Correspondence can bring many things. Recently there has been a lot of mail, much of it from friends and family with discussions of life, projects and goals. I even had a request for money recently from a needy soul that could not be turned down. What I wanted to share today was a series of communications from this last week that has occupied my mind for several days. Maybe after reading these you too will pause and consider what a gift we have been given to serve and learn from our patients. Their contribution to us is tremendous and must never be forgotten. This is a sacred trust that I am appreciating with a new understanding. Thank you Jim for that. It starts with a letter from Jo. I find her vignette interesting and instructive but what comes later is beyond instructive. Let’s see what you think.

Hey David, here is a funny story,

As student nurse anesthetists we are fortunate to have some common sense especially since we have some critical care background and have actually touched patients. Anesthesia physician residents often do not have this luxury. They get thrown into an operating room because they have graduated form medical school and are expected to perform. While SRNAs are guided on how do things should be done in the operating room for a long time.

Recently I heard a story about a M.D. resident that was interesting. The surgical case involved a patient scheduled for a total knee replacement with an epidural catheter and an Laryngeal Mask Airway (LMA). A Nurse Anesthetist enters the OR to send the physician on a break. The patient is breathing 38 breaths per minute and chewing on the endotracheal tube. The physician states, “Oh that’s new this must have just started”. Propofol is then slammed intravenously and B/P drops precipitously and then the low blood pressure is then chased with ephedrine trying to bring the blood pressure back up.

There is a lesson to be learned here. You can’t blame the physician resident because many times when they are new in their training they do not have sufficient oversight. The patient obviously needed something other than slamming propofol - possibly a dose of narcotic and not hypnosis. The epidural was infusing but did the patient get a loading dose up front? These things may all effect how the patient was tolerating the surgery. What I have seen clinically is that when epidurals catheters are working well you need far less opioids and less volatile agent as the MAC is lowered. These patients usually wake up very comfortable.

The morale of the story is to feel good about the education that we receive as nurse anesthetists and feel proud to be apart of this prestigious profession of Nurse Anesthesia. Remember that 65% of all rural anesthesia is given by Certified Registered Nurse Anesthetists (CRNA’s). Some day you might be taking care of me or my loved one and I want the best and most competent anesthetist on the job.

Jo

At first I glanced over this note from Jo and scribble a few notes to myself while reviewing the many interactions that I have had with residents. Jo is a dear friend of mine - however I find that her reasoning incomplete. At least there is more here that is bothering me that I can not mine fully. She states correctly that patients with epidural catheters require lower MAC and less opioids then proceeds to disparage the hypnotic and suggest that the patient needs additional opioids? I began thinking that the idea of giving more opioid for a light patient is the wrong choice and her criticism of the resident could take a different slant. For me the propofol is not a wrong option but the lack of vigilance by the resident deserves comment. So ran my thoughts. To confirm my suspicions I ran off a note to a friend, we’ll call him ‘John’, a long time anesthetist back East. I was dealing with the trees and not the forest. My thoughts continued at that time this way:

John,

I was not there in the OR and all of this is second hand information but an interesting discussion about CRNA SRNA and Resident relations mainly. We all have our prejudices I guess. For me the physicians do just fine and receive extensive training. At times in the beginning of their training there may be things that happen that are not the best practice. Who is to say that Student Nurse Anesthetists do better really? Personally I do not find it profitable to compare providers but to look for a best practice regardless of the practitioner. John, I thought you might get a kick out of this story and look forward to your comments on the scenario. Hope all is well with you and that your scheduled surgery goes well. I am wishing you all the best from Los Angeles.

David.

The response I received back has been lingering in my mind for the past few days. When I started the NurseAnesthetist.org/ web site my goal was to try to put together something with content that would be both instructive and entertaining while showing what it is like to be a nurse anesthetist student. John goes beyond my expectations.

Hi, David

I have many thoughts tumbling through my head at this stage of my career. As to the story your friend related, I find your take on it to be the more reasoned. Yes, the average SRNA is probably much more oriented to the care of the patient, by virtue of the nursing background. This stereotypical SRNA is also more clinically astute because s/he’s been on the front lines, watching actual patients get better or get worse and die, so s/he has earned to look at everything, make no assumptions, and always to keep that “sixth sense” activated whenever s/he is responsible for a patient. Those hard-earned lessons from the ICU on a 12-hour night shift do stand the SRNA in good stead.

And it’s probably true that the average MD trainee at whatever stage of her/his training is probably less experienced and clinically seasoned; more educated in basic sciences than the average RN (notice I said “more” educated which doesn’t necessarily equate to “better” educated). But a friend of mine long ago put it this way: “Good nurses know a lot about medicine while good doctors know a lot about nursing”. When I look back to the people who had the most influence on my developing anesthesia career (and it’s STILL developing) I find nurses who took it upon themselves to be very educated (and very WELL educated) and physicians who had that common sense and humanitarianism that is stereotypically viewed as the hallmark of nursing. What each had in common was a curiosity that motivated their learning, a humility that taught them that their learning would never end, and an empathy for the suffering patient who was at once her/his sacred responsibility and greatest teacher. The other thing they had in common was my enduring respect; you see, I’ve seen callous CRNAs and empathetic and truly altruistic physicians. We must be careful not to be guilty of that error which we decry in others: judging an individual by the letters behind the name and not the character attached to the person.

