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CRNA 131 | CRNA Clinical Cover Photo

Embrace the diversity of anesthesia because it holds the key to your growth as a CRNA. In this episode, Guest Host David Warren shares his personal journey through the thrilling world of CRNA clinicals. He reveals a wide range of valuable lessons he has learned, offering knowledge to aspiring CRNAs and even anesthesia enthusiasts. First, David discusses the importance of knowing your school and sites. He explains how to effectively conduct research on your CRNA program in order to fully comprehend its distinct advantages and cultural aspects. Next, David talks about how to adapt to the equipment. He shares his own experience of transitioning from a simulated anesthesia machine in school to real-world equipment in clinical settings. Then, David discusses the most challenging aspect of clinical practice: working with different personalities. Finally, he uncovers the striking variations in anesthesia practices across different locations. Don’t miss out on what you need to know for CRNA school clinicals. Tune in now!

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What I Wish I Had Known – CRNA Clinicals By Guest Host David Warren

I am your guest host David Warren. We are talking about what I wish I had known prior to starting CRNA clinicals as a Nurse Anesthesia Resident in CRNA school. Think of this as part one. Part two is going to come in the next few weeks. I started CRNA clinical and this is all very fresh on my mind. I wanted to share the content with you while it is still fresh on my mind. I also recently did an episode on what I wish I had known prior to starting didactics in CRNA school. You can check it out here.

For those of you who don’t know me as a guest host, my background is in Emergency Medicine as a nurse practitioner. That is a whole topic within itself that we will cover at some point in time but not in this episode. My goal with creating content here is to bring you valuable insight into what is going on in the life of a nurse anesthesia resident and someone who’s in CRNA school. We’re diving right into what I wish I had known prior to CRNA school in the clinical portion.

To give you a little background, I am in a front-loaded DNAP program out on the West Coast. I started in January 2022, and I finished my didactic portion at the end of March 2023. I started clinical in April of 2023. I finished my first clinical rotation. I started my second CRNA clinical rotation. I want to dive deep in now on some of the things that I wish I had known, what I wish I had known prior to starting this clinical journey because I did one of these videos on my YouTube channel a few months ago about what I wish I had known prior to CRNA school and the didactic portion.

Now that I’m starting clinical, some of those things that I wish I had known are starting to arise. I want to share that information with you. I hope that you find it helpful. I hope that you find it insightful. If you are a nurse anesthesia resident, you’re probably resonating with a lot of this because I feel like a lot of people that I’ve talked to, a lot of my colleagues in the field who are nurse anesthesia residents feel the same way. I have some points listed here. I’m going to go in order and this is no particular order of importance but these are things that I wish I had known prior to starting my clinical journey.

CRNA School Clinical Locations

The first is to know your school and know your sites. In my program out on the West Coast, I knew when I applied that I was going to have to be traveling for clinical. That all of my clinical wasn’t going to be in one state. I was going to have to go to multiple states across like year and a half time span to get all of my rotations in.

That was made very clear upfront during my interview and I was okay with that. However, whenever you’re applying to a school if you’re thinking about applying to school or you’re already in school, you’re stuck there now but know what your clinical rotations are going to look like. Are you going to be in one state at an academic medical center, one hospital the whole time or are you going to be going to different places?

At my last clinical rotation, some of the CRNAs I worked with had a mix of training. Some of them did all of their training in one academic medical center. Some of them floated all over and went all over the place like I do now. That’s going to be school specific. Know going into your clinical training or into your application to CRNA school, what you’re going to be doing. Are you going to be staying in one area or are you going to be floating around to multiple different states?

The second part of that is to know the sites that you are going to be going to and how those sites are run. Are they CRNA-only sites? Are they medical direction sites? Are they supervision sites? If it’s a medical direction or supervision site, do the physician anesthesiologists push your induction drugs for you? Do you get to do your own regional? All of those questions come about when you start talking about different sites and how different CRNA clinical sites are run. That’s something that you can bring up and ask in your interview.

You can ask, where are the clinical sites? What practice environment do the clinical sites offer? In the school that I’m at, over 90% of our clinical sites are CRNA-only sites or independent sites. We do have some supervised ECT sites but they’re very loosely supervised. The physician anesthesiologist is not in the room on induction. Usually, not pushing your drugs for you. You’re doing everything and your own regional. Again, when we say supervision or medical direction, that’s very facility dependent as to what that means and what that looks like.

