Athlein1

They let me fly the coop, too! I am officially done and looking forward to January exam/start dates. Words cannot express the elation and sense of accomplishment (and relief, honestly) you feel when you are done. At the same time, you know there is still so much more to learn... To those of you who are pursuing this path, keep at it and don't give up. If I can do it, then you can do it! This is a fantastic profession that's worth every bit of effort you put into achieving this goal. Good luck to everyone. Will try to post interesting stories now that the preceptor has exited the building and I am on my own!

CRNAs can do emergency trachs - not surgical, to be specific. But there is a nifty device that should be in every OR (or at least readily available) called an emergency crichothyrotomy kit. Here is a link that shows you what it looks like: http://www.progressivemed.com/emsproducts/airway/emergency_airway.html You insert this through the cricothyroid membrane and use an adaptor to attach a jet ventilator. A surgical tracheostomy is a procedure performed by a surgeon, not anesthesia. It takes even skilled surgeons several minutes to perform this procedure, so it is literally the last option in an emergent, can't ventilate/intubate scenario.

Really? If that is the case this early in your experience, then I would rethink the technique of LMA placement. LMAs are used in the difficult airway algorithm because - correctly placed - they are so reliable. One of the CRNAs who proctored me has been giving anesthesia for nearly forty years, and he told me this very early on: Do not tell me that you cannot ventilate. It is YOUR JOB to ventilate the patient, so you better %^&*ing figure it out. Maybe, maybe once or twice in your career will you have a patient that you really cannot ventilate. Then, it's up to you to get oxygen into that patient by whatever means necessary. Until then, don't tell me that it's the LMA, or the habitus of the patient, or some other excuse. Look to yourself first before you go blaming the equipment. And don't tell me that you cannot ventilate. You MUST ventilate. I cried the whole way home that afternoon. But here I am, just a few weeks from graduation, and I am thankful I learned that tough lesson early on. I know that it will rear its head someday, but I have not been in a "can't intubate, can't ventilate" situation ever since. I haven't had to change LMAs, intubate mid-case (except for the one time that a small case became much bigger when the surgeon ran into an unexpected surgical issue), or chuck the LMA for the tube at induction. If the ventilation is sub-optimal for any reason before the case gets started, the case doesn't start until ventilation is adequate. Seems a no-brainer, but we have all worked with providers who have a questionable LMA and just "hope that it gets us through this case". That is courting disaster. You MUST ventilate.

