. Figure out whats important to you. And ..Godspeed and Good Luck on the journey!! All my best - piper

Yep, I agree with athomas; I would feel much more comfortable with an INR in the neighborhood of 1.5. I dislike the LMWH for this very reason. Post op is going to suck as well as intraop. Makes more sense to hospitalize, heparinize...can turn it on and off as you need; then re-establish a regimen for home. Getting a cardiac consult because of those valves? Would be a good discussion with the cardiologist.

Not so much of a quiz, really...perhaps a poll on practice. I was given a break by an MDA on an adult case; he said..."Oh..you nurses and your soft bite blocks..." then went on a mini-tirade about soft bite blocks being useless with ET's. I asked him to elaborate on it a little. His feeling was that nobody used to insert soft bite blocks instead of oral airways with ET's; when LMA's came along and soft blocks were being used, folks started using them with their intubations, as well. "After you take out the tube, can you ventilate through a mass of soggy gauze?" he went on..... (I didn't tell him my patients were usually awake and cooperative on extubation, and let me take out both their ET and bite block at the same time...!) BUT...he made me think a little about this, and I'm leaning in his direction in practice; I like his thinking. Almost everybody I know uses soft bite blocks with ET's - some folks talk about lip injury (ischemia?) during long cases, or patients breaking their teeth on the oral airway, as reasons to use a soft bite block. I can't find any evidence for either of those claims....and I think if you injure a lip or inflict pressure enough to cause ischemia to lips...you probably are not gentle enough with the insertion or are inserting it wrong! Anyway...thought I would throw this out to all under a "how do you practice" discussion....Thanks.

You know, I think the physical demands on the CRNA are less than those of unit nursing, but I find myself pretty tired at the end of the day. I think there is something about being "hyper-vigilant" that tires you even though you may not be doing as much running or lifting. Of course, a busy OR with quick turn-arounds can leave you with little time to sit or stand still. Perhaps those with more experience find that this goes away after a while, but I know for now I feel VERY busy during the day, and pretty tired (though a "good" tired!) when I get home.

Lou, thanks for the link..interesting! Believe it or not, our program requires us to handwrite our care plans, every room's case, every night; we can't just write "Versed 1-2 mg" - we have to reason "Versed, 1-2 mg IV - anxiolytic, amnestic.." etc. Fear of "copying and pasting" instead of "doing our own plans.....". This for the full first full year of clinical, and 18 months into the program..... Anyway, thanks for the link...a great idea.

good catch guys....as deepz knows....it was the overwrap. Good lesson for all of us in the room. Situation was confusing in that the patient did indeed have some type of histaminic response...and of course, the history. First time I encountered this...but I won't forget it...several CRNA's I talked to either experienced or heard of a similar incident. By the way....the plastic is virtually impossible to detect visually when in the cannister. I wonder if it might be useful to have colored stripes or such in the plastic.....the tech was a very experienced tech, too....felt awful. Anyway...thanks for your responses!

Thought I would add an experience that happened to me recently; after reading the "ventilate-or-not induction sequence" thread a few pages back. I enjoy reading other's experiences, and hope this one may offer some insight for future practice: Did a machine check before my first case; thought the absorber was a bit dusky, so asked a technician to change it as I went to go see my patient. I returned a bit later to the room, saw the absorber was changed, did a pressure check on my circuit to ensure there were no leaks, and a few minutes later wheeled my patient into the room. Patient was 1 ppd X 40 years smoker; used bronchodilators prn but not for the past year or so. Big history GERD; RSI. Induction time, sux in, well ventilated, sat never drops below 100. Uncomplicated intubation with open cords. Cuff up......can't ventilate. No breath sounds. ET CO2 immediately 30 plus or so, and stayed there or higher. Trying to ventilate....making a little headway, bag is tight, airway pressures in the 50's and 60's trying to get a breath in. Thinking about the smoking....patient must be bronchospastic. Bronchodilators, Zantac, Benadryl, and epi....(patient concurrently showing signs of anaphylactoid reaction....marked rash, mild response to epi; was vasodilated). Slightly better ventilation, according to MD; CRNA notices the same improvement (now with ambu) on way to PACU, where patient is extubated after a while....lungs clear bilaterally on arrival in PACU, clean emergence and extubation. Sat never dropped below 100; ETCO2 in 30's. Anyone want to hazard a guess at the cause of the problem? I'll tell y'all in a little bit....:)

gaspassah...just a couple of things....I have never heard that the author of "Silenced Screams", Jeanette Liska, experienced her awareness because the ologist let the vaporizer run dry.....she does not say that in her book...is there another source? Much of current media frenzy about awareness might be attributed to Aspect's marketing efforts, and the efforts of another woman who suffered awareness during eye surgery. Awareness is a real entity, and not something one can pass off on a dry vaporizer. As for the BIS monitor, I do not use it much myself, and agree that our vigilance is most important. On the monitor side of life, tho, I'm not sure I agree with an all or nothing philosophy....either trust it or not...I think patient context is pretty important. I don't always trust the pulse ox, either! :) thanks for listening.......

Well, jwk...jes take a peek at any good anesthesia reference, and there you will find it. Funny what a good read will do. Could be me, but you sound a little defensive. I think anybody would agree that good practice should have solid reasoning behind it. Devine was just asking a question....and that is exactly what students should be doing, and encouraged to do. Keep asking, Devine!

Emerald, I would guess that the anesthesiologist was concerned about ischemic optic neuropathy secondary to hypotension; prone positioning has been widely implicated. Short prone cases (a couple of hours or less) are of less concern. ION is well reported; a good literature search can give you more info than you need. Good luck!

As always, an interesting discussion. Most of the experienced clinicians I work with do not use the BIS monitor, even though it may be available to them. I believe they operate on the same principles that Yoga just talked about. I also know one with over 30 years of experience that uses a BIS monitor on almost every case he has (and he has no relationship with Aspect!). I would not dismiss the BIS monitor as being "voodoo" and completely unreliable. While I also question the marketing tactics, and to a lesser extent,the Aspect-backed studies, it certainly seems reasonable to include it in the armamentum, especially for a high-risk patient. The caveat, is of course, is that the patient's needs drives the anesthetic delivery, and not the monitor. I may not use it much myself, but I have no problem with those who do.

Hate to disagree with you, jwk, but physostigmine is, of course, a cholinesterase inhibitor, and has LONG been used as a reversal agent - don't know where you came up with idea that it has no indications as one. That being said....I certainly don't see it being used much these days at all, and have not seen any combinations as described above. Devine....sounds like an interesting mini-research project......My guess is that you will find most clinicians don't use it at all anymore. Good luck!

Good clinical scenario, Brenna's Dad. Thanks.... Just one perspective - there are many ways to skin a cat, as everybody knows. I probably would have done the exact same thing as you. By no means am I an expert (!) but it seems to me that we must be good at "tweaking"...trying something (that seems sane, safe and reasonable, of course...) and then watching what happens...then trying some else if need be. Anyway, thanks for a good discussion.....

Thank God for a clinical post! ....VERY interesting...thanks Yoga, et al...........wish I had more to offer, but sure looks like its being covered. We don't talk enough about hypothermia.....

Ok, DNSC - you talked me into it! :) Thanks for the replies......