The time has finally come to put the “Junior SRNA” title away and pick up the new “Senior SRNA” moniker. Starting this coming Thursday our class will have officially started our senior class rotations and the specialties that go with it. The monthly rotations will start September 1st and change with each coming month for the next year. Of course there will be some rotations that last two months, specifically pediatrics, but each month on the first we all will be shifting gears and on to a new experience.

For me, I will be starting the cardiac surgery rotation at Los Angeles County Hospital. This is a shared experience with the MD resident. Fortunately for me I will be with my good friend AJ who has shown me so much in the past. AJ is a 3rd year anesthesia Resident at the USC Keck School of Medicine program and was there when I started my clinical experience at LAC-USC Hospital.

The way it works is that we share the cases alternating each day who puts in the lines while the other person does the airway management and takes credit for the case. We can not both take credit for the case for certification purposes but the learning goes on anyway. In this way we both get the most out of the experience and for me this is totally acceptable. I will be finishing up my general surgery rotation at Arrowhead Regional Medical Center in Riverside tomorrow and AJ will do the preoperative evaluation for me so that I do not have to travel after a long day in the OR and then do the preop at another hospital for the next day. That is a relief.

David and two Texas Weslean Students at Arrowhead Regional Medical Center

Finishing Up at Arrowhead Regional Medical Center

Being at Arrowhead Regional has been a really great experience. This past month the schedule has been really good for me. In the morning a Whipple procedure is scheduled for my room. This will be the second Whipple for pancreatic cancer that I have done in the past two weeks. These are really big surgeries with the necessity for central line placement and central venous pressure measurement, arterial line placement before induction and two large bore IV’s for access. In addition I will be placing an epidural catheter for post operative pain management. All of this requires extra time so after discussing these plans with the MD attending staff this afternoon the patient will be in the preoperative holding area at 6 AM for the line placement. At least I will get the epidural and arterial lines in and after this gentleman is asleep we will get the central line secured.

David behind the Blood-Brain-Barrier during a hand surgery case

Looking back over the past year and seeing the growth that has taken place is easy today when I think about this Whipple case and how I am comfortable with the issues in the anesthesia management for this surgery. A year ago just getting a patient asleep was a major big deal. So it’s good to review how far we have come and to reflect on what is yet ahead to learn and grown in. This coming year of specialty rotations is bound to be extremely challenging and rewarding in all that we will learn. I am so much looking forward to all of it, the hard work and the satisfaction of knowing that we all have done a great job taking care of our patients when they are the most vulnerable.

The end of the First Year at USC Anesthesia School has come at last. At the end of the month of August – it has come so quickly – will mark the beginning of our senior rotations. This means for me that I will start at LAC-USC in the Cardiac Surgery rotation September 1st.

To celebrate the occasion a little letter from the Chief CRNA at LAC-USC is recorded below. Kari Cole is one of the most outstanding CRNA’s I have had the privilege to work with and her letter of encouragement is heartily welcome by all of the new senior students.

Dear All,

I hope this email finds you in good spirits.
Here are a few housekeeping issues:

1. BACKPACKS:
If you haven’t already, please reduce the size of the backpacks you are bringing into the ORs. At this point, the only thing you need to bring in the OR is ONE reference book, a couple of pens, stethoscopes (regular and precordial) and maybe a nerve stimulator and head strap (depending on where you are rotating). You may want to think about losing the backpack altogether and move into something a bit more professional like a black attaché.

2. VALLEY REVIEW:
For those of you who are planning on attending Valley Review Courses, please inform me (and the schedulers at other sites) when you are planning on attending. Since you are now in the ORs on your own at LAC, I will need to know when you will be out for the review.

3. POLISHING:
Start working on polishing your skills. You all have the basics down, now start fine tuning your anesthetics and your approach. Push yourself to try new things…..do NOT use roc and propofol on every induction! You may have to “sell”: your plan to the attending and/or CRNA, which can be a lot of work but in the long run, it is worth it. You need these skills (anesthetic and interpersonal) before you graduate.

4. CHANGING OF THE GUARDS:
The seniors are graduating and you will be taking their places as seniors and as mentors. The new group starts in a week and a half so be prepared to meet and greet your new colleagues in the ORs and in class. Remember, first impressions are lasting impressions! Think about the senior that impressed you the most when you first started. Were they: approachable? genuine? enthusiastic? helpful? Your attitude makes a world of difference to those individuals who are just starting.

