As a nursing student stuck with pages and pages of powerpoint slides, I needed a great study guide. But how could I do that efficiently? CRNA school doesn't leave me much time to fiddle with microsoft word... so I use this hack I learned back in nursing school to utilize the PPT slides as the foundation for my guides that I can easily study from.
I completed my first clinical rotation as a nurse anesthetist student and I can say it was amazing! Prior to starting clinical I was having doubts about whether I made the right decision to start CRNA school, but once I was hands-on, actually intubating patients back-to-back, titrating anesthetic gasses, adjusting ventilator settings and extubating, realized how much I truly enjoy it!
I split this initial post into two because I can get a little long winded. However, I did some interesting cases this week, so I'd like to share!
Today I did anesthesia for ECT's (electroconvulsive therapy) and a Thyroidectomy.
My first day, I did 11 ECTs. Yes, 11. It is a wake up call because you think you're good at bag-mask ventilation... then you do ECTs and realize how much you SUCK. Haha... no seriously... everyone told me that's how it was going to be, but I thought I had my masking skills down. Uh no.
People really hype up intubation and it's obviously a skill you need to have to do this job, but people don't die from not being intubated. They die from not being able to VENTILATE ! So, please, don't downplay masking. It's essential to keeping your patient alive.
I’m going to keep it 100% with y’all. For the longest time I thought they didn’t even do ECT's anymore. Forreal. If any of you have seen the 1975 film, One Flew Over the Cuckoo’s Nest, its portrayal played a major role discrediting its use. As psychotropic medications came into play, performing ECTs diminished, then over the last 50 years or so it’s regained its reputation many disorders such as severe depression and other affective disorders.
Here's the rundown of how I learned to do ECTs:
Monitors are placed on the patient (HR, BP, SpO2, nasal cannula w/ETCO2).
Special leads are placed on the patients head (I did bilateral ECTs).
Once the patient is prepped, the medication Methohexital is given. It is considered the "gold-standard" and is a barbiturate that works on the GABA (a) receptors causing sedation.
After the patient is asleep, a small dose of succinylcholine, a paralytic is administered. Rocuronium/Sugammadex can also be used.
A special bite block is placed in the patient’s mouth that has an oral airway implemented into it.
Begin bagging the patient with the Ambu bag.
The patient is shocked, then the patient will seize.
Seizures lasting longer than 120secs generally require immediate administration of Propofol or Ativan.
During this time, you are monitoring the patients vital signs, and maintaining a patent airway.
The electric shock causes the activation of the autonomic nervous system with a parasympathetic discharge causing a brief bradycardia or pause (yes, it looks like your patient just went asystolic, but don’t push the code button!)
After this, a sympathetic response causes an increase in heart rate and blood pressure causing profound hypertension and tachycardia that can last 3-5 minutes. Antihypertensives such as Labetalol can be used if the hypertension is sustained.
Glycopyrrolate or Atropine is also given as a pre-mediation if the patient is bradycardic at baseline or if they become bradycardic from the procedure.
After the patient seizes, you continue to bag them until they begin spontaneously breathing!
Usually the patients aren't here for their first time. Look up what they've received before and prepare those drugs.
Some additional things that I've learned,
Other medications like Propofol and Etomidate can be used, but with some caveats. Etomidate doesn’t blunt the sympathetic responses to the seizure, and also lowers the seizure threshold causing a longer seizure. Propofol has its benefits of blunting that response. Methohexital is used because it does not change the duration of the seizure. Propofol can also be used but it can decrease the seizure duration. Ketofol = Ketamine & Propofol has been shown to also be a great alternative to general anesthesia & paralysis. However, at my clinical facility we did not use this approach.
Some contraindications: Recent MI, stroke, aneurysm, & osteoporosis
Onto the Thyroidectomy...
This was a cool case to do because I used a NIM (nerve integrity monitor) tube. This tube has special leads in it that connect to a monitoring system to ensure that the Recurrent Laryngeal Nerve (RLN) is not damaged during surgery. It literally acts like the game Operation. You touch the nerve, & the machine buzzes! Pretty cool.
So, to jog your memory, the RLN innervates the posterior and lateral cricoarytenoid muscles, which adduct and abduct the vocal cords. Remember, ADDuct = together, ABduct = apart. The Superior Laryngeal Nerve has two branches, the internal and external. The internal is sensory, and the external is motor. The external SLN provides innervation of the cricothyroid muscle and tenses the vocal cords! Bilateral injury to the RLN will cause stridor and paralysis of the cords... this can lead to re-intubation then tracheostomy. If you have unilateral damage, this will cause hoarseness as it only causes ipsilateral paralysis!
