CRNA 136 | CRNA Clinical Success


Are you about to embark on the exhilarating journey of becoming a CRNA? Or perhaps you’re already deep into your CRNA program, navigating the intricate world of clinical rotations. Either way, this episode is tailor-made for you! In this episode, guest host David Warren brings us an insider’s perspective on the top 4 things he wishes he had known to do before and during CRNA school. From knowing your clinical rotations to being adaptable in difficult situations, David does not gatekeep anything for aspiring CRNAs. Learn how to decipher the clinical landscape, make a lasting impression during your rotations, understand the reality of clinical practice versus what’s written in the textbooks, and more. Your clinical journey is about to get a whole lot smoother. Tune in now!


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Tips For Clinical Success Before And During CRNA School With Guest Host David Warren

I have a very special episode lined up for you. It is part of our guest-host series, where I am bringing current CRNAs on the show for you as a guest host. My thought process behind doing this is I wanted you to read from a variety of current students who are at different stages of their CRNA journey, and allow you to step into their world and read them talk about what it’s like to be a current student dealing with things like difficult preceptors, anesthesia topics, clinical topics, maybe even things like time management, stress management, and things like that. These episodes are going to be gold. I hope you enjoy them as much as I always do.

I know for a fact that the reason why CRNA School Prep Academy is where it is now and the reason why I have learned much is from diving in and talking to current students, along with CRNAs share a wealth of information, and taking all of that information and compiling it into the system that we have created. You’re doing the same thing by reading the show and developing your method, strategy, and system for success. I hope you enjoy these guest episodes. Let’s go ahead and get into the show.

My name is David Warren and I’ll be your guest host for this episode. A huge shout out to Jenny for welcoming me onto your platform to share content. I hope you guys find this useful. We are talking about what I wish I had known prior to starting clinical rotations as a nurse anesthesia resident. A little bit about me, I was a prior emergency medicine nurse practitioner for about eight years before starting CRNA school. I’m a second-year Nurse Anesthesia resident out on the West Coast in California. I’m in a front-loaded 36-month DNAP program. The first fifteen months of my program were on campus, churning it out, and learning all of that active phase of CRNA school starting.

Point #1: Know Your Clinical Schedule And Clinical Rotations

In April 2023, I started my clinical journey. I’m going to share with you some things that I wish I had known before starting my CRNA school clinical journey. The first thing is not something I wish I had known but more of something that you need to know before you start CRNA school. This even goes back to the application phase whenever you’re looking to apply to CRNA school and searching for schools, this is super important. You need to know about your clinical schedule and clinical rotations. Know everything you can about that, whenever you’re looking at schools and applying to schools. I’ll give you some examples of this.

For instance, in my program out in California, I have to travel for clinicals. I go somewhere every twelve weeks. I’m moving usually across state lines. I’m doing my rotations in California, Arizona, and Texas. I can be in any of those states for 12 weeks at a time and then somewhere different for the next 12 weeks. I knew that going in. My point is I want you to know that about whatever school you’re applying to. Know what their clinical situation looks like. Know if you’re going to have to travel for clinical every twelve weeks, find your housing during clinical, or have a home base or a home clinical site where you do the majority of your clinical rotations. You go for maybe specialty rotations for a few weeks at a time and then come back to your home site.

Know all of that. Ask those questions or find out that information either online or by talking to the program. Know what the clinical situation looks like at the school of your choice. I will tell you this. Not all school clinical rotations are created equal. For instance, in the school where I am out in California, over 80% of our clinical rotations are independent CRNA-only sites. Meaning there are no physicians, anesthesiologists, or residents. There is nobody competing for cases. It is CRNA only. That is huge. I didn’t realize the importance of that until I got into the clinical setting and CRNA-only site. I was like, “This is super interesting and cool. I want to do more of this.”

Not all school clinical rotations are created equal. Click To Tweet

For instance, the CRNAs at the CRNA-only sites are the ones doing the preoperative interview. They’re the ones ordering the preoperative tests, doing the inductions, maintenance phase, emergence and extubation, neuraxial anesthesia, and the ultrasound-guided regional blocks. There are no other anesthesia providers there apart from the CRNAs and that is huge. Know those kinds of things going into whatever school you want to apply to.