Know going in where you’re going to have to go for clinical. If you’re going to have to go to multiple states, stay in one state, stay at one medical center, or if you’re going to be traveling around maybe within that state. All good questions to ask going forward because that may not fit with your schedule. Maybe you want to be in a school where you’re doing all of your rotations at one site and you don’t have to move.

There are certainly advantages to that. You’re not spending thousands of dollars a month packing everything up, moving to an Airbnb, and doing that 12 weeks in and 12 weeks out. The disadvantage to that is you’re getting all of your training in one area. Maybe in all these different areas, they do things differently. You can get a feel for what you like, what you don’t like, what works well, and what doesn’t work well. There are advantages and disadvantages to both.

You can be successful doing either, honestly. There are CRNA programs that offer both of those extremes and people graduate and are successful CRNAs. It’s not going to hinder you but you have to look at the pros and cons and weigh. Is that something you want to do or not? Based on whether you want to travel or you want to stay local where your school is.

CRNA Independent Practice Sites

The different types of sites, whether it’s like supervision or independent practice. I would encourage you to try to get those independent sites if you can because I’m at an independent site now, the CRNA-only site. It is very different. The whole vibe and the feel are very different from my last site, which was a supervision site. Try to get that experience if you can because it’s super interesting to see CRNA-only practices and how they work and how they run and how things are done.

Try to get that experience if you can because it's super interesting to see CRNA-only practices and how they work and how they run and how things are done. Click To Tweet

It’s a great environment and I would highly encourage you. If you have the opportunity to do a rotation, if you have an elective opportunity, or if your school sends you to CRNA-only sites like some schools do. I would ask in your interview. That’s certainly a good question to ask where are your sites and what’s the culture in that site? Are you supervised or are you in an independent site? Things like that.

Historically, people have more towards the West Coast. The Midwest are going to be independent or they’re going to have independent sites. Things over on the East Coast are going to be heavily restricted and that’s a pattern. There’s not to say that there aren’t independent sites on the East Coast or fewer when compared with other parts of the United States. That’s something I wish I had known because it’s worked out well for me so far. I knew going in I was going to have to travel. That was a given.

I also knew that most of the sites were independent but now that I’m at an independent site. I’m like, “This is cool. I would love more of this.” Looking back, had I gotten into CRNA school at a place that didn’t have independent sites? That would be a thing now that I’m like, “I wish I had that.” Use that as an opportunity to ask questions in your interview about where your clinical sites are, and what’s the culture at that particular site.

Anesthesia Machines

We’re going to jump all over here. The second point is the equipment you train on in your simulation lab or at your school is going to be different from the equipment you use in the real OR. That took me a little bit of getting used to. We’ll start with the simulation lab. I remember my first day in the simulation lab seeing this ‘90s model or ‘80s model anesthesia machine. I’m like, “That’s cool.” I have no idea how that works but over the course of a year and a half, we learned everything about the anesthesia machine.

I felt like an engineer. You have to know all the parts of it, the high-pressure system, the intermediate-pressure system, the low-pressure system, what the vaporizers are, and what the APL valve is. There are all these things that you have to know. Most of the anesthesia machines out there have the same functionality but there are differences in those anesthesia machines, especially the ones that you train on.

A CRNA looking at an anesthesia machine
CRNA Clinical: Most of the anesthesia machines out there have the same or similar functionality. A lot of the same functionality, but there are differences in those anesthesia machines, especially the ones that you train on.

When I trained, as I said, it was not antique but digital. It was different. It was an earlier model than what people use in the OR nowadays. Having to get used to that equipment change was quite challenging for me, honestly. That first day in the simulation lab when I saw the anesthesia machine, I was like, “That looks like a new machine,” because I had never seen a machine at the time.

Spending a year and a half of that machine and learning the odds and ends of it, I feel like I was good in the simulation lab. When I went to clinical on my first day, I was taken aback because I was like, “What is this?” There was an anesthesia machine there and it had like a big iPad screen there in the middle of it, which a lot of them do now. A lot of the newer machines have the iPad look and touch screen there where you can change things.

That’s something that when I first got in the OR, I was like, “It’s different.” It’s not what I’m used to because the ventilator waveform on my machine was about this big. The ventilator waveforms and all the gases and everything on the other machine were like an iPad screen. I’m looking at all this stuff and I’m like, “That’s interesting.” We’re talking in school about watching your tidal CO2, your expired O2, Sevo, nitrous, or whatever the expired gas that you’re measuring is.

It’s hard to do that simulation lab or at least it was for us because we didn’t have live patients. They weren’t on actual gas. You didn’t have number values pop up there. In the real world, whenever you’re in the OR and you’re looking at this digital screen, there are a lot of things on that digital screen. Granted, we covered all that stuff in CRNA school but seeing it in practice and applying it was different than what we did in our simulation lab.

