3ccBolus

Hey all- I'm an SRNA with a little more than a year left in school, and I'm here seeking some advice with intubation technique. I started out, as did the majority of my class, using the Mac blade for intubations. Most preceptors advised me to become competent with the Mac blade, and then transition to the Miller blade. At this point I am pretty comfortable with the Mac blade. The majority of intubations go smoothly, however, it seems like every 25th case or so I run in to the same problem. Its always the same problem, and I'm not sure how to fix it. The problem is that as I enter the posterior oropharynx and lift up, I will have a great view of the entire epiglottis, completely covering the cords. My first inclination is to go deeper in to the vallecula and lift again, but for some reason this often does not work. I then apply cricoid pressure, and at that point I might have a grade III view, of just the most posterior aspect of the aretynoids. I can maybe sneak an Eshmann through and save the intubation, but sometimes not. A lot of times when this happens, it is not on patients who appear to be anterior, or whom I would expect to have difficulty with their airway. I have yet to find a solution for the scenario of blade in vallecula, epiglottis completely obstructing view. This happened to me yesterday on an African American 6', 240lbs patient, with a mallampati 2. I was using a Mac 4, and repositioned the blade as deep as I could once I saw the epiglottis was obstructing my view. I'm just not sure what else to do besides reposition the blade, and/or use cricoid pressure. The thought that keeps coming in to my head when this happens is: "I wish I could directly lift the epiglottis." This leads me to think that perhaps I would avoid this situation with a Miller blade. Has anyone had a similar experience? Is this one of the limitations of the Mac blade, or is it just a limitation of the person wielding it? Should I try to transition to the Miller blade to avoid this scenario? Any tips appreciated. Thanks, 3cc

One thing I kind of wish that I had done before hand is paid more attention to the Anesthesia flow sheets on my ICU patients. (If your hospital has flowsheets) It will give you a good idea of the drugs that they are using, and in what dosages. You can research them on your own from there. Also it might give a little insight into the things that anesthesia is responsible for that you wouldn't necessarily think of. You might be able to get a little bit familiar with some of the extra monitoring going on in the OR, like end tidal gasses, CO2, Train of four (you may already be using this, depending on your ICU), BIS monitors, etc. If you just kind of look over the flowsheets you might come away with a few concepts that you want to read up about on your own. I also think it might be helpful to review the development of an action potential if its been a while since you looked at cellular physiology. A lot of the foundations stuff will draw on this basic understanding. Its hard to understand HOW a drug works if you don't understand what is happening in the cell. Maybe also refresh yourself on the different adrenergic receptors, what each one does when it is stimulated, and which vasoactive drugs affect which receptors (alpha 1, 2, beta 1,2, dopaminergic, cholinergic). Be able to say Epinephrine acts on ______, ______, and _____ receptors. You'll definitely get all of this information and more in school-- but you may have a little less studying to do when you start if you look it over now. I wouldn't get too crazy in to it. A solid understanding will you put you in a really good place when school starts. Besides all of that, I would definitely take a vacation, enjoy your life, and scratch a few things off of your bucket list. Take care of any of those things you've been wanting to do for a while, because you most likely won't be able to for the next 2.5-3 years. Good luck!

I second the Morgan & Mikhail suggestion. It's a great book to get started with. However, some of it probably won't mean much to you until you start school, and are immersed in the anesthesia world. Good luck!

Haha,- Yes, I was fortunate enough to land a job in a high acuity ICU right after graduation. I basically knew that I wanted to be a CRNA straight out of high school, so that helped me not waste any time, and helped me focus my efforts. Not that any time spent practicing nursing is a waste by any means. I worked for 2.5 years with some of the sickest patients in my area, and very little support in the way of new technology or adequate staffing.. So I think it toughened me up pretty well and gave me the clinical knowledge that I need.

I am one of the youngest in my class at age 24. I think our range is from 24 to 40.

Propforall- I think you made the right decision. You will be exceptionally well rounded when you begin your program.

