Nurse Jess in Top 30 Anesthesiology Blogs

Anesthesiology Blogs

This morning I woke up to an email sent by Anuj, the founder of Feedspot. I will admit, I haven’t heard of Feedspot before today (and maybe for you as well). I’ve never been listed as a top blog so I was surprised and honored to be awarded one of the top 30 anesthesiology blogs.

As I browsed the list, I noticed that I was the only personal nurse anesthetist blog. The rest consists of anesthesiologists and larger organization blogs. I will do my best to continue to represent the nurse anesthesia community.

As I transition from a graduate to a new nurse anesthetist in a new community, I learn a lot. Part of becoming an anesthesia professional is

  • recognizing your limitations and when you need an extra set of hands,
  • asking your colleagues for their professional opinion as you develop your anesthetic plan (especially for cases you’re less familiar with, for cases with different surgeons, for cases with different patient populations),
  • asking for mentorship and help for improving your weaknesses, and
  • knowing that the health field will change.

For example, the United States has a shortage of several anesthetic drugs. And there’s an opioid epidemic that has torn this country apart. The healthcare costs continue to rise, and the length of stay continue to decrease. To help prevent potential complications such as respiratory depression and opioid addiction and to improve pain management strategies, I believe that it begins preoperatively with the patient, continues intraoperatively, and postoperatively.

After the Enhanced Recovery After Surgery (ERAS) protocol came out for colorectal surgery, many more ERAS protocols have developed for different surgeries (and each institution has their protocols). The ERAS peaked my interest in providing opioid-free anesthesia. Part of that process requires providing blocks (or ‘numbing’) for a specific area of the body. Tom Baribeault, one of the founders of the Society for Opioid Free Anesthesia (SOFA), spoke at the University of Michigan-Flint’s anesthesia conference last year. He added fuel to this fire.

After speaking with several of my colleagues who already provide opioid-free anesthesia, reading peer-reviewed journal articles, and completing the American Association of Nurse Anesthetists (AANA) course on enhanced recovery after major abdominal surgery, I set off to do just that. In between my cases, I’ll follow up with the patient and the post-anesthesia recovery unit (PACU) nurse and see how the patient did. I will continue to improve this technique.

In the end, the goal is to provide safe and effective patient care for every patient.

Happy Chinese New Year, the Winter Olympics, and the Florida high school shooting

Happy Chinese New Year!

Ruff. 🐶 I will be spending it on a 12 hour shift.

On the brighter side…

Watching Red Gerard win the first gold for the USA in the snowboarding event was amazing.

After falling in his first two runs down the slopes, he has a near perfect execution and beautiful flips and turns on his snowboard in his final and third run.

It just reminds me that even if you fall, you get back up and you keep pushing to be the best version of yourself. When you do that, you will get better. What can you do to improve? Where are your strengths and weaknesses? What are the steps to get better?

***

On the sadder side…

The Florida high school shooting with 17 dead just makes me so sick. After reading the statistics of mass shootings in the USA in the New York Times, I cannot believe that there’s a mass shooting every day.

I can’t imagine going to school not knowing if I’ll make it out alive that day. It is ridiculous.

If we really care about safety, then we should care about gun safety. It should not be that easy to buy a gun for anyone. Just like you need a license to practice nursing, you should need a license to purchase a gun. The process of getting that license should require safety training, mental status checks, and the requirement to renew the license.

I mean, just to fish professionally, you need a license. To do someone’s hair or nails, you need a license. To buy a gun and be a safe and responsible user, you need to have a license.

I get that the 2nd amendment gives Americans the right to carry a gun, but we also have the right to be safe in our communities and guns are lethal weapons. Especially AK-15s. Why is that kind of gun sold to lay people? What do the gun shop owners expect lay people to do with those guns?

When people own things, they tend to use those things. Those things include guns. This obsession with “our right to gun ownership” needs to let up. We should focus on improving the safety of our neighborhoods by getting guns to licensed personnel.

A gun is not just an object like a TV, or a fishing pole. It is meant to injure or kill living things, including people. It should be treated as such.

