The COVID-19 Crisis: CRNAs to the Rescue

One of the most memorable photos from the COVID-19 pandemic is an image of two healthcare workers in full PPE embracing, face shield to face shield. It’s an even prouder moment for the nursing community as the two are a certified registered nurse anesthetist (CRNA) couple from Tampa General Hospital. 

These two CRNAs, Mindy Brock and Ben Cayer, are on the hospital’s airway team. When a COVID patient is in respiratory distress and requires intubation, they are there to sedate and intubate the patient. This is a high-stress situation where time is of the essence, as a COVID-19 patient’s oxygen saturation is known to drop rapidly.

Mindy and Ben are just one example of the roles that CRNAs have played in helping fight COVID-19 across the country. Keep reading to find out more about how CRNAs are contributing to this health crisis.

How CRNA Qualifications Help 

CRNAs are advanced practice nurses who are trained in skills such as intubation, arterial line insertion, central line insertion, and pain management techniques, such as regional blocks. Prior to earning their degree and certification, CRNAs are required to have intensive care unit (ICU) experience so they are well-versed in managing critically ill patients. 

This education and training takes a CRNA to the head of the bed in an operating room, surgery center, or doctor’s office, but the COVID-19 pandemic has CRNAs finding new opportunities to pitch in. 

Continuing the Fight in Medically Underserved Areas

CRNAs have full practice authority in 29 states. This means they can practice without a physician’s supervision. As a result, CRNAs often provide care and airway expertise in traditionally underserved areas. An example would be in a community access hospital where hiring a CRNA can be a cost-effective practice. 

According to the American Association of Nurse Anesthetists, on March 30, 2020, the Centers for Medicare & Medicaid Services issued a temporary suspension of supervision requirements for CRNAs. This suspension meant hospitals and health systems could utilize CRNAs to the fullest extent of their practice. In a press release about the suspension, Kate Jansky, the AANA President, said this decision allows CRNAs to manage and staff intensive care units as well as staff operating rooms without a physician’s supervision.   

Traveling to the Front Lines

Lots of facilities canceled their elective surgeries to slow the spread and preserve their PPE, and many furloughed CRNAs took the opportunity to travel to some of the hardest-hit areas to provide their services. One example of this was when 30 CRNAs from the North American Partners in Anesthesia (NAPA) group traveled to New Jersey to join in the fight against COVID-19. 

CRNAs traveling to states that were hit hard would work on intubation teams as well as resuscitation teams. When a COVID-19 patient coded in the hospital, the CRNAs would provide assistance in airway management, medication administration, and other potentially life-saving tasks. 

Many CRNAs left behind families and risked their personal health to serve those most in need. Some have even come out of retirement to volunteer. 

Recommended reading: Love Thy Neighbor: Wear a Mask

Even with the right PPE, the work is dangerous. CRNAs are working with the airway, which means they are especially at risk for getting contaminated droplets on their clothing or breathing them in. An estimated 20 percent of the anesthesiology department at Mount Sinai Health System in New York City had contracted the virus as of April 2020, according to the Associated Press. Even with the increased risk many have voluntarily given their time and knowledge.

Returning to the Bedside

Because CRNAs have worked in different ICU settings before going to graduate school, some have opted to return to the bedside during the pandemic. For example, many have stepped into roles helping manage ventilators and airways in ICUs as well as taking patient assignments. 

With elective surgeries on hold in many parts of the country, working in the ICUs or in emergency triage settings allows CRNAs to utilize their hard-earned skills. 

The Takeaway

While 2020 has looked very different for the healthcare community than anyone had anticipated, there are countless stories of nurses, including CRNAs, who have answered the personal call to help. The pandemic has also shined a light on CRNAs’ services and engaged politicians and communities to lobby for expanded practice rights. 

Where there is a health need, nurses — including CRNAs — will answer the call. 

Guest Post by:

Love Thy Neighbor: Wear a Mask

Michiganders are now required by Executive Order from Governor Whitmer to wear a mask indoors and in crowded outdoor settings except in certain situations. All workers in indoor businesses should also wear masks and businesses must turn away customers who don’t wear masks.

The Emergency Alert showed up on my phone today at 4:44pm

Our state leader is setting the right example by wearing a mask and is attempting to change the “American culture” of individual freedoms fast. She has to set this executive order to tell everyone the seriousness of this pandemic and what we all must do to combat COVID-19.

Unfortunately our national leader, the president of the United States, does not want to set a good example and has made masks a political movement. It should not be a political movement! Instead, this is truly a public health crisis.

