Gina Wald, DC BSN CCRN

Gina comes to nurse anesthesia practice prepared as a doctor of chiropractics. Her experience includes several years as an RN in a neuro/trauma ICU. Her insightful assessments and understanding of anatomy is enormous. Here are a few of her insights at the start of clinical anesthesia rotations.

Though I am not the blogging sort, I am supportive of this forum; I would have loved a resource such as this when I was investigating and applying to NA school. The webmaster has graciously invited me to “join the conversation”, so here I am…

We started our first rotation a month ago, after a meager but grueling semesters’ preparation. I will never forget the tension in our classroom the week before we were to be cast to the lions.

Even the loudmouths of the class (myself included) were scared into silence. We knew what to expect, and while all 16 of us started this journey anticipating, even desiring a life-altering residency experience, we were scared. It was a strange mix of “I can’t wait to get started” and “Wait, I’m not ready yet”.

I am in the “kindest” of first year rotations, a So. California Veteran’s Administration Hospital where the CRNAs and attendings are brilliant, eager to teach, and supportive of our endeavors. And still I am exhausted. I cannot find time to do it all. I feel strapped beyond belief. I want to read more, to know and contextualize more, to have time to reflect on all that I am learning and doing. But there is no time. I determined last week that I must stop working, as much as I love having a place to go where I actually have some competence. It’s time to leave the nest, and begin the plummet we all must take before feeling our wings.

Days in the OR are wonderful. We start morning conference at 7:00 am with the CRNAs and Attending anesthesiologists. We present our cases for the day, and take whatever beating is dealt out. They kindly remind us that while we have looked everything up in the books, we still don’t know much about anesthesia. It’s important not to take it personally, and I worry about those of us with too thin skin. (Dermal hypertrophy should be listed as a prerequisite for all NA programs). There is no coddling here, but I know they are grooming us. We have only 18 months to go from inept to competent. I love the regional anesthesia exposure we are getting at the VA. As a chiropractor, I know my hands are good, I know the anatomy intimately and can visualize the structures as I place my needle. This is fun for me. Intubation is another story, and while my first couple seemed easy enough, I have struggled since then, taking in everyone’s advice, trying to keep my frustration from invading my thoughts during induction. There is always something I forget to do in a case, and I wonder how long it will take me to “get it”.

I love what we are doing. I love watching the transformation take place in my classmates, and feel my own mind making a very clunky shift. The skills and knowledge I brought from my experience as a neurotrauma nurse serve me well, but the thought process in anesthesia is a different paradigm, one which is much more in line with my background. This is such an exciting time, and everything I was looking for. If only I could get some sleep. To be continued….

David Godden, SRNA

This marks the near mid point for our first semester clinical rotations at the Los Angeles County Medical Center. After a month and a half I have to tell you that I am tired but still very excited to get up at 4:30 every morning to go the hospital and set up the OR. The days are long and difficult at times but so interesting.

The cases that have been completed in this first six weeks have been various general surgical cases. This last week I was in the ER room on Friday and had the good fortune to be able to take care of a 3 year old with a perforated appendix. Little Lucia was so sweet. My preceptor Jim taught me to have her play with the inhalation mask before the induction so that she would not be afraid of the mask when we gave her oxygen. Lucia had a working IV so we discussed the options of an IV anesthetic induction verses inducing anesthesia with sevoflurane. My choice was for the mask induction since I had never done this before and had only read about it knowing the advantages for pediatric cases.

What made this situation additionally stressful for me was all of the people around. I am nervous enough at the start of an anesthetic especially during the induction period. Not only was my preceptor and the Attending Anesthesiologist behind giving me all of their well appreciated advice but Kari the Chief CRNA at the County Medical Center was there with her student Anya. Kari and Anya were between cases and wanted to turn the heat up on me. Actually, little Lucia’s smile was so engaging it was a magnet for everyone around so it wasn’t me they were interested in. It just felt like I was on the Hot Seat with a lot of people observing. Throw in a couple of surgeons and there were enough people for a party with me as the director. Oh my God, I had a Zen moment.

We all trailed off to the OR after I had given Lucia a milligram of midazolam. (Figure that out – 15 kg at 0.1 mg/kg and you get 1.5 mg of versed). The one milligram was not enough and I gave her another one half once we were in the operating room. I was recalculating all of the medication doses a couple times in my head and was getting overloaded. We scooted her to the OR table and handed her the mask. At this time she was pretty groggy but still reached up for the mask feebly.

On the OR table after the sedation she was very calm and took the mask oxygen very nicely. I turned on the sevoflurane and off to sleepy land in a few minutes with an easy hand mask ventilation technique. After a couple of minutes of a mask sevoflurane and rocuronium for muscle relaxation, I was able to do a DL (direct laryngoscopy) with a good view of her vocal cords. Her trachea was intubated without difficulty with a 4.5 uncuffed endotracheal tube and the surgery was begun after another few minutes of preparation. I was almost in a trance myself.

The interesting thing about this surgery for me was not just the first pediatric case but the surgeon. The attending surgeon was someone I knew from UCLA from a few years back. At the time she was a second year surgical Resident doing a month of rotation in the cariothoracic ICU. Eventually she became the Resident of the Year in our Unit. We became quite good friends and it was very nice seeing her again after her training now teaching others. The open appendectomy was performed quickly under competent hands and Lucia did very well.

When I woke Lucia up at the end of the surgery she cried a little even after giving her some IV morphine. My preceptor picked her up from the OR table and carried her back to the PAR unit with me dragging the oxygen tank and IV bags along behind. That must have been a sight. I have to tell you even with all of the work, the lack of sleep and the stress of performing with so many watching eyes, the sight of little Lucia cuddling up on the shoulder of Jim my preceptor on the way to the recovery room makes all of the work and stress worth while.

Gina Wald, DC BSN CCRN

Gina comes to nurse anesthesia practice prepared as a doctor of chiropractics. She is a first year student of Nurse Anesthesia at the University of Southern California. Her experience includes several years as an RN in a neuro/trauma ICU. Here are her first suggestions to James a prospective nurse anesthesia student.

James,

I am a first year SRNA at USC in California.

I knew before I started nursing school that anesthesia was where I wanted to be. While I loved working in ER, I chose my first nursing job in ICU, because I knew I would need experience with invasive monitoring (PA catheters and arterial lines) vasoactive drips, and ventilators. Those were my priorities. I would have started NA school after only a year, but decided to have a baby instead, which pushed back my plans. But the time in ICU was well spent, and I don’t regret one day of it.

There are students in our class who come from an ER background, and they will be the first to tell you that they feel intimidated by some of the ICU type stuff with which they are unfamiliar, but they are doing just fine and we will all graduate as safe and competent anesthetists. I know one CRNA who had all of two months experience when she started the NA program, and she is a fine and knowledgeable anesthetist.

I agree with David that the best thing you can do for yourself right now is to meet with or speak on the phone with several program directors, fax them your CV and ask where you could strengthen it. I did this before I graduated and it gave me a very clear plan of action.

I wish you all of the best in your endeavors. Do not give up. This is the first test of many regarding your perseverance and determination. You must really want this, and don’t let anything stop you.

Gina Wald, DC, BSN, CCRN