For instance, there was a CRNA that I worked with at my very first clinical site. He trained in Connecticut, where he went to school Through his school training and first job there, he never pushed his induction drugs or did any spinal or epidurals as a CRNA. As a nurse anesthesia resident, he got his numbers that way by getting the bare minimum but as a CRNA, he didn’t push his induction drugs or do neuraxial anesthesia or ultrasound-guided regional anesthesia. He only did clinicals in one place. He did all of his clinicals at one hospital. That was his training for three years.

Know these kinds of things going into your clinical site. Know if you’re going to be doing one ultrasound-guided regional anesthesia rotation or at every one of your clinical sites. For instance, at the school where I’m at, I do ultrasound-guided regional anesthesia at every clinical site I’m at. I don’t have a specialty ultrasound regional anesthesia rotation. Some programs have that where you go for a month and do your regional rotation.

My program incorporates that regional experience into every clinical site. Those are little nuance things that you need to know before you start your clinical rotations. Before you ever apply to CRNA school, know what clinical situation you’re getting into. MC is a care team model site. Are you going to be in a medical direction, an independent, or a collaborative site? That’s important because the CRNA that I was telling you about who trained in Connecticut when he came to that clinical site where I was at, was expected to function independently and push his induction drugs.

It seems very straightforward and common but you’d be surprised he was expected to function at that level and do ultrasound-guided regional anesthesia. Getting that training while you’re in school is so important because you may want to take one of those jobs that you’re going to be independent in whenever you graduate and are expected to function at that level.

Somebody like myself, where we’re being trained at these independent sites, could certainly go work at an MC secure team or a medical direction site. It’s very hard if you’re being trained at a medical direction or a care team site where you’re not functioning independently. It’s hard to go from that to an independent site if you haven’t used those skills in a long time. I would encourage you to look into and know what your clinical situation looks like.

This is not something that I thought about before I started anesthesia school and my clinical rotations. It’s not something that I considered. Now that I’m in rotations, I see how important it is to have those independent CRNA-only sites to get your regional or neuraxial experience and all of those things, and to see how CRNAs function independently.

Consider what your school of choice’s clinical situation looks like. Let that guide some of your decision-making processes whenever you’re applying to CRNA school. That’s something that you need to know before you ever apply to CRNA school and before you go to clinical but more so know that thing while you’re applying or even before you apply to the CRNA program of your choice.

Point #2: Treat Each Clinical Site As A Job Interview

2) Treat each clinical site as a job interview. It seems straightforward but you’d be surprised. There are lots of nurse anesthesia residents that don’t do this. What I mean by that is to treat this as a job interview. Show up on time and know what you’re expected to know. At my first clinical site, I would always show up at least an hour early. I would get the patient pre-op and get the room set up. I didn’t have Pyxis access to draw my meds but I would get syringes laid out.

CRNA 136 | CRNA Clinical Success
CRNA Clinical Success: Treat each clinical site as a job interview.


When the CRNA came in, I would ask them if they would log into the Pyxis. I would go ahead and get the meds drawn up and ready to go. I would try to do everything to take that extra step forward so that they could see that I was putting in the initiative. That pays off because whenever anesthesia providers see you doing that thing when they see you taking that extra step or that extra initiative, they will come to get you for cool stuff. In the end, my first clinical site was as a care team side.

There were several physician anesthesiologists who saw that initiative. They came and got me. They said, “We have this cool case going on over here in Room 7. There’s a trauma that’s about to roll in. Come do this trauma with me.” They would pull me in all these different directions to come to do cool stuff once they saw that I was taking that initiative. That was huge for me. I realized the importance of doing that. I’ll give you another example.

There were several times that my cases were scheduled for 8:30 or 9:00 in the morning. Normally, our cases were 7:00 to 7:30. I would still show up at 7:00 AM. I would go find another anesthesia provider and say, “Can I jump in the room with you and help you with your case?” I said, “Come on in.” Taking that extra step, whenever people see you showing up early like that, especially when your case has already been scheduled, asking to go into different rooms, they will take that like, “This person wants to learn. Let’s facilitate that.” They will pull you in multiple different directions to put you in cool stuff.

At the very end of my first rotation, the chief CRNA offered me a job and said, “I know you’re a year and a half away from graduation. We would love to have you come work with us whenever you’re finished with your CRNA training. If you have our contact information, give us a call. This is something you’re interested in.” Treat it like a job interview. I can guarantee you that had I not been prepared, had not taken those extra initiatives, and didn’t know what I was doing, they wouldn’t have offered me a job this early on.