I do not want to become numb to the reality of mass shootings. I want the US to be safer than it is now. I do not want to go to a school, a theater, a nightclub, a concert, and worry if my life will be in danger. It should not be that way. We need this to change.

It may involve the government asking for guns to be returned for compensation, and start to enforce gun safety classes (including accuracy target training), assessing mental health and other harmful associations (for example if they are on the no-fly list, terrorist, etc), and require a license, just like you need to drive a car. And like a driver’s license, you will need to renew it, proving that you’ve received updated information. Just like a driver’s license, there should be a gun registration for the gun owner’s license so it is much easier to keep track of how many guns are being sold.

Just like how cars can kill people, the guns’ intention is to kill. Why is it not regulated more?

It is our “right” to drive and it is our right to own a gun. It is also our right to pursue happiness. We can only do that if we feel safe in our communities. And that includes keeping track of gun owners and the type of guns they own.

We need to change America for the better.

Do you agree, disagree? What do you think can improve the gun safety in America so there isn’t a mass shooting everyday in the USA?

Sticking up for yourself

It’s been awhile since I last posted back in August so here it goes.

I graduated, took boards and passed in August. I took a trip to China for my fiancé’s grandpa’s 90th birthday. On the same trip, we went to visit Xian (the terra-cotta warriors!), Taiwan, Osaka, and Tokyo. It was such a great trip to be with my fiancé and visit all these places.

At the end of September, I was getting ready to start working at a hospital. I made the mistake of not asking for a contract before deciding to work there.

Unfortunately, unless a contract is signed, verbal agreements don’t count. I didn’t trust the “man in charge”, especially since he changed the terms only a week before starting work.

At this point, I could’ve started working for him, or leave and stick up for myself.

Fortunately, I was in a position where my family supported my decision and me financially. At this point, I left for California as my fiancé began his schooling at UCSD.

For the next couple of months, it consisted of several interviews and difficult decisions. It also consisted of me actually cooking some food to eat (it had been while!). I finally decided to pull the trigger and move to Northern California.

I started working a couple weeks ago and I’m enjoying it so far. Of course I asked myself, do I still remember everything that I learned? It takes a little time but a lot comes flooding back, even after months of not working.

If it was not for all the support of my family and friends, all the CRNAs and anesthesiologists, all the nurses and support staff, I wouldn’t be where I am today.

Anyways, the biggest takeaway is to stick up for yourself.

Also, happy belated CRNA week. And happy anesthesiologists week. Go team go 🙂

Two weeks from graduation

In two weeks

anesthesia school

is over.

Is this real life?

so much more

needs to be done.

Studying for boards

Completing clinicals

Presenting at M&M

Securing a position

Emptying my apartment

Attending graduation dinner

with family flying in.

This chapter of my life

is almost done

and a new one

is about to begin.

Can’t wait.

The Dark Side of Nursing

In the spirit of learning through social media, I’m inspired to follow up on Dr. Eric Levi’s post on The Dark Side of Doctoring.

In case you haven’t read about it, it is regarding a physician who committed suicide. It is about how something is wrong with the basis of our healthcare system. It’s about how nearly 1 in 12 people who go into healthcare — to help people — end up needing help themselves because of our system. Our system continues to fail us because we push people to — and then beyond — their limits.

It is not simple enough to say, take a mindful minute.

It is not simple enough to say, just take a break or two.

It is not simple enough to say, get the help you need. Because even when we are surrounded by the resources that we need, we still fail. People often see a healthcare provider within 30 days before committing suicide.

We are in a culture where it is expected to be short staffed. We are in a culture where it is expected to:

  • squeeze each healthcare provider —
  • do something a specific way dictated by people who have never taken care of patients before,
  • refuse to discuss changes to an OR schedule because it’s mandated by the administration,
  • take call and expect to be a fully functioning person the next day.

It is one thing to be resilient. It is another thing to damage the human spirit.

One of the worst experiences in my career started at the beginning. I was a brand new nurse working at the nursing home/rehabilitation center. The LPN (licensed practical nurse) who worked there for years, knew her residents, knew the medications that the residents received. But one day, she called in sick. Of course, that meant I had to give all of the medications. 50 residents. 6 with PEG tubes. In 2 hours.