The equipment’s going to be different. The anesthesia machine is one example. Everything you use or everything that I used was going to be different except for your Mac and your Miller blade. That’s standard but you’re going to have different video scopes. You may have a GlideScope, McGrath, or whatever other video scope you have.

The LMAs that you use are going to be different. It’s very different putting in an LMA on a mannequin versus a live human. It’s very different intubating a mannequin than it is a live human. All the equipment and things you use are going to be different when compared to what you use in your school. That’s not necessarily something you can prepare for because you can’t pop in the OR and be like, “I’m going to take a look around.”

You have to have that in the back of your head though that, “When I go to clinical, things are probably going to look different.” For us, type A personalities or even people who are laid back, it’s different. We don’t feel in control. When you go in and you see all of these things that you’ve learned about but it looks different. That’s a thing that you’ll have to get used to.

Even now at my second clinical site, the anesthesia machines are different than my first CRNA clinical site. I’m now at my second clinical site. I’m still trying to make sure I know what’s going on in the machine. Everything’s the same. You still have your ventilator, your vaporizers, and your gas. Some things are digital, touchscreen, and twist knobs. There are all kinds of differences in those pieces of equipment that you have.

That’s something you have to take into consideration. Everything down to, again, maybe the IV catheters that you’re using are going to be different at your different clinical sites. Know going in that you’re going to have different equipment than what you’re used to dealing with. You have to be willing to adapt. That’s part of being in CRNA school.

You have to adapt to what you’re given. When you’re starting to feel comfortable for twelve weeks or however long your rotations are, right at the end, you’re starting to feel great. Everything’s good. You’re comfortable, and then you’re onto a new site. You’re like, “Back to square one. We’re going to climb the mountain a little quicker this time.” That’s where I’m at now.

I feel like I was good at week twelve at my first site and now I’m days at my other site. I’m like, “We’re slowly getting back up there,” and that’s very normal. All of the equipment, all the things, and anything from the machine to the ET tubes to the LMAs to the video scopes are all going to be different from site to site and especially from what you’re training on in the simulation lab, so just know that.

The way I would remedy that is on your first few days of clinical, show up early. Grab one of the anesthesia techs or CRNAs that may be there early and have them walk you through some of this stuff or you can do it yourself. Go into your OR, walkthrough, and play around on the machine. Get to know where your equipment is. Look at the equipment if it’s different than what you’re used to. Have a good idea of your equipment is what it comes down to.

That’s anywhere you go, even as a CRNA. You need to have a good idea of your equipment and know your equipment. If you’re not familiar with it, go in early and get familiar with it before you start having to have patients in the room and you’re trying to take care of patients. You need something you don’t know where it is and you see how that can snowball. That’s my second point. The equipment is going to be different.

Different Types Of Personalities

My third point is something that we probably all know. That is all the personalities. It’s how I have it titled. All the personalities in CRNA school clinical are going to be very different. You’re going to meet people who are super kind and want to teach and help you. You’re going to meet people who maybe aren’t so kind and who probably don’t want to help you. You have to be resilient. That is what it comes down to because you’re going to meet both extremes.

You’re going to meet people who are, as I said, very nice, kind, loving, and caring, and will put you under their wing and we’ll take care of you. You’re going to meet the extremes of that. It doesn’t mean they’re bad people. They mean you should have different personalities. As you probably surmise, there are very strong personalities in the anesthesia world. The anesthesia world is very small.

You’re going to have to learn to navigate those personalities. Personally, that is one of the most challenging aspects of being in the clinical environment. It’s navigating the personalities. I’ll give you some examples from my last clinical site. After I’d been there for a few weeks, I knew, based on who I was working with, how the day was going to go.

I knew some people were super laid back. I could do within reason whatever I wanted to as far as my plan if we were doing general surgery. Normally, for general surgeries, we would do gas and an ET tube, etc. If I wanted to play around and do a TIVA, intubate the patient and put them on the ventilator and then run a TIVA, which is total IV anesthesia. I could do that or I could put them on gas. I could play around with a combination of any of that.

Some of the preceptors I had were fine with that. If I wanted to experiment with new medications, I tried Esmolol on induction one time or played around with PRECEDEX or Ketamine. I could do that. There was the opposite extreme of those preceptors and those were the preceptors who were like, “We’re going to do it this way. We’re going to do X, Y, and Z.” They would take the initiative. If the patient’s hypotensive, they would get up and treat the blood pressure before I would have a chance to if I’m charting.