this is a cross-posting from ogp - and a tragic example of why the airway is not the most important thing, it is the only thing! also, an interesting question brought up on ogp: why was a healthy young woman who appeared to be of normal body habitus intubated nasally in the first place? doctor's error to cost $35 million county to settle suit over brain damage by mickey ciokajlo and tom rybarczyk tribune staff reporters published october 4, 2005 cook county is set to approve a $35 million medical malpractice settlement with a woman who suffered severe brain damage after undergoing a botched procedure at a county-run hospital. the woman, a 30-year-old mother of two, was subjected to the failed procedure at oak forest hospital only because physicians there had misdiagnosed a viral infection as appendicitis, according to the lawyers involved. the case is one of the largest settlements in cook county and matches a $35 million settlement reached last year in a case involving an anesthesiologist at northwestern memorial hospital that left a boy brain damaged. that case did not involve the county. "the facts in the case are horrible," said cook county commissioner peter silvestri, chairman of the board's litigation subcommittee, which approved the settlement last month. "the settlement is justified and certainly should be paid." at its meeting wednesday, the county board will be asked to approve the settlement, a record for it in medical malpractice cases. william maddux, the presiding judge of the law division, approved the settlement last week. under the terms, the county would pay $20 million, with insurance carriers funding the remainder. the case involves neveen morkos, a christian who immigrated to the united states to avoid religious discrimination in egypt, and dr. gustavo albear, an anesthesiologist. morkos and her husband, hany, moved to tinley park in february 2004 to live near family members, who had immigrated a few years earlier, said eugene pavalon, the morkos' lawyer. they did not have health insurance, so when neveen morkos experienced acute stomach pain on may 19, 2004, an ambulance drove her to oak forest hospital, which has a small emergency room. cook county runs three hospitals that provide health care regardless of a person's ability to pay. problem misdiagnosed doctors told morkos she needed an emergency appendectomy. it was later determined that she had a viral infection that did not require surgery. albear, who was 78 at the time, was called to prepare morkos for surgery. albear medicated morkos to get her muscles to relax. since morkos would not be able to breathe on her own while medicated, albear then inserted a tube through her nose to provide oxygen to her lungs. however, albear did not secure the tube properly, pavalon said. when the tube became dislodged, albear was unable to reinsert it, depriving morkos of oxygen. by the time surgeons were able to perform an emergency tracheostomy to provide oxygen to morkos, 10 to 12 minutes had passed. she then went into cardiac arrest. "there was no doubt that the negligence in this case caused this tragic occurrence and neveen's irreversible brain damage," said pavalon, a lawyer with the chicago firm pavalon, gifford, laatsch & marino. "so not only do the circumstances justify this record settlement, but this is one of those traumatic occurrences that simply should not have happened." after the incident, morkos initially was in a vegetative state, but she has improved. though she requires round-the-clock care and cannot walk, she can now say her husband's name and recognizes her children, halana, 6, and victor, 3, pavalon said. she also can write in arabic. morkos is in a burbank nursing, but her family desperately wants her home, pavalon said. the money from the settlement will allow them to build or buy and modify a house and provide in-home care. morkos was not working at the time of the incident because the family was newly arrived in the country and she was caring for the children. she was college-educated and had taught computer science in egypt. she was always looking for a better place," said nermeen morkos, neveen's older sister. nermeen morkos said she visits her sister every day and looks forward to bringing her home. "we hope she can walk someday," nermeen morkos said. "we are praying to god; we are waiting for a miracle for her." albear could not be reached for comment. when asked in the deposition he gave for the lawsuit if he remembered the episode, albear said, "i will recall for the rest of my life." albear retired in 2004 after the incident, said patrick driscoll, head of the civil actions bureau of the cook county state's attorney's office. oak forest hospital did not discipline albear and state records do not show any previous disciplinary issues. he renewed his license with the state last summer, but driscoll said he understands that albear, who turns 80 on wednesday, is no longer practicing. although no parties in the case directly blame his age, pavalon said he thinks it was a factor. albear also had arthritis in his hands. "i think probably he never should have been in that [operating] room," pavalon said. no age restrictions silvestri said the county does not have age restrictions for its doctors. he said when this case was discussed in committee, commissioners asked county officials to research the issue after they were told that some hospitals impose work limitations based upon age. through a spokeswoman, officials of cook county's bureau of health services and county board president john stroger's office declined to comment before the board's approval. albear worked for 23 years at palos community hospital before retiring in 1994. in his deposition, albear said he got a job at oak forest hospital six months later, noting he enjoyed his work and wasn't ready for retirement. commissioner mike quigley, vice chairman of the litigation subcommittee, said albear's age was not so much the issue but rather his overall ability to perform. "the more you hear about the case, the worse it gets," quigley said. "someone should have been able to determine that this physician was incapable of performing critical procedures. he shouldn't have been in a position to fail."

I would consider this option only if you have NO other choice. I have been a commuter for most of my CRNA program (we change sites every other month, and the nearest site is 45 minutes on a good day). I calculated my average commute time to be between two and four hours per day for over 80% of my program. I have been in two accidents (neither my fault, just the unfortunate result of the number of hours and miles I have spent in my car). My car is a mess and I am physically and emotionally exhausted from commuting. Road time takes away from study time, too, so expect to have to put in longer hours at home studying at night and on the weekends. It can be done. I am weeks away from graduation, and I haven't committed hari-kari yet, but I am seriously close. If I had to do it all over again, I wouldn't think twice about selling my house and moving closer to school. As I said, the mental and physical price I have paid to stay put and commute has been very, very high. Good luck with whatever you decide.