Wearing a mask is a symbol of caring for thy neighbor, anyone you come in contact with. The mask protects the other person from you, just in case you are amongst the 40% of asymptomatic coronavirus carriers.

Being an asymptomatic carrier means that you have no symptoms whatsoever and you still have the virus and can easily spread the virus to others. Currently, the WHO and scientists worldwide tell us the primary way of getting this severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the name of this coronavirus, is by being close to others in less than 6 feet and breathing in their air.

This coronavirus is not going away until a viable vaccine is ready, which is unlikely to happen until next year. We must remain vigilant and always think what we must do to protect our loved ones and those on the front line. Just when Florida and Texas think they are in the clear and open up the country prematurely, now they are paying for it with American lives and wrecking havoc on thousands of families. If Florida was a country, they would be number 4 in the highest number of cases right now.

Love Thy Neighbor: Wear a Mask

This is especially important as a nurse. You must always protect yourself in order to protect and serve others. Encourage those around you to follow good practices.

I have to admit it’s been difficult. I wished for my sister to drive from New York and visit me and my newborn. Unfortunately I had to decline and tell her to visit me next year when we have a vaccine. My newborn is completely vulnerable and I would feel horrible if something happened to him. She had also visited several groups of people in the week leading up to the planned visit and planned to stay in a hotel for a night. It doesn’t help that videos come up that show hotel rooms still not being adequately cleaned even during the pandemic.

What have you done to encourage others to wear a mask? How have you struggled during this pandemic? Let me know in the comments below.

Happy International Nurses’ Day

2020 is also the year of the nurse and midwife as designated by the World Health Organization (WHO) in honor of Florence Nightingale’s 200 year anniversary of her birth.

Florence Nightingale is the pioneer of modern nursing.

It is almost very fitting that this is the year of the nurse and midwife. They are on the frontlines of taking care of patients with COVID-19 and must advocate for not only the patient but also themselves. The protection and safety for themselves is vital for taking care of others.

Unfortunately there are already too many stories of nurses who were not equipped with the appropriate amount of personal protective equipment (PPE) and died because of it. Every hospital system should do everything to support the nurses and anyone on the frontline to get the right PPE. No system should deny the nurses safety and their own judgement on what is required to keep them safe.

As for the midwives, I am proud to say that I choose a midwife to be my primary care provider. Thankfully midwives and the hospital system have a good working relationship and thus many best evidenced based practices are utilized. I’ll go over it in more detail tomorrow. Goodnight for now.

Day 1 of Stay Home Stay Safe Order in Michigan

Wow.

So much has happened since I last posted but almost more importantly, this pandemic is just starting to get crazy.

That’s right, just starting.

It’s been 2 weeks since Michigan declared a state of emergency when there were two positive cases of COVID 19. Now there are 1791 confirmed positive cases with 24 people dead.

“Flattening the Curve” by Staying Home

Right now our hospital systems can handle the number of cases. It will still be able to as long as people stay home. This week. YES. This week is the critical week that will help determine if our hospitals will be completely overrun with patients and us having to make decisions on who gets a ventilator and who doesn’t. I hope that we don’t get to that point. But the only way to stop it is by staying home.

I’m happy to see that Michigan has a stay home order. That is a necessary step to get people to take this seriously.
If we continue “Shelter in Place”, meaning staying home and only going out for groceries or essentials once a week, then we will be doing our part to “flatten the curve.”

“Flattening the curve” means that we will not exceed the number of available hospital beds.

If we all do our part, then this graph predicts that we will likely peak in the number of hospitalizations (4877 people) around May 18. As you can see in this graph, 4877 is much lower than our maximum capacity.

Staying home will make it possible to save more lives.
If we as Michiganders stay home, then it is possible to never overload the hospital system and decrease the number of deaths.

Moving back to Michigan

I moved back to Michigan about a month ago and since then I’ve done a couple of things:

  1. I got a new job
  2. I bought my first home and I’m moved in last week
  3. I attended the AANA (American Association of Nurse Anesthetists) Annual Congress

A lot of big and exciting changes are happening in my life.

Probably one of the hardest things for me to acclimate to a new institution is getting used to new

  • flow (from pre-op, intra-op, to post-op for all different surgeries and procedures),
  • equipment and location of materials,
  • staff (are they seasoned nurses and techs or are they unfamiliar with the preferences of the surgeon),
  • physician anesthesiologists (do they communicate well with you, give pre-medication, follow protocols well, etc) and
  • surgeons (knowing their preferences, speed of surgery, etc).

Sometimes when things don’t flow as well as I’d like, I have to think about the big picture: “did the patient safely go through surgery?” If yes, “what else could I do next time to improve? What did I do well?” I continuously reassess my day. Sometimes I’ll reach out to my colleagues to ask them of their opinion as well.