It’s different personalities. Again, that’s all going to come with people, where you’re at, what sites you’re at, and what the culture is there. It is going to vary from place to place very wildly. Sometimes, you’re changing preceptors daily. You’ll start with somebody and you’ll end up with somebody else. It’s getting into that routine of who you’re working with. The good thing is if you’re at a site for a long enough period of time, usually, you get to know pretty much all the anesthesia providers there. You get to know if they are nice, helpful, and good. You get to know who’s going to let you do what after a little while.

That’s one of the challenging things about starting at a new site. You don’t know anybody but then, on the plus side, they don’t know you either. Some of the people you work with, after you work with them 6 or 12 weeks and you’re competent, they’re going to see that you’re competent. They’ll start letting you do stuff. If you take the initiative on wanting to experiment with things, they will let you do that.

One of the challenging things about starting at a new site is you don't know anybody. But then on the plus side, they don't know you either. Click To Tweet

However, when you start at a new site, they don’t know who you are and you don’t know who they are. They may be a little more on your back watching you trying to figure out do you know what you’re doing. Are you safe? When you start proving yourself, get a few cases in a few days in and you’re doing everything right. You’re nailing your intubations and you’re keeping up with the case. You’re running the case yourself, then they begin to trust you.

That goes a long way as well. All the personalities are going to be different. It’s going to vary from site to site. If you’re in CRNA school, you will see this in your didactic phase as well because all your professors are CRNAs or physician anesthesiologists. It depends on where you go or what school you’re at but you’re going to see those personalities in your professors.

Now, those same types of personalities are present in people who are not your professors at your school. You’re going to have to navigate the personalities because that is one of the most challenging aspects of being in clinical practice. As a student especially or as a resident, it’s navigating those personalities. I wish I had known how different those personalities were but my word of advice to you is this. Whenever you encounter those personalities, find a way to take something away from them.

All the people that I worked with at my first clinical rotation over twelve weeks all taught me their own ways of doing things because it was my first rotation, the first few weeks. I had no idea what I was doing. I’m watching them and doing some things myself. I’m gathering what I like and what I don’t like. I’ve built some of my habits around the people that I’ve worked with. That will be you as well. If you’re applying to CRNA school, you’re going to build your CRNA clinical habits around the people that are training you. They’re going to be some habits. You’re like, “I don’t like that. That’s not for me.”

If you're applying to CRNA school, you're going to build your clinical habits around the people that are training you, and they're going to be some habits. Click To Tweet

There are some habits you’re like, “I’ll pick up on that. It’s a good idea.” I know when I first started. One of the CRNAs was like, “After you pushed your Prop and your Roc and you’re just waiting for the Roc to set in, you can hit the pause alarm on your monitors. It counts down for two minutes. That’s roughly when your Roc’s going to set in.” However, with time, you can feel when you’re bagging the patient. You can feel when the patient starts to loosen up and you know when you’re ready to take a look and to intubate the patient.

That comes with experience. You’re not going to know that feeling in your very first few times doing intubation or giving Roc. You’re going to pick up on little clinical tips like that. As I said, some things you’re going to like and you’re want to take for yourself. Some things you’re like, “I may not try that,” but it’s good to know.

The thing is, you have to be open and willing to navigate those personalities because there are some people who aren’t going to be super nice. You’ll still learn things from them. There are people who are going to be very nice and you’re going to learn things from them too. Navigating the personalities, I could say a lot more about that but we’ll stop there. That is probably the hardest part.

Different Types of Anesthesia

The last point ties into that and that is anesthesia is different depending on your location. Now I will put the caveat like this. Anesthesia is not that different. You’re doing the same thing. If you are in CRNA school, you know this. If you’re a CRNA, you know this. If you’re looking to apply to CRNA school, you may not know this. There are 1 million ways to do anesthesia. There are 1 million cocktails that you can come up with to do anesthesia.

The cool thing is there are a very small few of those cocktails that are wrong in the wrong patient population but the majority of those cocktails are right for a lot of different people. You can do anesthesia a lot of different ways and it doesn’t make it right or wrong. That’s the cool thing. You’re going to go to one of your clinical sites one day and you’re going to do anesthesia for your list or 5 or 6 patients that day.

two medical professionals in an operating room with anesthesia equipment nearby
CRNA Clinical: You can do anesthesia in a lot of different ways, and it doesn’t make it right or wrong.