Darien, To answer your question about PDAs - no, I am still not using one, even though I am in the homestretch with only a couple of months of school left. I have the time to learn to use it now, so I am definitely going to get a good one in the weeks to come. I think it is a very worthwhile investment for any SRNA, even one that is as technologically-challenged as I am. I hate computers and anything even remotely related to them (with the exception of the iPod, which is the most brilliant device ever, and makes you a hero in the OR when you bring music the surgeon likes). But, I cannot even count the number of times a preceptor has asked me some random trivia question that I would be able to answer on the spot if I only had a PDA. And forget about toting books around. My first M&M book only survived until my first ruptured AAA, and then it was a bloody biohazard mess. So, long answer - get a PDA, learn to use it, and reap the benefits in clinical when your preceptor asks you how to use etidiocane or some other obscure question!

The annual meeting has a review course that spans a couple of days as well. FYI - we are also hearing that the format is changing due to the issues with testing last year. I wonder if anyone knows if that is rumor or truth?

No.

Not trying to be incendiary here, as I come from a military background myself and would be in the military now if it weren't for a medical disqualification. But, I notice that you didn't mention the attrition rate. I just returned from the AANA meeting, where I met a student from one of the Armed Services programs who told me that their attrition rate is close to 50%! Even worse, they just cut a student 3 months away from graduation. That's tough odds, man.

One correction: Anesthesia providers are always required for ECTs because a muscle relaxant and induction agent are used to prevent injury from tetanic muscle contraction and lower the seizure threshold. It is a general anesthestic, albeit a very short one.

Thanks for the guidance, Kevin. As always, we appreciate your input!

Look at M&M on the section that describes the laryngeal notch - p. 78-9. I worked with two excellent clinicians who showed me how to perform this technique, and I can tell you that it really works when correctly applied. The key is to use enough pressure exerted in an inward/upward fashion. It has rescued me more than once...

I tried it once for a rapid intubation, though it was not a true RSI. Despite divided doses, patient flushed red as a beet within just a few seconds. BP in toilet, impressive tachycardia. Healthy adult, fortunately. Took quite a bit of neo to get it resolved, as I remember. By the time I was done treating the hemodynamic changes, the patient was bucking. I have used miv successfully a few times for T&As PSR, and it came in handy when I switched from a private practice clinical setting back to a teaching hospital. During the few days it took me to readjust to looonnnnng closures, I used it for relaxation after the intermediate agent wore off and before extubation (nimbex + miv). I can also attest to the foolhardiness of mixing benzylisoquinoliniums and aminosteroids. Did this with vec + mivacurium as described above. Pt was significantly weak for over an hour! Caution!

It's three months to go for me, too. Are there any other graduating seniors who are starting to get a bit freaked out because there is so much more to know before graduation, and yet so little time? Every time I think I have this thing under control, I have a crappy day where I can't get epidurals in, I miss an intubation, or my mind can't bring forth the important stuff I have learned when I am on the spot. Is this a normal feeling? I am wondering if others are feeling this, too, or if you are just so focused on finishing and getting a job that the "I-can't-graduate-because-I-still-have-more-to-learn" hasn't set in...

The "everything else" is the amount of work you have to put in, and the stuff you have to put up with, in order to get through a nurse anesthesia program. It is no cakewalk, and the math is the least of it. Read the FAQs at the top of the page, and then scroll through the old threads for awhile. We get lots of posts just like yours - people who are not in the nursing field who are suddenly attracted to nurse anesthesia because they are considering their "earning power", as you say. There is so much more to this field than the paycheck. Take the time to shadow a CRNA, and decide if nursing is right for you, before you embark on a change of career plans that will take you at least 7-8 years to complete.

No, I don't get to spend much time with my family at all. None of us do - it's the price you pay. I have missed birthdays, weddings, and much fun stuff over the past three years. If you are not prepared to commit to an educational process that takes 60-80 hours per week of your time and leaves you emotionally and physically exhausted, then anesthesia school is not for you. If you want a job that gives you shift work, little professional responsibility beyond doing your shifts, and no call, anesthesia is not for you. My advice - get through your nursing program and then reassess your plans. It's still too early for you to know what you will like in the nursing profession.

