I received a wonderful email today from Gina my Pal with a capital P. As you may recall Gina has been a practicing doctor of chiropractice medicine and decided that this was not enough for her. We have now been classmates for two years in the anesthesia program at the University of Southern California and will be graduating soon….this month in fact. This short note came today in an email from her which I just had to share. I will get back to you about what has been going on with me and why it has taken me so long for any new posting on this web site. Her letter follows. Thank you Gina for for your friendship and genius. You have been an inspiration to me.

Dear Class,

The clock is ticking my dear friends and we are so close to the end, my pulse is quickening as I type this. My very best hopes and wishes for all of you as you start your careers. You are such an amazing, talented group of people, and it has been a tremendous privilege to know you and experience this adventure with you. If ever I can be of service or help to any of you, please never hesitate to call.Which brings me to the point of my email. We are spending our last moments as the class of 2006, and already are starting to spread our wings; we know amy is headed to the great Northwest, and several others are looking across the country for our first positions (Aloha, Manda Manda?). I would like to propose that we elect one of us as a point of contact person for the Great and Wonderous USC Class of 2006; someone whom we could email or call for current contact info on a classmate. Douglas won’t have that usc.edu email address forever [unless he starts an affair with Dr. McDonaugh (sp)], and I’m pretty sure Helen will be getting a new address and phone number once she’s married. I know from past experience, as I’m sure you all do, how quickly a class can get scattered to the winds, all the more so with a profession such as ours where mobility is a key feature.

Is there any of us who would proclaim themselves stable enough for such a role? If I want to know what Joy’s new email address is, or Lunsford’s phone number, who could I call? Keep in mind that we could be using each other for letters of reference as our careers develop. Or in the case of Lunsford, I might just be thirsty and want to have a beer with my old friend from USC (Downtown Brown, of course). Remember part of why we chose USC was for the alumni connection. Since it’s not bloody likely most of us will be active in the USC Alumni Association proper, let’s create our own little Association. Let’s stay connected.

I immediately thought of either David Godden or Karen for the role, as they are both Uberorganized, and soon to be entrenched, I mean immersed at LAC/UH, which sounds pretty stable to me. Either of you interested? Somebody else feeling ultra stable and want to volunteer? I just don’t want to risk losing touch with this group of people I have learned to love like family (without the hairpulling, namecalling, and clothes borrowing dysfunction).

BTW, Karen, Godden, and Manda Manda, Dr. Yasafusifusi from Cedars spoke very highly of you today.

Have a great finale everybody. Looking forward to seeing you on the 2nd.

gina~ They can’t stop the clock!

So there you have it from Gina. You are such a peach. My bet is that Gina will be world famous one of these days. She has that special something, the charisma and intellect to really make things happen. It has been such a gift meeting her and the rest of the friends that I have made during these last two difficult years. Which brings me to why I have not posted more in the past months.
This is actually difficult to write or disclose. School, that is academics, is easy – at least for me. Many people struggle with memorizing vast numbers of facts but not me. I am pretty good at that. What has been difficult is dealing with the scrutiny and criticism of a few during clinical rotations. I wish that I could tell you that all it takes to be a great practitioner is intelligence. This is not the case. I have thrived in the clinical arena and done well in supportive environments and have suffered during difficult assignments where small people feel better about themselves when they can dominate and put others down – that means me. I guess this is important information for anyone that is interested in going on and pursuing nurse anesthesia. It is a difficult road where the gauntlet must be run well and no one comes through unscathed. This last month has been particularly brutal. I have survived and continue to thrive which is the good news.
This month of clinical rotations is in General Surgery at a big County hospital and it is our last. This past week has been very busy but wonderful, coming home and back to friends that I have grown up with in anesthesia. The surgeries here at the County have been complicated and intense but really interesting and handled well. My confidence has increased a thousand fold this past week which is the good news. I am so glad to be home.

So I have not written anything for a while now because I have been too stressed out, busy and just plain tired. Working 12 to 14 hours in the operating room then the travel time not to mention all of the preoperative preperation that has to go on just leaves little time for writting. You understand. Maybe this is all good information and will be taken to heart by anyone interested in nurse anesthesia.