For now, go blue!

Words Create Reality

Words create thoughts.

Thoughts create reality.

Change your words, change your reality.

Good thing words are free.

In a Ted video, Lera Boroditsky described a tribe that didn’t use the words left and right and rather described direction only in terms of north, south, east, and west. The tribal members were better with a sense of direction compared to anyone else.

In Russian, it’s common to use varying descriptions of the color blue. Whereas in English, we say blue. It is much easier for a Russian to differentiate the different shades of blue compared to an American.

In a book called “Bringing up Bebe,” the American mom says in France, there are descriptors for “a behavior of small annoyance,” which help differentiate small bad behaviors from horrific acts. Because such a word does not exist in English, a kid who doesn’t finish his carrots versus a kid who kicks a dog may be all labeled “bad kids”. It doesn’t help distinguish the level of “badness” and the behavior from the child.

According to the Rich Dad’s Guide to Investing, if you use the words of a rich person, then you will become rich. Gaining a financial education is one of the key factors that will get you there. You gain education through the words you use.

One of the new advances in medicine and nursing that are rocking the world right now is the use of pocket ultrasound. While ultrasound has been available for years, it has remained prohibitively expensive, especially in rural and poor countries. However, the Butterfly IQ has come out, and I believe it will change how people are diagnosed. Some healthcare providers may be reluctant to use it because it was not utilized in their initial training, but as with any advances, it will be imperative to learn new words (and images) and ultrasound education, to fully embrace the new technology and change the way people are diagnosed.

In each field, we use different words to give us more details, and it dictates our thinking. Our thinking turns into action (or inaction), and that becomes our reality. So to become a better anything, you have to learn the words.

That is why if you say you can’t do something, then that is your reality. That is why if you say you do something, then that becomes your reality.

So if you believe you belong in nursing school, then you will do everything you can to get there. If you believe you will become a great nurse anesthetist, then you will find the resources to become one. If you believe that you can make a difference, then you will learn great behaviors from your role models.

Whatever your dreams are, believe in the new words to create a better reality for yourself.

Happy Nurses’ Week 2019

Happy Nurses’ Week.

We are there for patients during their most vulnerable times and we advocate for them when we see something that isn’t quite right.

One of the things that I learned in nursing school is to keep asking questions. After conducting a head to toe assessment, we should ask ourselves: Is there a reason for a certain lab value or condition? Can we correct that? If yes, how (which drug, route, fast or slow; is there evidence-based practice to support it)? When should we re-evaluate our efforts to ensure that it’s improving the patient?


Anyways, a lot has happened since my last post. I’m moving back to Michigan. After practicing out in Northern California as an independent CRNA, I feel that I’ve learned so much in the last year and gained much confidence as well. There are some things that I feel has improved.

  1. The communication among the surgeon and the OR staff. Letting the nurses and the support staff aware of my presence, discussing with the surgeon my anesthetic plan.
  2. Regional anesthesia. While I did perform them in school, the experience I gained while performing them with and without other anesthesia staff has been tremendous. Attending a Maverick regional anesthesia course improved my hand-eye coordination with the needle. Interscalene blocks, TAP blocks, adductor canal blocks…
  3. Ultrasound guided arterial lines. It is the preference for the cardiac anesthesiologists to perform ultrasound guided central lines and arterial lines. So why not make it a standard of care for ultrasound guided arterial lines? Sometimes the ‘feel’ of the pulse is not accurate and a visual of the artery improves the first time success rate even for beginners.
  4. When there’s a sick(er) patient or a patient with a potentially difficult airway, I ask for another CRNA or an anesthesiologist to standby to help me start the case. As a professional, I’m aware of when I need additional help and when I will be able to manage the case on my own.
  5. While the first couple of cases I was a little apprehensive of starting and ending the case of my own (considering that in my training I always had a CRNA and anesthesiologist in the room during those times), I feel much more comfortable with induction and emergences on my own. The positive aspect is that cases tend to start shortly after entering the room so that there is no delay (unlike in a medically directed setting where it may take more time for the anesthesiologist to arrive if s/he is not readily available for whatever reason).
  6. Reducing the amount of opioids used in surgery by utilizing a multimodal analgesia. As you know, the opioid crisis is exactly that – a crisis. There are simply too many people who continue to have post-op pain and require opioids. That is one of the ways that is contributing to the crisis. If we can improve our processes to reduce the amount of opioids during surgery, postoperatively, and utilize other evidence based pain management strategies, then we should all move towards that.

That’s it for now. Until next time.

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