versatile_kat

I work in a private practice hospital and have really gotten adept at extubation with the dressing being put on. Once the stitches start going in, I reverse them (if needed), get them back breathing, titrate in any additional narcotics and get all my ducks in a row for extubation (face mask nearby, suction, oral airway, cannula, etc.). I extubate deep 95% of the time, so there's no worry about them bucking. I do this for almost all of my cases - from AAA's to LumLam's to Crani's. This way, once they're bringing the bed in, it's been about 5-7 minutes and the patient's regained their reflexes (enough to move them onto the stretcher and roll them out the door without real worry of a spasm). You can't be perfect 100% of the time ... your staff should be a little more tolerant of your needs at the end of the case. It'll get better as time goes on. How long have you been at this facility?

Wes - here's a cut and paste from one of my previous posts (July 2005) about missing an intubation ... "Most students feel like the intubation "makes" the rest of the case. If you get it in the first time, you function with a sense of success and think more clearly. If you miss it, that's all you can think about at the beginning of the case (when A LOT needs to get done rather quickly) and it kind of ruins the rest of that case - which then leads you to second guess yourself on subsequent intubations that day. Here's something I thought about any time I missed and it helped immensely! Intubating is a skill, just like IV's, A-line's, etc (albeit a more complex one). All it takes is repetition and some great clinicians to guide you and you'll get it eventually. So - when I miss on the first try, I step aside, focus on what the CRNA/MD does during their intubation and utilize whatever skill they showed on the next one. Whether it was getting a better sniffing position, changing the angle of my scope, switching blades or manipulating the cricoid before anyone else does to get a better view. All of these "pearls" helped tremedously in the beginning and kept my focus on the bigger picture of delivering anesthesia - not on how crappy my intubation was. This mindset eased my stress level tremedously going into the intubation and throughout the rest of the case (and you know how stressful you feel just starting out in clinical)." Don't sweat the intubations - pretty soon you'll be sinkin' em like Tiger!

There is also a great PDA program available from Skyscape called "The Manual of Anesthesia Practice". I would refer to it one the nights I was on call. It's a great reference, with tips that aren't in Jaffee.

I've always found that in my fluffier patients, if I go about 5 inches straight up from the crack, eureka! - you should take a step back and double check the desired insertion area before numbing them up and going in with the epidural needle. It also helps if they are as straight as possible, so have the L&D nurse help keep mom's position. Find the hips and get started - if you have to, tell mom you'll be pushing pretty hard on her back in order to find the correct space and use your index finger's proximal interphalangeal joint to start at around T8 and go down slow. Good luck!

I don't detect any sarcasm in either response to your original question - what both of them said is right on. Relax.

She means for acceptance into a program ... not the minimum you get when you fill your name in correctly.

Well - the main difference is your benefit package - it mirrors the anesthesiologists ... same leave, same 401K %, obviously not the same pay . But I'd have to say the reason I'm so happy at this hospital is because of the people. Everyone is part of a big team. I don't know about the rest of you, but it seems at large teaching hospitals everyone looks out for themselves, and you're lucky if you can remember 30% of the staff's names! Completely the opposite at my current job.

Well - since I just started my first job this past Jan, I can definitely say it is all I thought it would be. Excellent coworkers (both CRNA and MD), great OR staff, nice mix of ASA 1-4 cases. And the bonus - I work for the anesthesiology group and not the hospital so my benifits are superb. Plus - the town is beautiful and close to Charlotte, so I'm not too far away from big shows and great restaurants. Most of my classmates stayed within the system we trained at and I can say they are not as enthusiastic. I'm wondering if it's like that for most of the new grads that decide to stay where they trained ...

Come on people - lighten up! Paindoc appears to have a lot to offer when it comes to anesthesia ... we could use some more professionals on this board with quality experience to add to the clinical discussions. Give the woman/man a break!

:rotfl: That's pretty funny ...

Good point. I agree re: your routine and assitance being more of a hindrance than a benefit. In most of my clinical experiences, however, all I need to do is (while still visualizing the cords) hold out my right hand and the ETT is placed in it.

Well - this is refreshing. In my opinion - the time during the case in which the circulator is a great asset is during set-up and induction. From assisting with getting the patient onto the OR table, putting monitors on and helping keep the mask on their face (if no mask strap is available) while I get my drugs in line. Then, during induction, holding the ETT out to the right of the patient's face and possibly pulling the lip out of the way for intubation. We know you're busy throughout the case with surgeon requests/charting, so we try not to bother you with too many of our own requests. The only thing we may request is a new bag of warm LR (if your hospital has those) druing the middle of the case. Just keep that "team member" attitude you already have and your rooms will be the ones the CRNA's love to work in - you get what you give and vice versa.

The subdural space is known as a potential space that lies between the dura and the arachnoid membranes. It's called a "potential" space because it normally does not exist. Here is a quick link http://www.burtonreport.com/infspine/EpiduralSteroidAnatomy.htm As far as technique ... you comparing it to IV starts is not far off from the truth. Just like any skill, it takes repetition and good coaching to become proficient. At our program, we go to an affiliate site for a month (a birthing center) and start labor epidurals the entire time. Some of my classmates think starting an epidural is easier than placing a spinal. Good luck in school.

MM - I notice you are in home health ... you may want to get into an ICU before you start worrying about graduate level classes. That may give you more confidence when it comes to physics and chemistry, since you'll be working with patient's on ventilators (physics) with/without multiple vasoactive drips (chemistry).

http://www.aana.com/becomingcrna.aspx?ucNavMenu_TSMenuTargetID=101&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=1018 At your leisure ... http://www.kishhospital.org/health_services/pain_management.html An instance where a CRNA utilizes prescriptive authority ...

For my awake FOI's (not like I'm an expert - only have 9 under my belt), I anesthetise the airway with 5cc 4% Lido in a nebulizer (about 5-10min before heading back to the OR) +/- Cetacaine spray to the posterior oropharynx, depending on the patient. For awake nasal I use viscous lido in an atomizer + afrin to bilat nares with the above. As far as Ketamine goes, I make a mixture of Ketamine & Propofol (1:10) in a 20cc syringe, give the patient whatever he/she needs to remain comfortable and start the intubation. It goes without saying, they receive around 4-5mg of Versed in preop. This technique has served me well and the patients remain calm and comfortable throughout. A bit of advice - if your program is like many others, the FOI are not usually done by students. So speak up when you have the chance and try as many as you can prior to graduating - you don't want the first time you do one to be during an emergency when you're the only airway expert around. Good luck!

LOL - that's exactly what I was thinking.

Congratulations ... Just remember - humbleness is next to godliness in the OR. Where will you be going?

Great Post.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10625002&dopt=Abstract

Suss! Don't go givin' the incredible edible egg a bad name!

I've read through most of this discussion with disbelief ... but, Nephro, here's something you may find interesting about when CRNAs administer life saving drugs - it's done intraoperatively. Which usually means you're DNR order no longer plays a part in your immediate care (or for 48 hours postoperatively in most institutions).

I wish we were ... from what I've read - it may cause SCh to go the way of the dodo. Are you using it?

Titratability (depending on the gas), hemodynamic stability, amnesia, analgesia, and muscle relaxation. But, once you start school, you'll see that anesthesia can be delivered a million different ways. And unless you end up in a rural hospital or doing missionary trips, you'll rarely see halothane.

You are correct in that it's a conversion factor for Woods units (from Dr. Wood, the pediatric cardiologist) ... getting from Woods units to dynes/sec/cm5 requires a conversion by 80.