There are over 120 CRNA schools in the United States. Figuring out which CRNA school to attend can be very hard. I personally recommend applying to 3-5 CRNA schools. Traveling for interviews and application fees can get pretty expensive!
In the following video, I discuss what you should consider when looking for a CRNA school. The CRNA school comparison chart is being updated and will be available in November!
I had every intention of integrating board review into my everyday routine as a CRNA student. I figured, we’re constantly doing “board prep” by learning the material right? But interestingly enough, I found myself still going through an intensive 5-week plan to prepare myself for the NCE or the National Certification Examination (no one actually calls it this). In the nurse anesthesia world, it’s “boards.”
When you decide to start CRNA school, one of the biggest challenges is realizing that life doesn’t stop for you to get through your program. Unlike my undergrad days where all I had on my plate was school, the occasional fight with the boyfriend or girl drama, there weren’t as many distractions and stressors as there are now.
“Me-time” suddenly turned into “Me + Nagelhout + 8 hrs sitting at my desk.” I don’t want you all to develop that equation every single day because it only equals one thing = STRESS.
Before starting your semester, whether it be the first or last, make a schedule (Read about preparing for your semester HERE). It doesn’t have to be extremely detailed hour to hour, but write down the important things like class time, clinical, study time, family appointments, etc. Then, find at least, 1-2 hours where you can do something that you love. It doesn’t have to be all at once, it can be as little as 5 mins in the morning and night each day. If you have a family, then schedule time to spend with them. It can be going to the park every other weekend, or having a special dinner. Make sure these things are in your schedule and the time is accounted for.
This isn’t going to make CRNA school stress free, but it will provide the structure that you’ll need to remember to take care of yourself! Make this a guilt-free time where you can do what you like and not think about anesthesia for one moment. It may sound crazy, but depriving yourself of the care that you need will lead to major mental distractions during your study sessions, making it less productive.
While it’s great to say that I sat at my desk for 8 hours “studying,” my mind was elsewhere. I was mentally and physically exhausted, but I continued to push myself because I thought that’s what you have to do while you’re in CRNA school. I learned quickly that it’s not an effective strategy…at least not for me. I started off CRNA school with a ticking stress bomb… like I said, life doesn’t stop.
My positivity and faith were the two things that prevented me from having a complete breakdown.
It blew up before I could even throw the bomb further away… I ended a very long relationship immediately before starting CRNA school. Any stability that I had, my #1 support system and foundation crumbled right before my eyes. Our family lost two great friends months apart, then less than 6 months later, my grandfather passed unexpectedly. It was a whirlwind of events… but I remembered that while nothing can bring those people or relationships back, it furthers my purpose, my dream and to make them all proud.
It was a whirlwind of events… but I remembered that while nothing can bring those people or relationships back, it furthers my purpose, my dream and to make them all proud.
I take out a decent amount of time during the week for blogging, Instagram shenanigans, running and relaxing bubble baths. I treat myself because I know I worked hard that week; I know I deserve a break from studying. “Work hard, play hard” has officially become my motto.
I take my break, relax, then get back to business.
What are some self-care practices that help you?
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I’ve got a year and a half before I finish schooling…and the first thing on my mind is the NBCRNA Boards. I recently purchased Apex, and so far I absolutely love it. First of all the content of the modules is in a format that’s easy to read and understand. It is mostly in short paragraph/bullet point format with nice diagrams and pictures. In addition, it includes workbooks that are associated with each module.
The CRNA school interview is a daunting task. It’s a major event separating you from acceptance to your top school. Adequate preparation is needed to be a successful candidate.
There’s no specific recipe that you should follow to stand out during your interview, but there are things you can do to prepare to sell yourself with humbleness and grace. The most important thing is,
I applied to CRNA school the moment the application was available on July 1, 2015. My recommendation letters were already in, and I was scheduled to take the GRE the following month. Once I took the GRE's, my scores were received by the school August 25 and my application was officially marked as complete. 2 weeks later I received a notification that my application was being moved to the interview round! (This is why I stress preparing for your interview once your application is in). A month later, I was at the school, a nervous wreck, interviewing for one of the 16 seats in their 2019 class.
Whether this is your first semester or last semester, it’s important to get organized prior to it starting. Most courses will post your syllabus beforehand, so print them out (or not) and have them ready! Some schools do not provide a syllabus for you (I just learned that) So if you don’t have a syllabus…I’m sorry, that’s quite devastating.
At my current clinical facility, drugs are drawn up in the morning, then locked in the anesthesia cart in the room. My first day, I was told to draw up the drugs and even though I'm a nurse, figuring out which syringes they wanted to use slowed me down the first couple times. Here's a quick guide to how I draw them up. It's best to draw your drugs up in order of what you'll be using, that way you won't forget anything.