I understand that there is a market for that thing because the anesthesia market is hot. It’s hard to find anesthesia providers. That is a component of that. I can guarantee you that if they didn’t think I was prepared or good enough to have a job there, they wouldn’t have offered it. Go into each clinical site and treat it like a job interview. Show up early. Know the information that you’re required to know and go that extra step because that will pay off.

Another thing that is important in regard to this point in your education is what you put into it. If you show up and do the bare minimum, you’re going to have bare minimum training, is what it comes down to. If you show up and go beyond your bare minimum, if you take initiative and you want to do cool cases, see different things and you show that interest, people will take you up on that 100% of the time. The worst thing they can say is, “No, you can’t do this case with me.”

I haven’t had that happen in my clinical journey so far. Every case I’ve asked to be a part of, they said, “Come on in and help out.” I haven’t had once somebody say, “No, you can’t be a part of this case.” That may happen and that’s fine. I wouldn’t take it personally. You’re not going to get those opportunities if you don’t ask and show initiative. Truly treat every rotation like it’s a job interview because at the end of the rotation, if they like you, chances are they will probably offer you a job. The closer you are to graduation, the more important that is.

I’m not going to take a job or commit to somewhere in my second rotation. I still have a year and a half left. There’s a lot more learning left to be done and a lot of places I haven’t been yet. I’m not going to commit to a job this early on but know that if you take that initiative, you show up and do things right, chances are you’ll probably get offered a job and it may be somewhere you want to work. The last thing you want to do is burn a bridge in the anesthesia community because everybody knows everybody in this community. You will find out how small it is. Paths cross more than once all the time. You will run into some of the same people again. Treat every opportunity like it is a job interview.

Point #3: Not Everyone Does Everything By The Textbook

3) This is something that I feel like I knew but caught me off guard in some regards. That is, “Not everyone does everything by the textbook.” You will encounter people who may do some unsafe practices. Generally, even if they don’t do things by the textbook, it is still considered a safe anesthetic. I’ll give you a very good example of this. In school in our simulation lab, we would learn that before we paralyze the patient, try to take a few breaths. Try to mask the patient before you paralyze them.

Not everyone does everything by the textbook Click To Tweet

In reality, that’s not super common, at least in my experience. Usually, you’re pushing induction drugs. Right after you push, you’re following it up, especially rot because it takes a minute and a half or so to onset. Usually, you’re waiting a little bit longer for sucks because as soon as you push sucks, they’re going to start circulating. You want to make sure they’re truly asleep before you push that paralytic because it onset so quickly. Not everyone does that.

In one of my very first cases, I was pushing my induction drugs. I pushed the rope and was getting ready to provide a couple of breaths. The CRNA was like, “What are you doing?” I was like, “Trying to give a couple of breaths here.” He’s like, “Did you get paralytic? Push the paralytic. What are you doing?” I push the paralytic. They started bagging. It’s very interesting. Maybe that’s been my experience. I’ve been to two clinical sites. I have yet to run across a provider who will back before they paralyze. Maybe I’ve lucked it out. I’ve got it in two sites where they never do that. In the two sites that I’ve been to, it’s not super common.

I’ve made that part of my practice. Unless I anticipate a very difficult airway, I will try to mask it but usually, I will push right behind it. In reality, patients are much easier to bag, when they’re paralyzed. They do have that resistance that you can feel whenever they’re not paralyzed. When a patient is fully relaxed, they are much easier. If you can’t mask and ventilate, you can put in earlier where you can hand mask ventilate. There are multiple different ways to do it.

It depends on what my preceptor wants to do. It’s not like I’m running the case entirely independently. At this time, my preceptor is still there. Depending on the clinical site, it’s still guiding me through what to do or standing back and watching. It depends. Not everyone’s going to do everything by the textbook. That’s one example. There are multiple examples of that same type of situation that I could give you. For instance, the Neo/Glyco dosing at my clinical site. Everybody gets 3 milligrams of neostigmine and 4.6 of glyco. That’s it. Nothing else. I’m not calculating the dose. Everybody gets that dosage.

Nobody uses quantitative twitch monitor so you can’t tell, “Are they below 0.9%? Are they fully reversed?” A lot of that is the guessing games. It is available but not widely utilized at my current clinical site. In my first clinical site, we used to get an X in everybody. You’re going to run into situations like that. You read something in the textbook. That’s how you’re supposed to do it. You get to the clinical and it’s done differently.