You’re going to go with somebody else the next day and you may be doing the same cases. They’re going to do things completely different and that’s okay. That’s where you pick up on, “I like that. That worked well for that patient. The patient woke up, was not in pain, no nausea, and vomiting. Great.” Maybe you do a case with somebody else and you’re like, “It’s like that. Maybe the patient woke up and was hurting bad.” You were like, “Maybe we could have done X, Y, and Z to better help with that.”

All that to say, the anesthesia that you’re going to see is different pretty much daily when you’re in one clinical site. You’re going to work with different preceptors who are going to do things differently. It’s even true and even more magnified whenever you are jumping clinical sites across state lines like I have. I did my first clinical rotation in a separate state than I’m doing my second rotation in.

A nurse and a CRNA speaking with an older patient in a hospital room
CRNA Clinical: The anesthesia that you’re going to see is different. That’s going to be different pretty much daily when you’re in one clinical site, you’re going to work with different preceptors who are going to do things differently.

While the anesthesia is the same or we’re doing general anesthesia with gas, some of the multi-modals we’re using are different. Some of the adjuncts we’re using are different. Some of the blocks we’re doing are different. It doesn’t make it right or wrong. It’s just different. That’s something you have to be ready for because you’re leaving one clinical site thinking, “I’m going to do it this way.” You get your next clinical site and they’re like, “We’re going to do this.” You’re like, “I haven’t done that yet but sure, we’ll give it a try.”

I’ll give you some practical examples. At my first site, we rarely gave Versed pre-op. Maybe in 12 weeks, I maybe gave it 3 or 4 times not common. This is not just for the 80-year-olds. We’re not going to give Versed to the 80-year-olds, but even the 20, 30, or 40-year-olds. We didn’t give Versed and is it right, perhaps? Is it wrong? No, you don’t have to do that.

Now at my current clinical site, on the second day, pretty much everybody gets Versed. From what I’ve seen, everybody gets Versed. Everybody of appropriateness gets Versed. I’ll put it that way. You’re not given 90-year-olds Versed but everybody of appropriateness gets Versed there. On this clinical side, it’s very independent. I can do pretty much what I want. As long as it’s safe for the patient, I can do it.

I will say, “I haven’t been given Versed.” Some people are like, “Why aren’t you giving Versed?” I’m like, “I haven’t. I don’t have a good reason for it, honestly.” If the patient’s anxious and they ask for something for their anxiety, I will give it then, but I don’t go up and give Versed to everybody like some of the anesthesia providers do. Is it right or wrong? No.

Some other examples, like at my last clinical site, we did not use ketamine very much at all because it came in 500-milligram vials. Unless you’re doing an 8-hour spine case, you’re probably never going to give 500 milligrams of ketamine. That’s a lot of ketamine. However, at this clinical site, we have syringes of 50 milligrams, which is much more conducive to everyday use.

We do use a lot of ketamine in cases at the facility where I’m now. Is it right or is it wrong? No, it’s different. Take any number of things and you will see that pattern. It’s going to be different no matter where you go. I’m picking up things that I didn’t get at my last clinical site. I’m getting to experiment a little bit with other drugs and that’s cool. Getting to do more blocks.

In the other place that I left, we didn’t do much regional anesthesia there. It’s interesting seeing how anesthesia is different based on where you’re at. Again, I’m going to tie this back to the first point, know where your sites are and know what practice environment you’re in. This ties into that because you want to be at a site where you’re going to be at multiple sites where you’re going to be able to see different things.

That may be a downside to going to an academic medical center where you’re only learning one way. You’re seeing everybody do it in that culture that way. It’s not right or wrong but it’s different. Whereas if you’re going over multiple states or multiple different clinical sites, you’re seeing different patterns. You’re seeing people do different things. That is a cool part of traveling for clinical. You get to see anesthesia in different parts of the United States.

That’s one of the cool things now. I’m seeing things that maybe I didn’t see in my first CRNA clinical site. It’s not right or wrong. It’s gray. It is what it is. It’s safe for the patient. Therefore, it’s right. If I didn’t do it that way, it doesn’t make it wrong. Anesthesia is going to be different no matter where you go and no matter what area you practice in. You’re going to see different trends.

Those are the points that I have for you. 1) Know your school and know your sites. 2) All the equipment you use is different. 3) Know all the personalities. 4) Anesthesia is going to be different no matter where you go. I hope you enjoyed this episode. If this is something you’ve found of interest, comment and let us know what you think. If you have tips or suggestions for content that you would like to see in the future, specifically from me as a guest host, comment and let us know. I would love to answer your questions or provide you with content that you might find beneficial. Thank you so much for watching and I will see you next time.

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