Today I am happy to submit for your appreciation a true story. In some tales you hear the line the facts are true only the names have been changed. That applies to the “Road Trip” which was written as a sort of autobiographical recount from a long time CRNA. I hope that you enjoy this example of what it is like to be an anesthesia provider behind the scenes doing the every day work of an anesthetist. In reality this is something about being a rural CRNA keeping your finger in the dike, working hard to keep your skills up for when it really hits the fan; something about being “on deck” for half of your life knowing that in fact for 65% of rural hospitals, CRNAs do this “Road Trip” night after night. Enjoy.

Road Trip

“Damn, damn DAMN!” He thought. Two seconds ago, he’d been rushing across the hospital parking lot, thinking about all the things that could go wrong during an emergency anesthetic for a 400 pound patient, and all the things he’d have to do to make sure that none of those things would go wrong. Ten minutes ago, he’d been writing some last-minute Christmas emails and thinking about yet another New Year resolution to send cards next year.

As the initial shock and anger began to wear off, the hard reality of the slick, cold, gritty black ice of the parking lot began to make itself felt. His right arm hurt like a son-of-a-bitch, and when he tried to flex it, it wobbled uneasily, but bent very nearly as it should. “Nothing broken”, he thought as he picked himself up gingerly off the pavement and fumbled for his ID tag to let himself into the back door.

The reality of winter in the northland hit him, and he reflected that you could take the boy out of California, but you couldn’t take California out of the boy, and that, as long as he had lived in the North Weeds, he still had to remind himself that the footing could be treacherous. Then the reality of the life of a rural CRNA came back to the fore, and his mind tore itself away from the pain, and back to planning for the care of his patient.

Stercus contingit.

“Murphy”, he thought, “was an optimist”. What had started as a simple in-and-out look through a scope at the lining of his sedated patient’s stomach had turned into a desperate emergency. The high-resolution screen of the video system hooked up to the modern gastroscope had told the tale for the entire crew to see – a crimson geyser sprayed from a tiny hole in the lining of the man’s stomach. Under the magnification of the fiberoptic system of the scope, it looked horrible. “We have to open”, said the surgeon. Just like that.

“No plan survives initial contact with the enemy”, he remembered from somewhere in his past. That spout of blood was trying to kill this man, and the entire crew stopped and looked at him there at the head of the table, and he suddenly felt very alone. Quickly, he ran a mental checklist for a “rapid sequence IV induction”, a procedure that would quickly and safely exchange the patient’s fuzzy panic for calm sleep, and exchange the poor man’s labored breathing for the efficient mechanical swishing of a modern anesthesia ventilator pumping life-giving oxygen into the man’s lungs along with general anesthesia – the mysterious miracle that has been called “death with a return ticket”.

Years of practice and training informed his quick and efficient movements. Everything was laid out exactly where he knew it would be because everything was ALWAYS laid out where he knew it would be. Years of working alone in operating rooms where everything that could go wrong frequently did go wrong had prepared him to prepare. Even in preparation for the most seemingly trivial procedure, everything that might be needed was there. He knew that, sooner or later, everything that might be needed would be needed. Decades ago, he’d learned that, while there might be “minor surgery”, there was no “minor anesthesia”. In a series of steps that would have occupied several pages of some systems analyst’s flowcharts, but which took only precious seconds, his patient was asleep, a tube safely and surely in his windpipe, his blood pressure and pulse stabilized. With a terse nod to the surgeon and the man’s family doctor who’d been urgently summoned to help, he said “Go”. The incision was a small white rent in the yellow of the iodine-stained skin for a split second, and then drops of blood became a thick red line as the doctors went to work. He scanned all his monitors again, satisfied that his patient was responding as he should. Only then did he reach for the phone.

His partner of several years was home, and he breathed a sigh of relief as she answered the phone. A second pair of educated hands would be a life-saver – perhaps literally tonight. “Damn — I’m a one-armed bandit”, he thought to himself silently as he grunted with the effort of hanging another bag of IV fluid with his arm that did what it was told, but reluctantly and painfully. He could have finished this case alone, but he didn’t have to prove that to anyone, least of all to himself.

