Anesthesiology News – Is QT Prolongation A Valid Reason To Abandon Zofran?

 

 

 

 

 

 

 

 

Anesthesiology News – Is QT Prolongation A Valid Reason To Abandon Zofran?.

CRNA Student – End Semester 6 of 7

Once again the end of semester has dawned upon me. In retrospect this semester has been one of great strives in the clinical arena. As skills start to refine and your own personal anesthetic technique starts to emerge from bits and pieces from numerous anesthesia providers you have worked with, a desire for the end and independence takes form. The next 4 months will be a struggle to finally reach the end of the marathon I’ve embarked for such a long time of my life.

In this blog post I would like to address two aspects that are currently on my mind. First the job outlook in current nurse anesthesia practice and later lateral violence that continues to ensue in the healthcare industry.

While jobs are no longer plentiful in the field of anesthesia, It would be extreme to say the field is completely saturated (at this point). Like so many times that I’ve mentioned before to those who have asked me through this blog, there are still jobs in anesthesia, but being willing to relocate is essential during this time. The outlook for the near future is even of greater disparity between job supply and demand as schools continue to pump out more and more students as programs run rampant in offering more slots to potential nurse anesthetists. While creating a large cohort of anesthesia providers to care for the aging America, it worries me that this not only floods the market but enables less prepared students access to what was once known as a prestigious group in the nursing field that favored knowledgeable and respected practitioners. Truth be told, jobs are becoming scarce by the year, and like most other job markets in the U.S. competitiveness for job placement is a reality. Salaries have started to drop the 6 figure mark and for those who plan to live off financial aid, repayment will certainly become challenging especially if job placement is not immediate.

Finally, I would like to express sorrow for our profession in due respect to the ever evolving lateral violence we experience as nurses. It seems that ever since the wheal was invented so was lateral violence in the healthcare industry. What amazes me even more so is that usually practicing CRNA’s are the culprits even more so that Anesthesiologists. I cannot generalize because I have experienced great clinical experience with both flavors of anesthesia professionals, but must admit supervision by anesthesiologists in most cases warrants an experience conductive to learning. While some students tough it out, others feel more inflicted by the “care” professionals and choose a way out. It saddens me to admit that as caring professionals we are able to focus so much in the care of our patients but choose to treat a “future” colleague with disrespect. The fundamental aspect in this picture is that not all are created equal, people have different ways of interacting with each other, some are introverted and others extraverted. Some like to talk and are socially outgoing while others sit and listen. People come in all flavors and the only thing that should be evaluated is their performance and knowledge. This of course while taking into consideration that they are students and as such are there to learn. When even licensed 20+ years experienced practitioners make mistakes, we as students are many times demanded perfection.

I am signing off for the year and wish everyone a Merry Christmas and a Happy New Year!

Midtrimester 6 of 7 CRNA School – CRNA School Review

Moving along towards the light of the end of the tunnel. Trimester 6 of 7 is well underway. Just finished my 2 months in obstetrics and managed to rack up well over 100 spinals and epidurals combined. I really enjoyed OB, initially the challenges of regional anesthesia was unsettling while I acquired the feel for the technique. Fortunately with plenty of practice I found myself doing it faster and my success rate soared until I felt competent to handle anyones back. Like any other thing in anesthesia, time and practice is of the essence.

I am now in the process of preparing for my SEE- exam. It is mandatory in my program and attempts to prepare the student for the environment and questions one would expect when taking boards. For this challenge I decided to go through all of Morgan and Mikail once and Valley sweat book once. I have recently finished Morgan and just started Valley this past weekend (Still have 500 pages to go). Hopefully my score and statistics will show me where I am deficient and direct my subsequent study for boards hopefully by mid to end of May 2012.

In midst of the last class graduation and the numerous schools available in Florida, compounded by a plethora of private messages I have received through this blog and my account at a popular nurse anesthesia forum where I am member I have decided to write a small review of my program.

It is my understanding that there is a vast number of available anesthesia programs in Florida and in the U.S. It can be deduced that some programs are definitely better than others, but one thing is also certain, there exists standards and a commissioned body to oversee that “minimum standards” are accomplished by all these schools. To say one school is best or worse is a personal perspective that are different even among students from the same class or program. Someone might consider their experience in a program marvelous while others detested their experience.

