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 nurses that they are scientists, thus enabling them to realize and practice within this paradigm. Additionally, some 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 scientists. 

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 utilize the scientific method. 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. Whether we realize it or not, we all consume science and the scientific method on a daily basis. Once we clearly see ourselves as what we truly 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.

Contact Dan Simonson (dsimonson@mac.com) to enroll in his "How to use Pubmed" email tutorial. 

Evidence-based practice Powerpoint lecture by Joe Pellegrini, CRNA, PhD, http://www.aana.com/WorkArea/showcontent.aspx?id=14058 

            Forming strong relationships 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 a very short period of time (3-10 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 a 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 some 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. 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.

            The new version of the Firefox web browser was officially released this week. This is version 3 and there are some noticeable improvements. But before we get to them, let’s first talk about what a web browser is and why we might need a different one than Internet Explorer (IE) or Safari. IE is the browser that comes installed on a Windows machine and Safari is the web browser that is installed on the Macintosh.  

            A web browser is a piece of software that allows us to view the content of web pages. The software also allows us to navigate around the world wide web through URLs, uniform resource locators aka web addresses, and links. The most common browsers are IE and Safari, but Firefox and Opera are gaining popularity. I don’t have any experience with Opera, so I won’t be covering it here. Although, it claims to be fast, supports mouse gestures, and it is free, so you may want to check it out.

            I’m not going to give you the spiel about having to walk uphill both ways through the snow to get to school, but I can tell you that the internet has drastically changed the academic landscape in anesthesia. When I was in school, we actually had to open these stacks of paper held together by glue and fabric, called books, to gather information about anatomy, physiology, and drugs. Today, there is a veritable cornucopia of digital information at our fingertips, all for the taking. Granted, your sources should be carefully considered and checked for validity, but the information is available.

            This is the main reason that I like Firefox. It is another tool for collecting information on the web. The browser is fast and it makes navigating your favorite pages easier. It also contains some of the best security features of any of the browsers out there. Specifically, the software is extremely adept at detecting and blocking malicious, phishing sites. The previous version would gray out the screen and warn the user of a possible phishing site, but Firefox version 3 actually prevents the page from loading. They maintain their own database of dangerous sites and it is updated regularly. This gives me piece of mind and a sense of security while using the web. Additionally, Firefox has this new feature that they call Larry. He's sort of like the traffic cop of the internet. It's a small icon to the left of the URL that you can click on to see information about the security of a website, the number of times that you have visited, and the cookies and passwords that are being stored on your computer. 

Firefox also has lots of neat little gadgets and widgets that you can install to make it your own. The hundreds of little add-on programs are available so that you can plug them into the browser to make it more suited to your individual needs and web surfing habits. A few of my favorites are Cooliris, PicLens, and Googlepedia. There is also a neat function standard in the browser that gives you the option to remember your passwords. If you are like me, you may have to guess several times before you enter the right one. Well, Firefox 3 just waits until you plug in the correct characters and remembers that one. It appears to be a smarter browser.

I recommend you try it out. You may find that it serves you well when you are looking up your next obscure pediatric syndrome or the third active metabolite of Ziconotide. Install Googlepedia and the Wikipedia entry for your search will appear alongside your Google results. There are all sorts of little time savers in this program. There are also some good keyboard short cuts. Ctrl+T opens a new tab and Ctrl+F opens the "find on page" search function (this is good for ferreting out that little bit of information in a 19 page drug study posted online). Happy hunting!

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 step into the operating room.

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 adhering to the SRNA law. 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!

     Time is a precious commodity. You have to use every little second efficiently when preparing for a big test. There is so much information to pack into your head and so little time. Why not use your ipod to maximize your information absorption and retention? This is exactly what I will teach you in this article. We will cover using the notes function in your ipod and recording MP3s and importing them with the free open source audio software Audacity.

     Ok, if you have an iPod, you're in luck. It can be an incredibly useful educational tool. I found the notes idea on the Online Education Database. It involves creating notes, flashcards, bullets, or study guides and importing them into your iPod's note program. If you like this tip, go visit the OED and read the other 99 iPod education tips.

Portable notes [from Macworld]
"Podcasts are useful tools, but what if what you really need is easy access to class notes, minutes from a meeting, or a speech you’re trying to memorize for your daughter’s wedding? You can use the iPod’s Notes feature to store lectures and other material that you can peruse at any time.

To start, you’ll need to put your iPod into disk mode. Connect your iPod to your Mac, go to iTunes, and select the iPod from the Devices list on the left. Under the Summary tab, click on the Enable Disk Use option. Once you’ve turned on disk mode, your iPod should appear as a volume on your desktop. Double-click on the iPod icon and locate the Notes folder.

You’ll then need to convert anything you want to show up in the iPod’s Notes to plain text files [i.e. a .txt file], either by using a program such as Apple’s free TextEdit or by saving your Microsoft Word documents as Text Only (File: Save As). Then, just drag each file you want to the Notes folder on the iPod. If you plan to store a bunch of notes, it’s best to create folders—say, one for each class. You can help keep those lists further pruned by creating subfolders and organizing notes by week or topic, for instance.

Once you disconnect your iPod, you can find your files under Notes. If you don’t see this option in your main iPod menu, look under Extras. If you want to promote Notes to your iPod’s main menu, visit Settings: Main Menu, scroll down to Notes, and click on the iPod’s select button to turn this option on."

     The next tip involves using a free program called Audacity to record classes or notes that you need to review and importing them into your iPod. The first thing that you will need to do is download the program. Version 1.3.4 is still in the beta phase, but seems to be stable. I have been using it for about a month and have had no problems. The benefit to using 1.3.3 or higher is that you can record audio and convert it directly out to MP3. This is good because iTunes will readily accept MP3s.

     Once your audio is recorded, you can edit it to reduce background noise, cut pauses or comments out, and increase or decrease the master volume [check out the Audacity Wiki]. Then choose File>export>Save as type and choose MP3. Name the file and save it to some easy to remember folder. Next open iTunes and import the MP3 to your library. At this point, you can sync your iPod. Now you can take your home-brew brain food on a walk or to the gym. Exercise and education, now that is a winning combo!