5 Ways to Shine

Your anesthesia clinical rotations are hard. Suddenly, you are thrust into a foreign environment and culture and are expected to instantly assimilate. You also have to prove yourself each time you rotate to a new clinical site. Then, just when you feel like you are getting your legs and jiving with the swing of things, poof! You’re gone. Then you move on to the next hospital and start the maddening process of proving you’re not a liability and moron all over again.

The anesthesia community is a small one. It seems like everyone knows each other through some complex, six degrees of separation, social network. This is why it is imperative that you look good, wherever you go. Each rotation is a potential working job interview or reference source. This becomes especially crucial in a tight job market!

We all are being judged on a daily basis. Every day we step into the OR, we are on stage for our CRNA peers, anesthesiologists, surgeons, scrubs, operating room assistants, and circulating RNs. You can know every drug in the anesthesia cart and intubate class IV airways all day long, but if you don’t project yourself well, you won’t gain the respect and admiration of your colleagues. Keep these five points in mind the next time you are in the OR.

1. Show up early and stay late. Arrive before the anesthetist you are working with does. Set up your room for the cases that you will be doing that day and read about any surgeries and pathologies that you are unfamiliar with. If a great case is about to start in your room around quitting time, call home and let them know you’ll be late for dinner. This segues nicely into the next point.

2. Seek to learn. This is the time in your career to dive in to the big, complex cases. Don’t worry about looking like a fool, you’re a student. Expectations are adjusted accordingly while one is actively learning. Besides, if something goes wrong, this is the time to have it occur. You can tap the mind of a knowledgeable and experienced CRNA!

3. Don’ t be afraid to say “ I don’t know”. (just don’t say it too much) If you have no clue to the answer of a question that you are asked, be honest. Write it down, go home and look it up, and find the CRNA or MD that asked you and knock their socks off with your new and exhaustive knowledge of enflurane and its link to thyroid dysfunction in the fetal cat.

4. Talk the talk. When you explain a drug, organ, or physical ailment, use the appropriate terminology, i.e. medical lingo/jargon. Talk to your friends, spouse, or dog about up/down regulation, rate pressure product, endogenous vs. exogenous ligands, kallikrein, ad nauseam… This will serve you well while abiding by the law of being a student. Be able to explain your rationale for each and every action you initiate.

5. Offer to do the little things. This is where hidden gems of clinical education lie. Go start that IV on the 400lb ESRD guy who hasn’t been dialyzed in several days or intubate the lady in NICU who extubated herself in a halo. Assist the CRNA or MD with preop blocks or a blood patch in the ER. Go see the patient that is having their tongue and mandible resected in the AM for oral cancer. Do postops in OB and talk to the lady who had to be put to sleep after a bad SAB and unsuccessful ketamine IV sedation. Help set up the heart, vascular, ped. ENT, neuro, or trauma rooms. People will notice and you will be exposed to some special learning opportunities.

Bad days pass, bad rotations end. Good luck, and remember how far you have come!

CRNA Scientist

I have spent a lot of time and consternation considering the problem of the anesthetist technician and the apathy exhibited by this type of practitioner. I believe this lackadaisical attitude springs from a root problem which lies in the nurse psyche. Nurses are issued orders and warned against thinking and acting too freely (so as not to cross the line into the practice of medicine). Also, no one tells a nurse that they can be a scientist, thus enabling them to realize and practice within this paradigm. Additionally, many nurses who want to be CRNAs seem to just be reaching for the brass ring. Once it is in their hand, many just hang on until retirement, sometimes loosely. Physicians, on the other hand, are extremely driven individuals considered by society and trained to consider themselves as scientist.

Well, I too consider myself a scientist. I had to study anatomy, physiology, chemistry, physics, pharmacology, math, statistics, etc. to achieve my degree. Once I became a CRNA, the study didn't just stop. I still read textbooks, journals, and the internet to stay abreast of the ever changing advances in our field. I attend meetings and am a member of forums such as the Learn to Sleep Google group and Yahoo’s Clinical Anesthesia forum to learn from others, and hopefully teach when the opportunity presents itself.

Like a scientist, I develop hypotheses on a daily basis regarding my patient and some deviation from their normal homeostatic state. I then test this hypothesis with an appropriate clinical action. Then, I collect data and analyze it to determine if my educated guess was right. Based on these results, I gather knowledge and learn. I know this is happening because I am developing better clinical judgment and avoiding some problems that I used to have to fix (or at least anticipating the problems that I have no power over and will have to address, i.e. surgical blood loss).

There's an old saying "you are what you eat". I agree, but take this axiom one step further. I think that you are what you consume. All anesthetist consume science and the scientific method on a daily basis, whether we realize it or not. So, once we clearly see ourselves as what we are, perhaps we will hold ourselves to a higher standard of knowledge acquisition and retention. So, dust off those old books, read your AANA journal, join an online forum or discussion group and embrace that scientist inside.

How to Establish Instant Rapport

Forming a strong relationship and establishing trust are critical components of patient care. Our patients are literally putting their life in our hands. Many times, this complex, verbal and physical ritual must be performed within three to ten minutes.

The first and most important point to realize is that each patient is unique and special. That sounds sort of hokey but it instills basic respect for the individual. Next, the fact that we occupy our position and the clinical garb that we adorn ourselves with establish credibility and a certain air of authority. However, there is much more that we can do to facilitate and expedite this sacred bond of trust.

1. Look the patient in the eyes and introduce yourself as a Nurse Anesthetist in training or Student Nurse Anesthetist. Let them know that you will be helping them take a nap, monitoring their vital signs, and by their side during the entire anesthetic.

2. Touch the patient. Shake a hand, squeeze their shoulder, or pat their leg. This initiates the caregiver/patient relationship and facilitates the bond.

3. Smile and project warm confidence. Take a note from the Beach Boys and throw out good vibrations.

4. Rapport is a two way street. Share information about yourself as you get to know the patient, e.g. “I had this surgery too”.

5. Seek to understand. Show empathy.

6. Address the family. Look around the room or bedside and say hello. Talk to your pediatric patients and get on their level.

7. Be factual about risks and complications, but keep hope alive. Use age/ education appropriate terminology.

8. Freely provide pertinent clinical facts and answer questions truthfully, but frame the information properly. People will believe what you tell them.

9. Diffuse anxiety and disarm hostile situations. Seek to be the calm in the storm. Use humor when appropriate.

10. Finally, give them what they need. Two milligrams of Versed is a great drug for anxiety, but it may do nothing for someone who takes their TID Xanax and Klonopin with a Harvey Wallbanger chaser. The same goes for narcotics and the guy that’s writhing in pain even after he chewed up his AM OxyContin and put on two Duragesic patches.

I know this seems like a lot to consider and implement in such a short period of time. However, there will be situations where you will have to draw on each and every one of these points, plus all the psycosocial stuff you learned back in nursing school and maybe an episode or two of Dr. Phil. In the end, the best approach may be to find a colleague who is really good at this and study/emulate their techniques.

This is a great article on communication and rapport. Communication gaffes: a root cause of malpractice claims. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1201002