As to your friend’s assessment of what was needed, we all know that anesthesia is a complex specialty. From first principles, the patient should never have been allowed to come to such a state, under the care of an anesthesia provider, that the patient was chewing the tube and breathing 38 breaths per minute. The rescue of the patient from that unacceptable state can take many forms, some better than others. The bolus of propofol was a “fast” answer. Fast is important, but one must be careful not to overshoot lest one have to engage in the “dueling drugs” scenario as your friend described chasing blood pressures all over the place. You made another astute observation: “I wasn’t there…” This is a very mature approach to analyzing anecdotes about cases; you know that not everything that happens can be reduced to marks on an anesthesia record, and that even the most careful observer is biased to some extent.

I have a feeling that neither you nor your friend would have gotten yourself into the situation of needing to rescue the patient from inadequate anesthesia. In a couple of jobs I’ve had in the past, we’ve had trainees rotating through the anesthesia department. Now, I’m always careful about generalizations, and the following observation is given with the very large caveat that generalizations are poor tools to explain things. That said, I noticed that there were in general two “styles” exhibited by anesthesia trainees. One style was more “high tech” and the other more “high touch”.

One manifestation of this was the manner in which the trainee monitored the patient. Some stood with their backs to the patient and watched a bank of monitors. These tended to miss things that a more experienced onlooker would see evolving before they manifested themselves on the monitors. These were the “high tech” ones. Many were very intelligent — far more so than I — and usually more educated as well. As a generalization, these were doctors. Others gave their primary attention to the patient, and looked to monitors as a secondary information source, to validate their clinical impression of the evolving anesthetic. Most of their time was spent seated or standing in close proximity to the patient, their backs to the monitors. Sure, this has elements of a false dichotomy, but by and large, these latter were nurses. They didn’t treat numbers, they treated patients. And they usually “picked up” things before the “things” became “problems”.

Sometimes the “high touch” crowd couldn’t even characterize what it was that was about to go wrong. Usually the “high tech” ones could recite the “book learning” about what had just gone wrong. If you haven’t found this out already, in anesthesia it is frequently the case that we are too smart too late. You’ll also know the daily reality of something I once read: Most great discoveries are presaged not by the exclamation “Eureka!” but by “Gee. That’s strange….”

The only good thing that came out of Jo’s experience is that you are talking and thinking about it and learning from it. The occurrence of inadequate anesthesia in this patient — the failure of our specialty, the patient’s trust betrayed — became, if you will, a “chance experiment” in the laboratory that is your learning. No Institutional Review Board would ever have approved of the situation into which this patient had been allowed to deteriorate, even for the pragmatic good of your learning. But it happened. Remember, “stercus contingit”. You have been handed a learning opportunity, purchased at a very high price by your patient. Learn from it, get all you can out of it. And, as you progress in your career and teach others, remember the debt you owe to that patient, in whose care an error was made, allowing you to learn from the remediation — and yes, even the “cover up” — of the error.

Here is where I have a huge problem with many physicians with whom I’ve worked. There’s an attitude of entitlement. “I earned this degree. I got out of training with six figures of student debt. I am owed”. No. Wrong, wrong, wrong. They are who they are, they know what they know, and they have what they have, because of an unending string of patients who held still for their first clumsy attempts at the laying on of hands, who suffered at their mistakes as they repeated lab tests and painful procedures, who died at their imperfect hands — at all of our imperfect hands. David, I submit to you that this is a debt that can NEVER be repaid; the currency to satisfy such a debt has never been minted, nor could it be.

I recently had a physician make some comments to me in passing. I think he meant to encourage me; I’m not sure. He commented on my skill at regional anesthesia, especially in the massively obese parturient with whom we’d just dealt successfully. I described how I’d evolved in my skill to a peak several years ago, and how I’ve had to refine my skills as my senses and strengths change. I used to palpate everything, and my sense of touch was my paramount one. As I age, my tactile sensation has diminished, and I rely more on vision. And even that is failing as I approach my seventh decade of life. But I continue and I do my job well and carefully. He expressed surprise when I told him how old I am — that surprises everyone because I’m blessed with a youthful appearance. Then he told me that he doesn’t intend to work past the age of sixty, not at all while I intend to work until it would no longer be safe for my patients for me to continue to do so. I’ll know when that is, and a carefully selected group of people with whom I work will validate that judgment. Only then will I pursue a lesser career, and I will leave with reluctance and with regret for that huge unpaid debt, with gratitude for every patient who has taught me what I know. For now, CRNA doesn’t describe so much what I do as who I am.