Within minutes the other CRNA had come. No questions asked no protestations that it was her night off – because it had often been the other way around and she knew it would be again. With a brief exchange of questions and answers that a visitor might have mistaken for a foreign language, he brought his partner “up to speed”. The doctors, heads nearly bumping over the deep incision into the man’s massive abdomen, murmured in a language all their own and the technician and nurse half-listened, preparing and handing instruments in a frenzy of movements that spoke of years of having done this. A hundred collective years of training and experience came together over the man’s blue-draped body, homing with a grim intensity on that “bleeder”, conspiring to cheat Death yet again.

The two CRNAs worked together in the small area between the head of the bed, the cart full of drugs and equipment, and the anesthesia machine. In a space barely big enough to turn around, they divided the tasks and worked together with a silence broken only by an occasional syllable or two; they both knew what had to be done. Within minutes, another large IV needle was in a vein in the man’s arm, and a slim needle had been run up an artery in the man’s wrist to monitor his blood pressure. With each task completed, their pace became less frantic but no less intense.

Finally, the doctors looked up. “Got it”, said the surgeon, and for the first time, he took a deep breath. “We’re closing him up, and you guys wake him up and we’ll transfer him”. The CRNAs looked at each other, and each knew what the other was thinking. This desperately ill man would “wake up”, all right, but it would be tomorrow, miles away, in an Intensive Care Unit, of which this tiny rural hospital had none. They also knew that the same freezing drizzle that had turned the skating lot into a parking rink would have kept the helicopters parked safely in some hangar somewhere, and that it would be a long and careful trip in the back of an ambulance.

One general anesthetic, with everything, to go.

The ride was long and bumpy. Each breath for the patient came from a plastic football-shaped bag, squeezed by his beat-up sore arm. He thought it would never end, but like everything else in his career, it did.

This past weekend Todd and I drove up to the CANA (California Association of Nurse Anesthetists) Fall Conference in Monterey. After a long day in the operating room on Thursday we took off for the Central California sea coast. We had to be at the business meeting bright and early Friday morning to witness the goings on partly for a school project and also to get the low down on what is really happening to our wonderful state of California in the anesthesia world.

The conference was not all business meetings and lecture. Todd and I were able to get out Saturday for lunch down at the wharf in Monterey Cannery row district for a sea side munch-out. We both were off of our tofu diets for the weekend. Besides, the wives were not here with us on the trip and we decided to let loose a little, not too much just a little. There is always next week to get back on the program of exercise and healthy living but this was a weekend to relax a bit. Both of us have been under a lot of strain from the demands of clinical rotations and needed a bit of a break.

During the conference we were able to hobnob with some of the great names in California history of nurse anesthesia but mostly we were there just to soak up the atmosphere. As seniors this year I think that both Todd and I have relaxed a bit and are enjoying these conferences a bit more than last year. The attendance in the Northern Californian meetings this fall seemed a bit down from last year but the tides on the shores on Monterey remind me that these things go in cycles anyway so not to worry. This coming spring should really be a big CANA conference some where nice. From what I have heard the next CANA conference is going to be in Palm Springs so we have that to look forward to.

One of the great things for me at the CANA conference is all of the vendors and the booths that are set up. The book seller was there with the new editions of Barash’s Clinical Anesthesia Fifth edition as well as the new Stoelting Pharmacology and Physiology in Anesthetic Practice. These are two of the must have books in my library. The new editions at first glance look like good investments especially the Barash text which has gone through extensive review. Keeping an up-to-date anesthesia library can be a daunting task but while I am a student I have determined to keep the most current texts available to me. Later on during clinical practice I will have to see which texts and books I upgrade with new editions but for now I am committed to this upgrade process. These texts are so new that Amazon does not have them listed but you can see the links to the older texts in my Anesthesia Library list.

To view all of the pictures that I saved from the trip – well not all of the pictures but some of them anyway – you can see the Slide Show at flickr.

Every once and a while you meet someone that has a dream. It reminds me of what it was like so many years ago when I fist started on this journey to become a CRNA. For some it comes easy and seems so natural as if all of the currents and winds place someone one the beach without any apparent effort. For me it has been so long and difficult a struggle to become a something more than what I was. Part of it is becoming a Certified Registered Nurse Anesthetist and the rest of it has been a journey of self discovery.

Meeting Dawn is a reminder of this and here is her letter to the NurseAnesthetist.Org blog:

Great post even though that probably makes me a nerd. A good example of how we can overlook the little things. Glad to hear all was well. Great timing with the CRNA in with you, Murphy’s law.

Take care,
Dawn