The dust has settled, you’ve made it through school, you’ve nailed the dream job… so NOW WHAT? What does a day in the life of a CRNA really look like? While it can feel so far away, it’s vitally important that you get familiar with how you’ll be spending your days.
It’s a career that takes heart, passion, and grit. Shadowing (as early as possible) and gathering information from current CRNAs and SRNAs about the profession is crucial to gauge whether or not the CRNA path is for you.
In today’s episode, we dig into:
- The different types of schedules that are available to you (and how to choose what works best for you when looking for a position)
- An overview of getting your day started
- Tips for preparing for your cases ahead of time
- An in-depth look at the induction of anesthesia, navigating the maintenance phase of surgeries, and crafting a smooth emergence for your patients
- The importance of being a proactive member of your team by communicating effectively and assisting others
Happy shadowing, future CRNA!
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Watch the episode here
Listen to the podcast here
Day In The Life Of A CRNA
I have some exciting news to share with you guys. CRNA School Prep Academy is having its first in-person conference this fall, October 23rd and 24th, 2022 in Greenville, South Carolina. We are so excited to meet you. Richard and I can’t wait to give you a high five, fist bump, belly bump, or whatever you like. I want to go over with you guys some of the things you would walk away with if you were to attend. I also want to let you guys know that it doesn’t matter if you’re a nursing student or whether you’re in the application phase or even if you’re a newly accepted student, you’re going to walk away from this conference with something. I want to let you know that anyone is welcome to attend. We do give special discounts to CRNA School Prep Academy students.
If you’re interested in becoming a CRNA School Prep Academy student, you can go ahead and join and get a discount on attending this conference with us. Some of the takeaways that you will get from this conference are you’re going to get to network with nurses and nurse anesthesia students, program staff, and fellow future CRNAs. You’re also going to gain a thorough understanding of anesthesia pharmacology. You’re going to get actionable methods for managing stress through school. You’re going to learn study tips that will allow you to accomplish your academic goals. You’re going to create an accountability partnership with someone you meet. Learn more about a program and get insight from a program director’s perspective. You’re going to get a financial plan for paying for school and paying off your debt. You’re going to get a chance to ask nurse anesthesia students what it’s like to be in school.
You’re going to demystify the application process and stand out as an applicant. You’re also going to get a growth mindset lecture that will keep you grounded and empowered to push through the challenges you’ll face as an applicant and a student. You’re also going to get insight and behind the scenes of a mock interview session. Essentially, you’re going to leave with more clarity in your plan and confidence in your preparation. We hope to see you there. If you want more information, go to CRNASchoolPrepAcademy.com. We look forward to meeting you.
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Is CRNA For You?
We are going to talk about a day in the life of a CRNA. For those of you who are still trying to decide whether CRNA is a career path for you, I know you probably have a lot of questions as far as what’s out there. What is it like to be a CRNA? One of the best ways you can find this out is by spending time shadowing a CRNA. Don’t wait until you’re actively applying for CRNA school to start your job shadowing experience. First, it shouldn’t be something that you only do to check a box on your application. You should thoroughly be investigating what it’s like in the daily life of a CRNA from the shadowing experience so you can make sure that you’re making the right career choice because it’s expensive and time-consuming to become a CRNA.
If your heart is not in it when you’re in the thick of it in school, you’re going to not only experience more burnout, but you may not even be happy enough to where you want to quit. I don’t want that to happen to anyone. I would rather see your time better spent in other areas that you would enjoy. Again, starting the shadowing process early is key when it comes to determining whether a CRNA is the right career path for you. 9 times out of 10, when I talk to students and ask them how they got interested in anesthesia, the vast majority of them have had some type of experience in the operating room or an experience with the CRNA that opened their eyes to the possibility of being a CRNA themselves.
Again, a great way to gauge whether you’re truly passionate about pursuing this career path is getting to see it firsthand and seeing whether you get that excitement. I know seeing the CRNA at the head of the bed and knowing that was a nurse, everything that they were doing for the patient was extremely exciting for me to the point where I felt that drive and passion to pursue that as a career for myself. That was the driving force behind everything I did from that day forward that I made that decision to pursue CRNA. If you’re like me, I had heard a lot of nursing students talk about CRNA or they make a lot of money. It’s the best nursing profession.
There’s a lot of autonomy. At nursing school, a lot of nursing students talk about it and maybe are not even necessarily serious about it, but they know it’s a good profession. That’s where I was. I didn’t know if it was for me. I didn’t even think I could do it. I thought I wasn’t smart enough, that I wasn’t ever going to be at that level to be able to be a CRNA, but it wasn’t until I started getting some time in the OR as a nursing student that I had that flip in my brain switch on the green light. This is a go for me. I encourage you to take that leap of faith and get that experience now, especially early on if you’re still in nursing school.