With that said, I can only acknowledge what I know from my program, because I have not been to another school for comparison. Moreover, in my review I will attempt to answer some of the questions I have received in this blog about my program in a bullet format.

• There are 3 permanent staff members (PD included)
• There is a lab with a human-like simulator  (STAN) and 2 anesthesia machines.
• You don’t compete for cases with other schools. We are the only anesthesia provider students in the FH system.
• There are about 7 hospital sites, all from FH we are assigned to.
• There are 20-22 students per year.
• You are given at least 2 months in OB. Plenty if spinals and epidurals during that time.
• All lectures are in the campus (No online).
• Lectures are mostly through the 3 staff members.
• A handful of lectures were from previous students (I don’t think this applies any longer).
• A few lectures are from Anesthesiologist that practice at the clinical sites.
• Pharmacology was introduced by an anesthesiologist entirely during the first trimester.
• Peripheral regional is somewhat limited. Although a specified rotation exists, not all anesthesiologist will let you do them. That is currently being worked on.
• Plenty of opportunities for central lines, Swans and A-lines during your 2 months in Vascular and Hearts.
• No specific trauma rotation. Your trauma cases will be sporadic cases when you are at night.
• Sporadic independent practice. 97% of the time there will be a MDA or CRNA in the room with you. As you progress into your senior year, they are more inclined to leave you alone and let you handle difficult situations.
• A cadaver lab is now being implemented.
• 2 classes have graduated thus far. First pass rate was low (as can be expected from a program that just started) but the second class that graduated is above national average at >90%.
• I will probably graduate with 1100 to 1200 cases.

I’m sure more can be said in respect to the program Im in, and will be happy to answer any further questions directed to me. For now I’m signing off.

Wrapping up trimester 5 of 7 CRNA school

Wrapping up trimester 5… its a great feeling. Research papers done, projects presented and a whole lot of time in my hands except for the 40 hours in clinical rotations. 2 more weeks till trimester’s end and I can’t stress enough how much I’m looking forward to my upcoming vacation. I managed to pull off 1 week off for the AANA conference in Boston back to back with 2 weeks off for vacation. In all this results in 3 weeks off from school and clinicals. I can’t stress enough how I really need this time off, I find myself easily irritable at this point. Now on to the nitty gritty….

As previously described, classes during this term have been a breeze, and all projects and papers are ready for submission. Conversely, clinical rotations never stop, and during my Neuro specialty rotation I’ve had the opportunity to play around with managing narcotic drips (Remifentanil, Sufentanil) in a daily basis. Its definitely  a different form of doing things, since right anesthetic balance is essential to maintain appropriate SSEP and MEP monitoring. All in all its a different technique but nothing out of this world. Attention to ICP’s and prone positioning is also a big part during this rotation. Other than these minor technicalities, it is a case lie any other and vigilance is key as with any other anesthetic plan.

Now on to the political side of things… Overall my clinical experiences have been great, I can’t praise enough the school and anesthesia group for the wide range of experiences and expertise there offered. Working with a large anesthesia group allows us to experience a wide range of techniques and you realize there is 101 ways to skin a cat. Conversely, you can also become irritated when someone bashes you for attempting to do one thing (stating that it is wrong) when you just did it the day before with someone else and it was considered perfect. Take home message here is, whats absolutely right for one practitioner may be extremely wrong to another. You must adapt not only to the patient but to the practitioner in a daily basis. With that said, my only true rant from my program is the lack of “independent days” or as some may say, running your own room by yourself without someone there the whole time. Although instruction and direction is always appreciated and I’m aware I need it, it is a huge short coming to hardly ever run your own room throughout a program. I must admit they do allow independent days sporadically while being very limited. For the last 3 months 4 of my classmates have been allowed to do it, once each. It is important to note that this is not the rule, many programs offer independent practice throughout your senior year. I believe there are both pros and cons to this. Pros are obvious, you learn to make decisions for yourself and work thru problems. There is definitely a “sphincter” factor that plays a role. The cons are that you have less direct instruction that could have molded you to a better practitioner. Many things happen during the case, and insight of each individual practitioners actions in order to reach a resolution may mold you to react more effectively when your on your own. I believe a balance of supervision and independence is the most appropriate choice.