5. CONGRATULATIONS:
Be sure to give yourself (and your classmates) a pat on the back and/or a congratulatory hug for successfully completing the first year of the Program!! YOU ROCK!!!!!!!!!!!!!!!

Aloha,
Kari

Kari M. Cole, CRNA, MS
Chief Nurse Anesthetist
Assistant Clinical Professor
Keck School of Medicine, USC
Department of Anesthesiology

May you always do for others and let others do for you.

Josette Salas, RN BSN

Josette Salas is an RN from California. She has worked as a traveling nurse in some of the busiest Medical Centers on the West Coast including UCLA, USC University Hospital, Cedars Sinai and others. Her specialties includes Cardiothoracic ICU and Neuro/Trauma intensive care. She comes to Nurse Anesthesia School with a lot of great preparation and motivation.

Hey Gang, How is it going for everyone? I have been reading the blog and it sounds like everyone has been very busy. FUN FUN FUN at the old anesthesia corral. My clinical rotation is not as scary yet as others so I am kind of jealous about that. But I can’t wait for the good stuff to come around. Right now I am just doing a lot of hernias, D&C’s, laparoscopic stuff, tons of Orthopedic surgery and hysterectomies.

I can finally say I like the MAC blade and I have been pretty successful with tracheal intubations these past two weeks so I am feeling better about the whole induction thing. I hate placing Laryngeal Mask Airways but I am getting the hang of those too. You know I have small short fat fingers which is not helpful.

Today I got to do a spinal anesthesia case and ooooh-la-la first one here so of course I was all thumbs and asked a lot of dumb questions. Learning is such a great adventure but I hate feeling stupid all the time. I can’t wait till I am past that point of feeling stupid every single day to where I am feeling stupid just every other day.

I love using local anesthetic for my IVs starts. I think all nurses should do this but I don’t know if this is in the scope of practice for the RN instead of our purview as Advanced Practice Nurses in training – Oh just give me a break already!

OH I am going to the Washington DC in August for the annual AANA meeting which lasts for 5 days. I have never been to DC so this is going to be cool. I want to see the Capitol building if I can.

Currently I will be ending a rotation at the end of this month and then I will be going to the big Buffalo General Medical Center so hopefully I will see some interesting cases there. I don’t know when I will have the opportunity to go to the County Hospital for a Call/Weekend shift. I don’t think everyone here gets to do this but I am excited about doing this and am planning of learning so much there. I want to get the experience to equip me to handle anything that comes through the door.

Right now I hate the summers here in Up-State New York – it is like tropical hot humid disgusting nasty weather kind of place. Did I tell you about the winters here? Now it’s funny because the people here are just happy that it is hot and not frozen over like it was a few months ago so there’s no place like home.

Anyway I am going on and on. So take care and good luck with the rest of your current clinical rotations and I will write again soon. My picture is in the mail if you know what I mean.

24 hours in the OR on Holiday weekend

Yesterday was my first 24 hour operating room call. I have had to do other overnight OR scheduled time before but this was the first time I was scheduled for an entire day. Being a Saturday night and a holiday weekend made for several interesting cases.

During the day on Saturday we were busy with pick up ortho cases that were left over from the weeks work. Nothing to big just a couple of ankle fracture repairs, an elbow and an incision and drainage of a big old abscess. Nothing like the night to come.

I thought that the Los Angeles County hospital had all of the action but I was mistaken. It seems there were a few parties that got out-of-hand out here in the Inland Empire and friends started shooting friends, brothers started stabbing brothers and what not. We had two ORs going until the very early morning. At 03:45 we broke the two ORs for 15 minutes and then the final gun shot wound came up. It seems this guy was shot through and through across his hips taking out some of his bowel – he had blood in his stool and needed emergency surgery. This case ended up pretty messy and did not finish until 6:45 just 15 minutes before I was scheduled to leave. Oh joy – I can go home now.

All in all for the 24 hour schedule I did 6 cases, a couple of them fairly long. I did get an hour nap Saturday afternoon around 4 o’clock so it was not too bad. Looking at the coming schedule I will be doing another overnighter next week and the following week another 24 hour shift on the weekend. Thankfully it is not a holiday weekend and maybe the natives will not be too restless.