It takes at least 5 minutes to verify the resident’s name, the medications in the paper copy of the medication records AND the electronic medical record, give the medication, wait for them to swallow. Nevermind that medications still needed to be popped into the cup. Nevermind that I had to find each resident (because they do move around). And the patients with PEG tubes often require more time to crush and dilute. And don’t forget that when the tubes get clogged that it took additional time to rinse.

5 minutes x 50 residents = 250 minutes. Yeah, I was on a path to failure.

By the time I finished giving the morning medications, it was already time for noon or afternoon medications to be given. I didn’t go on break (no one was there to relieve me). I didn’t eat lunch. I didn’t have any support. I cried that day. Shortly after that, I never went back again. I was lucky enough to quit.

I couldn’t deliver quality nursing care. I felt that I could lose my shiny new license. I knew it wasn’t the right way and I knew I didn’t want to practice this way. I didn’t have any support.

And this situation doesn’t just apply to me. It applies to nearly every nurse giving medications. Giving the appropriate amount of time for each nurse to talk to their patients regarding their medications, their medical condition, and spending time with them when their loved ones aren’t around is vital. Giving each nurse the appropriate patient to nurse ratio is so vital.

The appropriate patient to nurse ratio gives the nurse more time, effort, and energy to take care of each patient. There needs to be more time

  • to provide nursing care,
  • to educate,
  • to prevent medication errors, infections, falls, deaths,
  • to question, coordinate and provide treatments,
  • to monitor the patients’ status,
  • to be the patients’ advocate, and
  • to be a resource for patients, their families, and other healthcare providers.

Michigan is currently pushing for a Safe Patient Care Act to decrease the patient to nurse ratio. If we want to reduce readmissions, preventable deaths, and provide safe and quality care, then we should pass this act. There have been multiple studies that prove this to be true. We need to care more about patients than the bottom line.

Changing Culture

The healthcare culture needs to change. To take care of others, we must take care of ourselves. But we cannot take care of ourselves if the culture does not allow us to do so.

We value being a hardworking person. That’s why we say it’s ok to do overtime, then being on call, then being at work the next day. That’s why we work way over 40 hours a week — pushing 60-80 hour workweeks.

We value being helpful. We want to help patients, and if we don’t do overtime, then we would be abandoning patients.

We value money. That’s why hospital administrators short staff the hospital and push up their profits.

These are our primary drivers. Instead, we should shift our fundamental values to:

Healthcare providers’ health.

  1. Valuing the healthcare providers’ health should be one of the most important values in healthcare. We are people and require a work-life balance (including students, interns, and learners of all type). We need time to be human, time be with friends and family, time to eat, exercise, and sleep. We need time when we aren’t thinking about healthcare and can destress.
  2. Depression and substance abuse is, unfortunately, high among healthcare providers. In media, we have an image of a drug addict. But healthcare providers have access to high potency drugs and can easily and quickly abuse substances. Addiction can hide behind a mask, a suit, and highly intelligent, functional people. A couple of weekends ago, I attended the Michigan Association of Nurse Anesthetists Spring Conference, and one of the topics was on addiction. It was eye opening. This was one of my favorite videos on addiction.
  3. If being on call is required, that they should be off the next day. Or there should be a rotation system so that you are not constantly called every night.
  4. That every effort will be made not to be short staffed.
  5. That working 40 hours a week — and not much more — is the norm.
  6. That means giving people adequate vacation time, paternal/maternal leave, and not making people feel bad about it or making it hard to take time off.
  7. That means giving 2 15 minute breaks and a 30-minute lunch for every healthcare provider for a 8 hour day (this does not happen on a medical-surgical unit, let alone over a 12 hour day).
  8. That means providing in-house educational opportunities.
  9. That means encouraging healthcare providers to do or implement research.

Patient’s health.