And now to my rant… so new CRNA grads just started in the O.R this month, while most are well aware of a senior’s level of experience at this point, I had to listen to one explain to me that there is 50mcg of fentanyl in 1ml and we should use at least 2 liters of flow with Sevoflurane because of compound A buildup. “Thanks, go to know.” All sarcasm aside, I appreciate someone trying to teach me, but give me some credit for the time I’ve been here, I know it is not much and that I have tons to learn, but really… 50mcg in 1ml… thats pushing it.

Nurse Anesthesia Semester 5 of 7 underway

Semester 5 of 7 is underway. I can’t blaim my long hiatus on school work, this term has actually been a breeze. Taking two non-anesthesia related classes which demand little if any effort. My absenteeism has actually been due to me taking back my life; back to the gym, dinners with the wifey, family visits, and having some “me time.” I cant help but see how far we’ve gone in the world of anesthesia. The juniors started observation in the OR this last week and it is clearly visible how my classmates and I have come a loooonnngggg way. Its funny to see how little things we take for granted today are a big deal for those who are just starting, its truly amazing. I am very proud of all my classmates who have gotten this far. Now, with only 9 more months to go, I have a glimpse of the light at the end of the tunnel.

So, as can be ascertained, my focus has been shifted to worrying about exams and quizzes to worrying about the flooded job market and boards. Lets see what happens…

CRNA School End of Trimester 4 of 7

Yet another mile stone has been met in my program and I can’t be happier. With basically all major anesthesia classes left behind me, I can now sit back and concentrate on clinicals for awhile without worrying about next weeks exam or quiz. Its a great feeling to be able to arrive home after a 10-12 hour clinical day and be able to relax instead of picking up a book. With that said, I know the remaining 1 year I have in the program will not be without its challenges. While minor “BS” classes will still entail the remainder of the program, I will also have to start reviewing the material I have learned during the last 16 months in order to be prepared for boards at the programs end. I plan to review Valley, Morgan and Michail, and Nagelhout between mid summer and April of 2012 when I’m scheduled to graduate. I believe that by reviewing this material on my own throughout the year will be better than trying to cram everything during the last few months before graduation.

On other news, I have grown increasingly worried about the job outlook for CRNA’s in the past few weeks. The market seems to be saturating by the day, and although I still believe there will be jobs by the time I graduate, I have no idea where I may have to relocate to. Central Florida where I live is completely saturated and securing a job in the healthcare facilities where I train will be almost impossible due to their increased hiring rate in the last few months. South Florida has been like this for over a year now, and many who have been hired in central Florida came from south Florida and the north east region due to the scarcity of jobs. Its not looking pretty.

As always, this is a phenomenon that is market related, but as time passes between now and the time I graduate the viable markets in the US are shrinking. I really don’t know what it will be like 1 year from now, only time will tell.

Getting into Nurse Anesthesia School

Frequently, I am approached by nurses who wish to transition into nurse anesthesia. While the greater majority of your nursing unit or nursing class colleagues/classmates may say they intend to go to nurse anesthesia school, most “greater majority” wont. Not because they aren’t capable, but something called “life” gets in the way. Motivation and dedication are also huge variables to this equation. With 113 nurse anesthesia schools in the U.S. and counting, chances are… if you really commit to this goal, you will reach it.

Getting in might not be easy, but its not difficult either. If you take the steps… BSN…GRE…Application…Interview…, more times than none you will be accepted. And if you had the drive to takes those steps, you will most likely succeed in what is most difficult…”staying in”. Don’t be fooled, its extremely time consuming and stressful, but its ultimately possible for the majority that engage in this journey.

So next time you here 99% of your unit or classmates say they are going to anesthesia school, nod your head, say good luck, and know that less than 10% will actually take the steps necessary to move toward this goal, and even less will actually get to actually apply. Furthermore, don’t put off your application because you think you should “beef up” your application with CCRN, or upper level classes. Apply wherever possible as soon as possible… more times than none, if your willing to relocate, and have put out 3 or 4 applications… you will most likely get in somewhere. Remember, the school you go to doesn’t matter, you are judged ultimately by boards, which is the same no matter where you get trained. In the other hand, getting in earlier than later will make a big difference in your pocket and in the prospective job outlook.