The very last thing you want to do is to be like, “The textbook says we’re supposed to do X, Y, and Z. How about we try that?” Don’t do that. I always tell that to the anesthesia providers or whoever I’m working with. Another example is when putting an LMA, they’re like, “You’re putting your LMA that way.” I’ll be like, “How do you put it in LMA? Show me your technique. Maybe your technique is better. Maybe I’ll like it more than how I do it.” That’s an example.

I will usually ask the providers if they question me about how I’m doing something. I will say, “How do you normally do it? Maybe I’ll watch you do one.” Who knows? I’ve picked up the things that I’ve learned by watching other people or reading the book. “Maybe I’ll watch you do it and if you have a better way of doing it, I’ll adopt that way.” You can play it that way. I always do that. If somebody asks me why I’m doing something the way I’m doing it, I’ll ask, “How do you do it? I would love to watch you do it your way. Maybe it works.”

This comes in when we’re doing nerve blocks especially. There are multiple different ways you can position a patient to do a nerve block, depending on where it’s at. A lot of the time, the providers are like, “What is the reason you’re doing it that way?” Sometimes it’s like, “Show me the way you do this. How do you position the patient because I may like that better?”

Phrase it that way. People will be much more open to telling you why they do what they do and how they do it. It’s like, “I would love to learn how you do it. Maybe it’s a better way than what I’m doing.” Not everyone does everything by the textbook. Good thing to know, it’s fine to question why somebody does something. Don’t do it in more of a defensive or hostile way. Genuinely be curious, ask, and let them know that and people will be very responsive to that.

Point #4: Be Adaptable

The last point is number four. You want to be adaptable. This comes in especially if you’re traveling for clinical. My clinical rotations are done all over three different states, California, Arizona, and Texas. Twelve weeks at a time, I’m going to a different site. You have to be adaptive whenever you’re traveling for clinicals like that because you’re going to a different site, hospital, anesthesia culture, OR culture, or preceptor. They don’t know you. You don’t know them. You’re trying to make a good first impression.

Be as adaptable as possible. That’s one of the pros to having rotations where we travel every twelve weeks. We’ve put in a different environment every twelve weeks and expect it to flourish. By the end of that twelve weeks, I’m feeling good and great. I got it down. You go somewhere new and start all over from scratch. It’s a good thing because you’re putting yourself in these uncomfortable situations and being adaptable.

The culture of how I did anesthesia and some of the things that I did at my first clinical site are different than what I’m doing now. I’m picking up a little bit of each as I go between each rotation and I’m enjoying that. Be adaptable when you go to your clinical sites, even if you’re at a clinical site for the majority of your training. If things change at the last minute, roll with it. Don’t be like, “I didn’t study for this. I don’t know how to do that. I’m not comfortable with this.”

Put yourself in that situation. You have preceptors there. You have somebody helping you out. Nobody is going to let you flat on your face and kill the patient. They may let you fall flat on your face and do something wrong. People, especially CRNAs or positioning anesthesiologists are going to stop you before you kill somebody. Let that be a lesson. They will let you fail, not at the expense of harming a patient.

CRNA 136 | CRNA Clinical Success
CRNA Clinical Success: They will let you fail not at the expense of harming a patient, but they will let you fail to be adaptable in that situation, learn from that mistake, and be better the next time.


You have to be adaptable in that situation. Learn from that mistake, learn from what you’re doing, and be better the next time. There are multiple times that I’ve been humbled by anesthesia because it’s challenging in different ways. That’s part of the training. You have to put yourself in uncomfortable situations and be willing to do that because it’s only going to get harder if you don’t put yourself in those uncomfortable situations.

You want to put yourself in these uncomfortable situations and be as adaptable as possible in your training. You want things to go wrong in your training. You don’t want things to go wrong when you’re a CRNA and it is the first time you’re encountering something. A CRNA told me that at my first clinical site. They’re like, “You want the sick, unstable patients that take so much of your time right now so that when you’re a CRNA, it’s not your first time experiencing that.” You have to be adaptable to be in those situations.

Those are the points I have for you. Let me know what you wish you had known before you started your CRNA school clinical journey or if you’re not in your political journey yet, let me know what you wish or what you want to know besides these tips. Thank you so much for reading. I appreciate your time. Let me know if you have other suggestions or content that you would like to have from me. I’d be more than happy to produce that. Thank you again to Jenny for welcoming me onto this platform. I will see you next time.


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