All of us have been a part of the healthcare system and therefore should care about this tremendously. A huge part of the problem is communication errors. Now instead of a scarcity of information, we have an abundance. We need to have a streamlined process. Electronic medical records (EMR) is a part of the solution, but there are still problems. Often, the EMR technicians have never worked in healthcare and are the ones putting together these systems. Instead of a single page where there is the patient’s history, treatments, labs, diagnostic reports., information is scattered. It requires going through several different tabs and is very time-consuming. And even then, it is still easy to miss information.

Instead of being focused on coding for such and such, it should be about improving the patient’s health. Giving enough time and energy for each patient will improve the patient’s health. Sitting down, understanding each patient’s situation, and developing a course of action together. We need to focus on patients’ health, and not on patients’ paperwork.

Healthcare providers’ input.

To improve healthcare, it requires input from those in the trenches. It does not make sense to ask outside consultants who have no healthcare experience to improve healthcare. Yes, this does happen frequently. And these consultants are expensive. Why are we so focused on making healthcare into a business model rather than a patient care model? Instead, we should ask the providers themselves on what they think needs to change.

Price Transparency.

What blew my mind the other day was reading an article about how parents who were worried about their daughter’s cut took her to the emergency room. The emergency physician said it was a nothing to worry about and put a bandaid on and sent them home. A month later the bill comes out to be $626 for a band-aid. It happened to be that there’s a facility fee for emergency rooms. But it is still ridiculous. Most people (especially those not in health care) need help triaging, or deciding how bad their condition is. When you’re the one in pain, it is always the worst thing that’s happening to you.

Part of the this problem is the blaming game. The doctors blame the insurance companies. The insurance companies blame the doctors and their coding. The patients blame the doctors, the insurance companies, the greedy hospitals and the government. I think what would help solve this problem is transparency about the cost of care. There’s a disconnect between the cost of healthcare and the services provided. For example, most people have no idea how much it costs to stay in the ICU for one day. Most people have no idea how much it costs to do one elective surgery. Sure, it’d be nice to call up the insurance companies and ask them but they come back and say, it depends on what your doctor bills. You ask your doctor and they say it depends on how much the insurance bills you. For the same exact surgery, the insurance will bill differently at each hospital (even surrounding a 50 mile radius). The cost of healthcare is just way too high because there’s no way to ‘shop’ for healthcare or healthcare insurance like you can with other services.

Transparency, or having a sticker price up front, would help patients decide where to go. In fact, there are already some places that often a total knee replacement for $15,499 that covers everything — the surgery, the rehabilitation, and any complications that occur afterward. Price transparency encourages facilities to provide high-quality care and decrease costs while still earning profits.

 


So I would like to ask, what is the ‘dark side’ of nursing for you? What do you think can change? Please comment below.

Career Day

Last week, I had the opportunity to represent as a CRNA student at a middle school. In my preparation, I found a few inspiring talks about how to choose a career.  I remember when I was in 6th grade, on my way home from swim practice, I broke down crying and asked my dad, “what’s the purpose of my life?” In retrospect, that was deep.

Anyways, Ashley Stahl, a career coach, said you should ask yourself three questions to choose a fulfilling career. This, hopefully, is a key factor for happiness.

  1. Who am I?
  2. What am I good at?
  3. What’s holding me back?

In detail:

Who am I?

This question requires you to think about the most important values in your life. Everyone is unique in that they hold varying values more closely. Family, friends, the media, etc. can all affect your perception of what is most important to you. Ultimately, choosing the ones that matter to you the most is what will help you live your life the way you want. Values will determine your behavior and attitude and guide your life.

Remember, other people’s values can pull you away from yourself. ‘Lists’ of how to be happy don’t often work. However, living out your values will make you happy. While some people value family time, others may value individualism and climb the career ladder. Others may value both. This can cause an internal struggle, or it’s possible to create or find an organization that allows you to live out both values. Others may value education, etc. It is helpful to find a career and organization that most aligns with your values. Of course, some values may change over the course of your life, depending on the stage in your life.

Personally, I value education, optimism, caring, persistence, kindness, and traveling. I’m sure several of these values were pressed into me. Taking care of my education is number one because no one can take that away from me. Always trying to beat my personal best. It’s a competition with myself to push me to do better than the last time. And to reflect, what did I do well? What can I improve on?