PS: My surgery has been put off until the 22 of this month. Several things have to be in place for it to take place, one of which is some sort of fibrin glue to be used in the repair. I am blessed to have tissue that doesn’t act its age, and a “sports medicine” orthopedist who normally limits his practice to athletic injuries in genuine athletes. He’s agreed to apply his skills for an old man who fell on the ice, whose “athletic” prowess is confined to paddling canoes and kayaks to photogenic places, or slogging along on a mountain bike or cross-country skis to places that aren’t crowded, and whose major competition is against entropy — and gravity. His method includes aggressive rehabilitation. It will return me to my “playing field” sooner, and ease the overwork my absence will impose on my partner and our already thinly-stretched locums. That’s important to me.

Thanks for your kind good wishes. I’ll keep you posted. In the meantime, work is busy, and that’s great therapy.

Valley Anesthesia Review course for those that know is a great three day review for preparing for the CRNA certification exam given by the AANA. This certification exam is a very extensive computer controlled test prepared for the graduate nurse anesthetist. Unlike our physician colleges we cannot practice our profession of Nurse Anesthesia without national certification……you did know that physicians can practice anesthesia without Board Certification, we cannot.

One of the great things about going across the country for this kind of review course is that you run into old friends. Josette was here in Ohio for the review course. You may recall that she is from the nurse anesthesia program at Buffalo New York. It was so great to see her and meet her friends from their program. I did not take too many pictures while at the Review Course but what I have is uploaded to flickr.

Four of us from the University of Southern California along with another one hundred and fifty some odd other graduating students sat, studied and listened to the lectures and presentation given at the Marriott Airport Hotel in Cleveland Ohio this past weekend. Todd, Elisha Christy and I traveled together from Los Angeles to Ohio this past Thursday for the review course. The presentation of the review material was excellent and gave us all a plan of action for studying for the certification exam that will come up for us in another 9 or 10 months or so. That is plenty of time to get a really good handle on all of this material. The amount of information is exhaustive and is the summation of years of studying.

The best story I heard this weekend was about this Navy guy taking the review course with us. After completing his two and a half year program and thousands hours of clinical it all comes down to this one comprehensive exam. If he does not pass on the first try the US Military will ship him out to the front lines as a staff RN. OH MY GOD, can you imagine that pressure. At least we can get a second shot at the certification exam if we do not pass it the first time. Well, we will all pass and go on with our careers so that is not even an option. However, how would you like that kind of pressure on you after several intense years of studying……pass this exam son or to the front lines with you for two years. Actually, it’s not a problem.

Elisha and DG have been getting up at O’Dark thirty every morning to get our seats in the conference room. The first morning I got into the great hall which was almost as dark as the outside landscape here in Ohio to see a figure way down in front huddled over her books preparing for the start of the day. I thought that I was nuts to get there so early but I guess Elisha and I are of the same mind. You know, “The Early Bird………..catches the worm.”

This is the last week of my Cardiac Surgery rotation at the County Hospital. The anesthesia techniques that I have learned this past month have been very interesting. Today I was able to put it all together for a sort of cap-stone experience in a big case.

Aortic dissection repair is not a surgical case that is approached lightly. This condition may result from chronic hypertension and possibly congenital weakness of the intima of the aorta leading to aneurysm formation and dissection. Unchecked an aortic dissection often proves to be fatal. Remember John Ritter from Three’s Company - he fell victim to a ruptured aortic dissection. Death from a ruptured aortic aneurysm is usually extremely quick and mercifully without drawn out pain.

This vascular case required not only sternotomy but a thoracotomy as well. These are big surgeries. Initially, the plan was for circulatory arrest and profound hypothermia with lumbar drain for cerebral protection. The surgical team decided on the double incision providing a greater exposure and was able to perform the surgery without the circulatory arrest. This was a good thing for everyone. Rewarming after a complete circulatory arrest with profound hypothermia takes several hours. As it was the surgery was long.

Preparation and setup for anesthesia was nevertheless extensive with two arterial line placements both a right radial and right femoral; a double lumen introducer central line placement in the internal right jugular and floating a pulmonary artery catheter were also part of the plan. Additionally, because of the thoracotomy and the extensive dissection into the left chest that was required we used a double lumen endotracheal tube which allowed us to deflate the left lung improving the surgical exposure on the left side. At the end of the case the double lumen tube was replaced with a single lumen endotracheal tube. This was a great experience and wonderful case for me to participate in. You can see the entire Slide Show of the case at flickr. I must warn you that some of the pictures are very graphic and not for the squeamish.

These cases require cardio-pulmonary by-pass. For this case it was a partial bypass that was used when the surgeons isolated the aortic arch. Never the less this resulted in full heparinization and use of the “heart lung machine”. You can see Julia here with her bight smile behind the mask. The presence of the perfusion team in the cardiac room is always a pleasure.

Enjoy the pictures at flickr. If you can recall your anatomy you will notice the structures of the aortic arch repair and marvel at the gortex graft creation by the sugical team.