16 Hours in the OR

This past week on Friday evening through Saturday morning I spent in the County Hospital operating room providing anesthesia to the never ending trauma cases that come in over a weekend. Maybe it’s just me but the natives are too restless it seems – especially when you combine alcohol and illicit drugs to the mix.

The last two cases were really special. One a stab wound to the face and the second a gun shot wound to a very drunk mans leg. The stab wound case was technically difficult to secure the women’s airway due to so much bleeding from her cheek and tongue laceration. Really it was more of a HUGE laceration. Her domestic partner, I believe, thought that she was stealing all of his cocaine or crystal meth or what ever and thought to teach her a little lesson. The stab wound went through her cheek and tongue to the other side of the face. You can imagine that there was a lot of blood in her airway. The lady was pretty hysterical and we just induced her (put her to sleep) quickly while she was sitting up on the gurney. After unconsciousness the attending anesthesiologist and I laid her down quickly while the surgeon held some pressure to her cheek. Two suction catheters going and ten seconds later she was intubated and her airway was secure. After that it was simple. I am really glad that the attending anesthesia staff was there to help out. Now that is not something you see everyday. The surgery was fairly straight forward and we left her intubated overnight to make sure the bleeding was under control and her airway was secure.

The next guy had the rudeness to try for another six pack at closing time at the local drive through liquor store at 01:50 in the morning. Evidently there was an altercation of some sort, who knows what really happened here because the guy was so drunk and combative. He came to us in the OR at about 3:30 in the morning just after we had finished up with the younger lady and the stab wound to the face. I could not even close my eyes for a couple of minutes. This guy was really out there jumping all over the place. We could hardly keep him on the gurney let alone transfer him to the OR table. After 10 milligrams of midazolam he saw it our way and we were able to get him to the operating room table and start the case. He ended up with facsiotomies of his calves and some vascular reconstruction. All this for another beer. Seems like to me he had had enough but who would have thunk it.

All in all doing a clinical rotation in a large county hospital and being able to take weekend call time shifts is a great clinical experience. There are things here that you see and do here that are not available at other times. The lack of sleep is not something that I cherish but I would not trade the chance to do this rotation. I will be at this facility for another three months and will be taking overnight call once a week in addition to the regular days during the week that I am there.

The routine week day cases are fairly standard type cases. The obstetric floor is covered by the student nurse anesthetists as well and we see a fairly large population of caesarean sections, tubal ligations, and labor epidural placement management type things. So the mix of cases here is really nice. Right now I will catch up on some sleep and then hit the books for an exam that is coming this Monday.

Being a nurse anesthesia student has its ups and downs. The stress is pretty intense and there is a lot that is demanded of you both academically and clinically. I love it when you are trying to get a difficult case started and the staff starts asking you questions about the case and all of the pharmacology and pathophysiology involved just when you are trying to get the endotracheal tube placed. If you thought that chewing gum and rubbing your tummy at the same time was difficult come join us for an afternoon or maybe hang out and spend the night at the County Hospital during a holiday weekend. Now that would be an education worth remembering.

The past several months have been so terribly busy that I have not written anything, I mean not written anything for any of the projects that are web based that I have going. The end of our first clinical rotations, finals and of course personal stuff that always comes up has kept me from writing and keeping the Anesthesia Log up to date.

Finals are finished, thank God we all passed. USC is a tough educational institution. One of our classmates decided to drop out for personal reasons and she is planning on coming back next year if the creeks don’t rise. We all wish her well. The rest of us are on to new rotations.

This semester Gina and I are at Arrowhead Regional Medical Center located in Riverside County California. This is one of the home sites for the Texas Wesleyan students and the Texas Christian University Students. The clinical site also has students from the Kaiser program and from the Navy. All in all the experience that I anticipate at Arrowhead Regional is going to be fantastic. There are NO anesthesia residents MD types only SRNA’s from these several programs which cover all of the operating rooms 24 / 7.

I am starting this week at Arrowhead and will certainly keep a running log of how things are going with Gina and myself. Its great to have a friend like Gina at the same clinical site together. I feel like our friendship is growing stronger since we now have a clinical site together. That is a great plus. Hopefully in the coming weeks Gina and I will be able to make some contributions to the Anesthesia Log that will be important.

Back to study time now.