When I don’t feel right, it’s because I’m not living out one of my values enough. When one value is lacking, it’s time to nurture it. It may be difficult to do if a value depends on others. For example, if you value being the best, and now you’re in school again (such as anesthesia school), and you’re back at the bottom of the food chain (in the OR), it will feel very uncomfortable. Either you shift your values (which can be difficult to do but a change in perception can help significantly), or you continue to struggle until school is over and you’re practicing on your own.

What am I good at?

This was one question that was hard for me to know, especially when I was younger. I expected everyone to be just as good as me in everything. Of course, this is not true. Ashley suggested that you can find your strengths by someone TAPping you… Teach, Advice, Praise. What are others asking you to teach them? What are others asking you for advice in? What do others praise you in?

Of course, you will realize that you cannot be good at everything and that you can improve your skills through practice, through visualization, through discussions. Tune in your natural abilities.

But how do you know? Through experience. My mom has always told me that any experience is a good experience (except drugs. Thanks for the advice). Anything that may pique your interest (or a part time job that will hire you) try it out. I recommend reading www.80000hours.org. It’s called 80,000 hours because that is the time you will spend in a career.

What’s holding me back?

Other people’s values and expectations of you will hold you back. Your fear of failing. Your internal talk saying, “I’m not good enough” or “I don’t belong here” or “I’m an imposter”. Yup, I’m guilty of this too. Several times throughout school I would question my ability. Do I belong here? To get myself out of this feeling, I used my value in optimism to take me out of the funk. “Jess, you are learning. You will make mistakes. Don’t be so hard on yourself. What can you do next time so you improve?”

When you are in a new situation, visualize the scenario. I remember my first semester of school when I arrived in the OR at 5:30 am to set up my room. It was certainly exhausting. How do I check out my machine? Which syringe size do I need for each drug? Where are the drugs? How much drug should I draw up, should I use? Which colored label belongs to each drug? Why aren’t all the blue ones, orange ones, white ones bunched together??! Where is all of the equipment, and which drawer? I physically walked from the door to the head of the bed and thought through my steps. Later, I had to think, how will I prone a patient? I physically held out my hands and pretended to move the patient’s head from supine to prone. Of course, later on I realized that I also had to be aware of all of my monitors and lines too.  The next time, I was considerate of my lines. The next time after that, I became more and more aware of my surroundings and different cues.

What helps is having a clinical instructor, a mentor, a boss, a friend, an acquaintance, who can listen, see, and understand what you’re going through and guide you through those difficulties. What are failures they’ve encountered that would make it easier for you?

There are days when you’re harder on yourself, and days when a ‘superior’ – be that an instructor, or a senior, or someone up the hierarchy in some way – will tear you down. One day is usually ok. But when it’s a constant uphill battle, it can be difficult to mentally withstand it. From being in school where there’s an evaluation of your work everyday, I’ve come to appreciate resilience.

I remember playing Final Fantasy and as one of the stats was resilience. I thought, WHO CARES about resiliency? I want strength! However, now I believe that the ability to pick yourself up after being knocked down is so vitally important. What is your coping mechanism? Some turn to drugs, some turn to family time, some will need to vent to classmates, some need therapy, some will dive in deeper in their studies, etc. Ideally, don’t do drugs because you’ll go down a rabbit hole that may be hard to get out (of course, rehab is an option but if at all possible, you can avoid it, why not?). How can you pass the daily evaluations?

Daily evaluations can be tough because one bad one can lead you out of the program. The fear of failing out of the program is real. Getting into anesthesia school is a big ordeal for yourself and your family and friends. It’s almost ‘everything you stand for.’ Failing out can be detrimental not just for yourself but from those closest to you. For example, there’s a story about an anesthesia student who failed out and then committed suicide on the day of her ‘supposed’ graduation. Very scary!!) However, ultimately, it is about what your choices and how you deal with each situation. For me, I have plan A, B, C. Of course, I want plan A but if that fails, plan B kicks into place. For me, having a backup plan (a backup anesthesia plan and life plan!) was a sense of calm that I needed to reassure myself that I can do it.