Goody-- I work in a 40 bed ICU. There are probably around 10-15 open heart surgeries per week. So at LEAST once a week I am taking care of a fresh open heart patient who is still sedated and not yet extubated. We recover and extubate the hearts on the unit rather than in a recovery room. I also see a multitude of critically ill medical patients, and other big surgeries (like big belly surgeries). I started off in the Neuro ICU, and frankly I felt like I was NOT going to get the type of experience that I needed for anesthesia school. I rarely saw Swan Ganz catheters. I used pressors on occasion, but never the multitude of vasoactive drips that I use now. I had ventilated patients all the time, but we were rarely weaning the ventilator aggressively for extubation. I think weaning lets you learn a lot about how to troubleshoot vents, what different settings are really good for, etc. The sickest neuro patient I ever had did not make me think nearly as much as the healthiest open heart, or septic patient I've had. Honestly, I felt like the only nursing interventions that I was doing in Neuro was either: Steroids, Mannitol, or the Operating Room. Of course you do have to be vigilant in neuro and recognize change quickly, but from a nursing perspective I think your interventions are extremely limited. I got out of there, and I have learned a ton more and I feel ready for school to start. I would advise you to check out another area if you can. At worst you will be a more well rounded ICU nurse. That's how I feel. I can take an extraventricular drain no sweat, or an intra aortic balloon pump. Experience different things and you will learn more. There are nurses who go to anesthesia school with only Neuro experience. Maybe some of them can chime in on whether or not they have felt well prepared. But my recommendation would be to try and get as much experience with other patients as you can. As far as stats: 2.5 years ICU (5 months of which were neuro) 3.7 GPA (BSN) 1140/4 GRE CCRN

I'm leaving for school next month, and currently have 2 years 4 months experience. At the time I interviewed I had almost 1.5 years.I have felt infinitely more comfortable at my job after about month 14, and even more so at the 2 year mark. I feel like I can handle whatever they might throw at me now. As far as how much experience I think is necessary-- I think I'll have a better idea once my school starts... But I think I'll be fine.

Did you get GradPLUS loans on top of your Federal Subsidized/Unsubsidized loans? I took out the max on both GradPLUS and the Sub/Unsub loans, and that leaves me an excess of $5000 per quarter to live on, which translates to about $1660/month. Its not much money, and probably not the standard of living you're used to with ICU RN pay, but its only for a short time. My goal is to use the excess loan money for rent and NECESSITIES. I'm going to school with about 14k saved up in the bank, so I'm going to try to use that for all the incidentals. Hopefully it works, I start next month, we'll see how it goes. If realistic rent is $1000/month you're either going to need to get a roommate, have some money saved up to help with your expenses, or maybe move out of Miami to a less expensive area.

I'm still waiting here.. I guess that means maybe I'm still in the running? Kind of expecting to see a rejection email every time my phone tells me I have a new message in my inbox. So I guess phone call is good, email is bad?

Any updates for anyone? I interviewed in December, and I'm pretty sure the March interviews are done with... I'm expecting notification one way or the other soon. Anyone else heard anything?

That sounds ludicrously unnecessary. Has the surgeon ever provided a rationale for this? A gas on a sedated and ventilated patient isn't going to change that dramatically very quickly. You can look at a newly extubated patient's condition and guess what their gas will look like, and draw it if/when needed. A crit shouldn't drop real quick, and if it does you should see other indicators about what's going on with the patient (chest tubes, hypotensive, tachycardic, low filling pressures etc). A machine that does this automatically, and checks some things q hour is a really unnecessary cost in my mind!

Likewise-- Bummer. But I guess I'm Cincy or Pitt bound now. Not bad schools either.

Amiro-- No I have not received an email from them yet. I am hopeful though after reading that they won't be done emailing until the end of January. I put in my application on the last day, so perhaps they are working their way towards me.. ? Good luck to you!

Hey, Amiro. I'm from Tennessee. I got a letter in the mail yesteday stating that they needed further information about my stats class. Unfortunately my undergrad school has very uninformative class titles. My stats class was named "Data Analysis and Practice," which doesn't reveal much about all of the work we did with chi-square distribution tables, univariate stats, bivariate analysis and blah blah blah... So hopefully a letter from the school can clear that up. Haha, this is the second school that, at first glance, has taken issue with the curriculum of my large state school, fully accredited four year university degree!