That way, you can engage yourself within the community and start to see, “Can I picture myself in this career path?” We’re going to go ahead and get into some different things I’ve experienced. I also want to say, there are many variations and different jobs out there; I’ve only experienced a tiny little portion of it. Talk to multiple CRNAs if you can, or even SRNAs. That’s going to be a good way to gauge what this career field is like because there are many different aspects and career outlooks for CRNAs. Don’t just take my experience. I encourage you to try to seek out multiple experiences and try to gather all the information you can to come to a great conclusion for yourself.
Typically, and again, this is my experience working at a level one trauma hospital. I also have experience working at an outpatient surgery center, as well as a pediatric level one trauma hospital. I have three different experiences to give to you. Relatively, the days all look the same as far as layout, but obviously, there are some differences between all three of them. Not in a major way, but there is. I’ll touch on that a little bit. Back where I worked for four and a half years, I did a lot of open-heart, but I was comfortable, meaning I could have a 7:15 open-heart and roll in the door at 7:00 and be ready to go.
I wouldn’t say that as a new CRNA- I definitely didn’t do that. As an SRNA, I definitely did not do that. As an SRNA, you’re always arriving early before your CRNAs are even in the building. You’re there as an SRNA preparing your room, going to pre-op, and getting ready for your day. The reality is you’re slower at it when you’re new at it, so you need to give yourself more time. The better, the more comfortable you get with being in certain situations, maybe you can give yourself less time, but you still have to be ready. It was still on me, even though I got to work sometimes with not enough time, I still had to make sure it was my responsibility to be ready for my room because it would look poorly upon you if you weren’t. Based on how far you live, give yourself time to get to work.
The Morning Routine
I typically would say most CRNAs get to work and they’re in the parking lot around 6:45 in the morning. That way, they’re out of the dressing room by 6:50 or 6:55 and in the OR by 7:00. Most ORs start around 7:30 AM. There are some rooms that start at 8:00 and 9:00. There are some rooms that maybe don’t start until 10:00. Occasionally, some places routinely start at 6:30 or 6:45. There’s a lot of variation out there. That’s what I mean when I say it’s hard for me to tell you what you’re going to experience depending on where you work. I spent four and a half years. We would occasionally do a 6:45 start. That was with the request of the surgeon for a particular day or case. That wasn’t the norm.
There are some facilities that I rotated through as a student that particular surgeons would normally start at 6:30 in the morning. That was normal for that surgeon. Again, it can all be different based on where you work. If you work at a level one trauma center, they never shut down. Surgeries happen 24/7, 7 days a week, and holidays, you name it. Do they staff a full schedule on a holiday? No. Did they staff a full schedule on a weekend? No. I should say back where I used to work, it got to the point where a lot of surgeons were taken advantage of having anesthesia staff there, so there were days that felt like a full schedule on a Saturday. Did they push the rules? Yeah, they definitely probably did at times with the cases they put on the weekends. If we were there to work, then we worked.
It's very expensive and time-consuming to pursue a career as a CRNA. So make sure that your heart is really in it. Click To TweetEvery place is a little different. There are some places where the weekends are routinely slow other than the occasion. There are places where the weekends can feel like it’s a full staff and full run day. You’re going to see a variation in that too. I would leave home, get to work around 6:45 in the morning and get into the OR by 7:00 AM. If I get a 7:30 case, chances are I’m going to go between getting my room ready, drawing up drugs, checking my vent, and looking up the patient. If I make it to pre-op, that’s going to take up all that time. I’ll be ready to go by 7:30, essentially. Maybe I’ll have time to run to the bathroom or I won’t. I’ll have time to make my coffee quick or I won’t.
Inhalation And IV Induction
For a 7:30 start, you usually hit the ground running pretty quickly when you get there. In my own personal experience in level one trauma hospital, mostly adults that I did anyways, I would have time to make it to pre-op, see my patients, and check base my attending. Where I work now, that’s not routinely done. That’s a different patient population. In pediatrics, you’re typically interviewing the patient’s family, not necessarily the three-year-old itself. The more people you’re introducing to the kids, sometimes, it can cause more anxiety for the kid. We try to keep the pre-ops to a single anesthesia provider so that way it decreases the anxiety for the family and for the patient.
You still want to check base with your attending. I always try to make a point to do that. It doesn’t always happen and sometimes that’s okay. Sometimes you can get everything you need to know from the pre-op note that’s in the chart if it’s a virtual chart or paper chart. Checking base with your partner is the best way to go about into the case to be the most prepared. If they may have missed something, or you may have missed something; it works both ways. Once you’re in the OR and the case let’s say starts at 7:30, typical induction based on now, if you’re working with kids, it could be an inhalation induction. If you’re working with adults, a typical IV induction.