 

Long time, no see

Hi readers of Nurse Jess,

It has been nearly a year since I posted on my blog. Some readers (aka a few junior anesthesia students) have met me and wondered if I’ve fallen off. Nope, I am right here!

Every time I considered posting, an exam, a care plan, paper, or even the limited time off to do nothing, pulled me away. But now I’m back.

I have so much to say and yet so little time to do it. I could write a lot, as I often do, to convey all of my thoughts. But I will try to keep it short to encourage me to post more.

Since the beginning, I’ve done over 700 cases and over 1800 clinical hours. And there’s still 4.5 months left of anesthesia school. It may seem like a lot, or a little, depending on who you are.

That time doesn’t include class days, the preparation for clinical, the preparation for anesthesia school (GRE, CCRN), the intensive care unit hours, the bachelor of science in nursing AND biology. In my mind, it’s been ten years of training. Wow.

I have to admit, the beginning of anesthesia school was tough. What makes the training challenging is at first, you are learning the basics of airway management (intubation, LMA, oral and nasal airway, chin-lift, jaw-thrust, etc.) and the anesthesia flow for each type of surgery and unique to each patient (preoperative, intraoperative, postoperative course). Not only that, but each anesthesia provider (CRNA and anesthesiologist) have their preferences and expectations of you. Even during the short breaks, one CRNA may be ok with your choice, but another CRNA would reprimand the choice. The only thing you can do is to understand their choice (What’s the rationale?). As they say, there are a 1000 ways to skin a cat.

Now, there’s less anxiety and more of a discussion, even as I go to different clinical sites. It’s much easier to anticipate changes and adapt to the circumstance. For example, just today there was a switch in the schedule. Last year, I felt more frantic and had to think about my each step more carefully (especially in pediatric cases when there’s a change in age and weight that require a change in equipment size and drugs). Today, it changed from a two-year-old, 15kg to a 6-year-old, 25kg for ear tubes (*real age and weight are changed). What are the appropriate emergency drug doses I would give? What equipment changes do I need to make? I switched a size 3 to a size 4 mask, and had a 5.5 ETT (endotracheal tube or breathing tube) with a MAC2 blade, and thought –

  • atropine 0.02mg/kg = 0.5mg = 1.25ml,
  • succinylcholine 4mg/kg IM = 100mg = 5ml,
  • epinephrine (1:10,000 or 0.1mg/ml or the big stick) 0.01mg/kg = 0.25mg = 2.5ml.

Anyways, that’s it for today.

Jess

#100Intubations

Anesthesia school is a 2-year marathon.

When you feel tired and beat up, you just have to keep going. Just keep going to clinical.

Anyways, I just wanted to announce a couple of things.

First, I’m done with my second semester and I’m onto my third semester. I took a week off for a family vacation in between the semester. It was definitely much needed. This semester is supposedly better in some ways. For example, there are less OR jitters compared to the 1st semester. But going to a new clinical site presents its own challenges (a new anesthesia machine, new charting system, different drug dispensing, different protocols, different equipment, different labels, different drug vials and doses, new names and faces, not knowing where anything is, new surgeons, new procedures, different patient population, etc). Now we’re going strong by going to clinical 4 days a week and 1 day of class (and my, that day is 10 hours long!!). When I look back at what I knew in October versus now, it is a huge difference. It’s incredible.

This semester there’s a couple of focuses: research, emergency management, regional anesthesia. I’m pretty pumped. I’ve come far but there’s still much more to go. Resiliency has never been more important than now.

Second, as of yesterday, I’ve done 100 successful intubations. It’s a great feeling.

Third, thanks to everyone who’s been writing me positive messages about the blog, supporting me through the flashcard purchases, and anyone who’s enjoyed reading my blog. I see that each month there are more visitors and visits than the next, despite me not updating it as frequently as I used to.

Fourth, happy nurses week again.

Fifth, congrats to those who got into the UM-Flint nurse anesthesia program. It was nice meeting some of you and I’m sure we’ll meet again soon enough!

I have to go now. Until next time,

Jessica