Nurse Jess in Top 20 Nursing Blogs

Top 20 Nursing Blogs 2018

I received an email about a week ago from Theresa Frost stating that I was on the Top 20 Nursing Blogs list on the Online Nursing Degrees website. I feel honored. But more importantly, I’d like to introduce two other blogs that are great for learning more about CRNAs (certified registered nurse anesthetist).

  • Life as a CRNA – There are some detailed information about what to expect on a day to day basis as a CRNA. There is also some advice for getting into anesthesia school.
  • CRNA Career Guide – It provides a comprehensive guide along with advice from several presidents of state associations of nurse anesthetists.

The Speed of Trust

I recently subscribed to the Blinkist, an app that summarizes nonfiction books and gets to the core of the book. I highly recommend it if you enjoy learning (and being a human, you naturally have curiosities in your life, right?).

One of the books is called the Speed of Trust by Stephen Covey. It tells us that trust affects everything, especially how fast communication and events go. For example, if you trust that the restaurant prepared your food safely, you’ll have no problem eating the food. However, if you had concerns over the food safety, you will hesitate and question the chef before maybe consuming the food (or even throwing it away).

Trust is one of the most powerful forms of motivations and inspiration. People want to be trusted. They respond to trust. They thrive on trust.

You must have self-trust so others can trust you. Because if you don’t trust yourself, then who will?

The way to gain trust in yourself is by following the Four Cores.

Integrity

Integrity is gained by making commitments to yourself and following through on them. Integrity is being honest with yourself. For example, if you tell a patient that you will return to them with information, then do that. If you tell yourself you will go to 50 crunches, 20 squats, 10 burpees, and jog a mile, then commit and do it! If someone blames another person for your mistakes, own up to it and take the blame. If you commit to waking up to the alarm clock and getting to work or school on time, then do it.

Intent

Having positive motives and behaviors will point you towards good intentions. Are you listening or do you just want to “win”? In many circumstances you can increase trust if you have good intentions.

Capabilities

Developing capabilities will improve your confidence. And life is always changing which requires you to keep learning. In the health field, learning what is the latest evidenced based practice and working towards incorporating it in your practice will keep you on the top of your game.

Results

When you build a track record of your results, you build self trust. In the world of anesthesia, you are constantly evaluating your actions– how well did the induction, maintenance, emergence go? How well did the patient do? What could I do differently to improve my results?

 

After developing trust in yourself, you develop trust in others

You develop trust through your actions and your truth. This includes understanding yourself — your strengths and weaknesses, your moods and behaviors, your actions and inactions. By knowing yourself, you can better understand others’ critiques of you and owning it.

You will also demonstrate trust by caring about others. Giving others credit when due. Being thankful for others’ actions. Showing that you are aligned in the same goals.

This will increase your credibility. This is important especially in the healthcare field and in the OR. You trust that the scrub tech stays sterile. You trust that the circulator nurse has the room and everyone responsible ready. You trust that the surgeon is able to safely complete surgery. You trust that the pre-op nurses get an IV and come talk to you if they have any questions. The more you trust yourself and gain trust in others, the faster things move and better the outcome.

With the lack of trust, everything and everyone is questioned. Only more delays occur. And that is why it is so important to gain trust in yourself and in others.

As a side note and reference to what’s going on in the real world…

Christine Blasey Ford showed tremendous courage in speaking out about her experience with Judge Brett Cavanaugh. She was incredibly credible — she had nothing to gain and everything to lose by speaking out, and the fear that her world would shatter and none of it would matter.

On the other hand, Judge Cavanaugh may have been a credible judge with many people who backed him up. He may have had a very credible record and people trusted his judgment. However, I feel that after his hearing, the American people, or at least me, do not feel that he would be impartial. He doesn’t seem like he would have the temperament of a judge. While one hearing doesn’t seem like it should change the fate of this candidate, he is also up for a LIFETIME job as a Supreme Court Justice. In my humble opinion, I believe that there are other candidates who would be better suited for this position. If he is confirmed, I believe that the American people will continue to lose faith in its institutions. Instead of trying to work together, we will continue to divide the nation.

I feel that problem with Judge Cavanaugh is not that he necessarily was a horrible drunk as a teenager and college student, but that he denied it and lied to the Senate. I believe that our principles and values are more important than ‘which party’ sits on the highest courts of our land.

Awake Fiberoptic Nasal Intubation

So all the times that you practiced your craft (handling a fiberoptic scope such as during the difficult airway class weaving down the bucket with little holes; placing double lumen tubes),

all the times you’ve asked experienced providers what they did (for an awake fiberoptic intubation),

all the times you watched one (once for an awake fiberoptic oral intubation),

all the times that you performed one (under optimal conditions with a Glidescope and an asleep patient),

and all the times that you did something similar (nasal intubations),

it prepares you for this moment — for this call:

“There’s an emergency intubation for you and it must be done as an awake fiberoptic intubation nasally.”

You call your partner who’s already bedside and workout a plan

He’s optimizing the patient – Afrin drops, nasal trumpets, racemic epi nebulizer, and 4% lidocaine nebulizer

You’re ready – 7.0 oral ETT in warm saline, lubricated tube and fiberoptic scope, ketamine, precedex drip, an ENT surgeon and team for possible trach

The patient arrives, looking more perky, sats 96%, sitting up, switch monitors, fluids, ETT on the tip of the fiberoptic, suction on, sedation is in

Standing in front of the patient on the right side with the camera on the left

ETT inserted 1/3 in, cameras in, orientation, following the bubbles, past the epiglottis, vocal cords, tracheal rings

Holding still, inserting the rest of the ETT, cuff up, fiberoptic scope out, circuit on, positive end tidal CO2, sats 99%

Smooth, success 

Optimizing Patients for Urgent Surgeries – Non-Elective Surgery Triage

Urgent surgeries — such as appendectomies, cholecystectomies, are common. Sometimes the patients are healthy and other times they are a train wreck. When they are of the latter sorts, the goal should be the optimize the patient for surgery so they are prepared to undergo the stress of surgery.

Understanding the classifications of semi-urgent, urgent, and emergency surgeries informs us of the time that we have to optimize a patient. For example…

It is the weekend call shift with limited resources. The surgeon schedules a laparoscopic cholecystectomy on a patient. Great, you go and look up the patient and find out that:

  • She’s scheduled for a CABG (coronary artery bypass graft) aka open heart surgery next week
  • There’s no echo, angiogram report, no cardiology note on the patient
  • BP 160/110, HR 115
  • Diabetic
  • On the kidney transplant list

So what do you do? The surgeon insists that it is urgent and must be done that day (later you find out that he has scheduled long cases for the next day).

Well, first the goal is to optimize the BP and HR so the BP is below 140/90 and HR below 100. We titrated in metoprolol to effect. We waited for vitals to stabilize before we went. Unfortunately, the surgeon later insisted that it was an emergency case so we had to go on the weekend.

However, was it really an emergency case? Could the case go the next day when there are more resources?

Without additional information, the goal for the patient was to do a slow induction, maintain perfusion, and gentle emergence.

Based on Non-Elective Surgery Triage (NEST), the acute cholecystitis could’ve been scheduled the next day on a Monday where there are more resources.

Non-Elective Surgery Triage (NEST) Level
Non-Elective Surgery Triage (NEST) Classification

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.