SRNA Life Mid-Trimester 4/7 Update

Wow, has it been over 1 month since my last post? I must be slacking. As can be presumed by my lack of blogging, this term has been a busy one, specialty rotations started while still taking on a heavy class load. But the feeling that this insanity will soon be over is bestowed me. Although graduation is still a good 13 months away, after this trimester I’ll be done with all the major core anesthesia classes. Classes wont be over, for the remainder of the program, there will always be some minor subjects to go along with 4 days of clinicals throughout the remainder of the program.

Enough about me and on to anesthesia…. As previously stated, specialty rotations started and my first rotation was in pediatrics. I must admit I was initially intimidated my the little rascals, not having children of my own didn’t help either. After being broken down on the first couple of days, I eventually opened up to “playing” with the kids in pre-op while allaying their fears. I’m usually very serious and for me to break down and start talking “kids” language and throwing my surgical cap in the air (pretending it is a parachute) was not a easy task. It almost seemed more difficult than the anesthesia itself. Fortunately, I got past that, and by that rotations end I was becoming a “big kid” myself. Furthermore, particular to this rotation is the technique of inhalational induction that must be used in kids without peripheral IV’s.  You must use your non dominant hand to hold the child’s head (occiput) while holding the mask with your other hand. Seems simple enough, but at times the child will trash all over and swing their head side to side. It is important to move with them while securing the mask and not immobilize their head with force. Also particular to this population is their laryngeal anatomy, which is more easily tubed with a straight blade. So my advice is, if you are using the MAC blade in general cases and know you will be in pediatrics soon… start practicing with the Miller, it will make your life much easier.

For now, I’ll be ending this blog post. I have a slew of exams coming up and must use my time wisely. For all of those out there expiring to become CRNA’s…. good luck!

Moving along CRNA school

As always… moving through the motions in becoming a CRNA. Last couple of weeks I’ve noticed a drastic improvement in my clinical skills and am feeling a little more confident in managing my patients in the perioperative period. Classes as always are engulfing my time, and I can’t wait for the end of this trimester (as always). These will be the last 2 hardcore anesthesia classes in the program and then I will only have 1 year of “BS” classes and clinicals to worry about. In a sense, this is the last challenging term in my program.

Furthermore, I will be starting specialty rotations in February. These include mainly : Peds, Cardiovascular, Vascular, Pain, OB, Regional, ENT, ICU. It will be fun to learn the intricacies of these patient populations while perfecting my overall anesthesia care.

For now I’m signing off… the weekend is almost over and I have many chapters to go through.

3 trimesters down 4 to go – CRNA School

For those who wondered if I were still around, fear not, I have not withered away, nor have I’ve been scorched so badly in clinicals that i’ve given up my dream. The fact of the matter is nurse anesthesia school is extremely time consuming and even a few minutes to an hour writing and editing this blog is sometimes difficult. Since my last post lots has happened, clinicals have gotten better, and although some preceptors are more challenging than others, my overall experience has been positive. I have not since the last post encountered a truly “difficult” preceptor and for most part, all are willing to share their knowledge of anesthesia with us students.

Moreover, as the post title clearly discloses, my first year in nurse anesthesia school has ended, and I  cannot be more thrilled to think that after one more year I will be months away of graduation. This term was hectic due to clinicals eating away 4 days out of the week and having to rely on only 3 days for didactics. Fortunately I still managed to scrape away with straight A’s, but just barely in one my classes.

Changing the subject altogether, and what might be more of a downer than anything else, the job market for CRNA’s are looking bleaker by the week. One thing that must be considered while deciding to partake in nurse anesthesia school is one’s willingness to relocate to wherever. I mildly joked with one of my attendings this week when he asked where I intended to go when I graduated. I said…. “who knows, the way the job market is lately, I’m starting to think I’ll end up in some remote city in the middle of nowhere.” He smirked and kindly replied “yeah… there’s a lot of you guys around lately.” The take home message here is … be willing to relocate if nurse anesthesia is your plan. I’m not saying its impossible to find a job where you want, but its becoming highly unlikely and chances are you will have to move. Personally, I don’t mind relocating, one of the reasons I decided not to buy a home or build roots where I am is because I might have to pickup and move the moment I graduate.