Loisane, Thank you very much for your reply! It was much appreciated! Guess I will keep the soapbox around... Jess, Good to know that you did not take my post as a personal affront. Here's an interesting thing about your reply. . I think that you will find as you begin school that these two issues are, in reality, inextricably intertwined. Csojet, I will be happy to tell you about Thoughtbridge. And, no, it's not really linked to Scientology, though some anesthetists do feel that it is a far-out concept with as much likelihood of success as a Spacestation on Mars. I have to study, but as soon as I get a chance, I will post info about it. Good for you for getting interested early!

What does RN vs CRNA salaries have to do with CRNA and MD relations? For those of you who do not like to read my soapbox rants, stop here now. I think newbies entering this field would do well to remember that there was a time not long ago that anesthetists were not making six figures, yet their level of responsibility and professional commitment was - in many cases, arguably - higher than it is today. And, the salaries of today are absolutely no guarantee of future compensation. I worry that we are creating our own salary bubble in this field. I am also worried that we are creating a cadre of graduates who expect a 150k package right out the door, and oh-by-the-way, also expect 6 weeks paid vacation, no nights, and no weekends. They don't care who stupervises them or whether their scope of practice is limited by some dude who thinks that being a physician and pushing a CRNA's drugs somehow makes him a superior anesthestist. I am in the interview process, and 150k sounds high, especially for a new grad. It's more likely that such a number represents a total compensation package, which includes paid vacation, insurance, and other benefits, or an independent contractor position. I know lots of CRNAs who make more money than that, but their position comes with heavy call responsibilities, and they are putting in some serious hours at the head of the table. Do CRNAs have skills that should be compensated at this level? Absolutely. There were very few times when I was a nurse that I left the hospital with my work still on my mind. Now that I am close getting launched, and won't have the reassuring presence of a preceptor who can save my a%*, I can tell you that I feel the weight of this responsibility daily. It is much more common for me to get home still thinking about my day rather than leaving it at the hospital lobby at the end of my 12-hour shift. This is not directed specifically at the previous poster. It just sets me off when we are having a discussion about the current political climate and the salary issue gets thrown in there to muddy the waters. Because let's face it, there are many SRNAs in school right now who want nothing more than a nice paycheck and relief at 3pm. Without students in the pipeline who feel passionately about more than their compensation, this profession could be in trouble. How many students know the latest opt-out states? How many really even know what that means? What is the status on Thoughtbridge? Who thinks Thoughtbridge is an offshoot of Scientology? If we really want to show respect to our predecessors, let's worry less about how we are going to spend that salary and worry more about how the hell we are going to maintain the level of practice that we currently enjoy (which is solely due to the hard work of our predecessors). Excusing myself now...

Good stuff! Okay, let's give it a few more days to see if anyone else speaks up, then perhaps we can begin to plan something. Merriment before the "Party with a Purpose" event might be fun...

Wondering if anyone would be interested in a meet-and-greet to network and put faces to names. A mini cocktail party after the day's lectures, perhaps?

The only school on the West coast that can be considered inexpensive (relatively) is Kaiser. Like Gaspassah said, all other programs are affiliated with private universities/colleges, with correspondingly high tuition. You don't necessarily get what you pay for when it comes to anesthesia education, either. So, you may want to broaden your search if lower cost is a priority.

Thanks for the replies. Very interesting! Students whose programs send them to pedi hospitals or give them dedicated blocks of pediatric time definitely are a step ahead of those who get minimal exposure. And FYI - I talked to two different prospective employers this week. Both expressed surprise that I hadn't done many peds yet, and they seem to expect that new grads are comfortable with routine peds. So, SRNAs, I guess the message is that we need to get those peds cases whenever we have the chance, even if we have to scrounge...

Just curious! Because we don't have a pedi-specific rotation in my program, most of my class are not doing much (if any) peds under age 2. It's a bit worrisome since graduation is right around the corner. Apart from getting the CCNA minimums, which is certainly an issue, we are wondering if new grads are generally expected to have a good deal of pediatric exposure. Also, are CRNAs out there doing kids without pedi anesthesiologist oversight (other than routine T+A & M+T, hernias, and such)? It's a big issue on the West coast, so it would be interesting to compare it to practice in other areas.

1. Yes 2. No

No, she is just humble and self-deprecating. Anesthesia school tends to do that to you.