Where I work now, we take patients back who are twenty years old, still don’t get an IV in pre-op and possibly still go to sleep before they get their IV, which I don’t think is super ideal, but it does happen. Doing an inhalation induction on a big kid is difficult and risky because they have a lot of muscle mass. It’s going through stage two and anesthesia. You can see people will get hyper reflexive almost where the whole body’s heaving. They’re almost trying to obstruct. The risk of spasms is there as far as laryngospasm go goes. They usually get tachycardic. They are hyper reflexive where they’re tensed up and agitated. They go through that phase where they relax after they get through phase two of anesthesia.
That’s a safer plane of anesthesia to be in. When you’re doing inhalation inductions, you don’t have an IV. You always have your IM drugs ready to go. If you had to give IM sucks to break a spasm or maybe with some Robinul as well; keep that in the back of your mind. Even in the adult population, you always want to have your emergency drugs out and ready to go. Typically, if you’re doing an induction with an IV, you don’t necessarily see that prominent phase two like you do in an inhalation induction because the inhalation induction is what causes that phase two to be significant. For an IV induction, you’ve got to worry about the burning of propofol. It always burns. Every now and then, you’ll get a patient who’s not sensitive to it, but it can be harsh on your veins and feel hot going in.
For IV induction, it’s nice of you to use lidocaine to numb the vein prior to giving the propofol. I’ve seen people mix the propofol in lidocaine. I’ve also heard that that doesn’t necessarily even benefit the patient at all. I’ve heard mixed things about those two different viewpoints. In my own personal experience, if the patient gets in the room, you can give some Versed or some fentanyl, but the next thing you should be doing is priming the IV with lidocaine. When I say prime, I mean push the lidocaine down near the closest port to the IV and then kink it off. Let the lidocaine sit in that vein and not move anywhere. Like if you were to do a bier block, you’re essentially doing the same thing.
You’re concentrating that lidocaine in that one area to create a local block. When you’re pushing 50 milligrams of lidocaine through a vein that’s close to the hub and then you don’t run the IV afterwards, you’re going to be letting it sit there and the lidocaine back. When you do then push the propofol, they’re not going to feel anything. It doesn’t always work out that way based on timing. Sometimes, the timing’s better than others, but if you can do that, that’s in my opinion, the best way to combat the burning of propofol, is to let that vein soak in lidocaine prior to infusing the propofol.
That same thing can be said if you’re doing a mat case with a propofol infusion. Priming that IV with lidocaine prior to starting the propofol infusion is the key to not having that vein burn; keep aware and be cognizant of what side you have the IV cuff on because if you’re pushing that propofol and their blood pressure cuff is going up, that will definitely cause pain. Always try to be cognizant. Put the IV cuff on the opposite arm of the IV if you can. Obviously, sometimes you can’t if they have like the AV fistula or something like that, you can’t use that arm for blood pressure, but you can always put it on the leg to avoid that possibility of burning propofol going in. If you’re doing like a TIVA or something like that, you don’t want every three minutes to have your infusion be kinked off by your blood pressure cuff.
You can put the blood pressure cuff on the leg. Those are some little tidbits of typical things that you would see based on what type of induction you’re doing. There’s also rapid sequence induction, which is where you have a high risk of having acid contents from your stomach coming up. If you guys have ever heard of aspiration pneumonia, that is the risk of having a full stomach going under anesthesia because you’re fully relaxing someone’s ability to close off their esophagus and windpipe. You’re relaxing that esophageal sphincter, so the bile can come up. You’re potentially paralyzing and relaxing someone so your vocal cords won’t necessarily close off if they sense fluid.
The gag reflex is pretty strong when you’re awake. When you’re not awake, it’s not strong. Especially if you’re paralyzed, it’s non-existent at all. You lose the ability to protect your airway. You’re at high risk of aspiration, especially if you already have a full stomach. We can do something called a Rapid Sequence Induction, where we’re giving the patient a little bit of what we call Cricoid Pressure where we’re pushing on the windpipe a little bit essentially. The esophagus is below the windpipe so you potentially squish the windpipe or the esophagus a little bit as you’re doing your induction.
If you did have bile come up, you’re at least stopping it from coming all the way up. Those are the typical inductions, whether you’re doing general anesthesia, twilight anesthesia, or MAC anesthesia, which stands for Monitored Anesthesia Care, and if you’re doing an IV induction versus an inhalation induction. Those are obviously the style of the airway and what kind of airway you have. You can do a general without an endotracheal tube. You typically use something called an LMA. I have also seen plenty of generals done with an oral airway, especially patients who come in with blocks and we’re on a propofol infusion. Technically they’re unresponsive, which is a general anesthetic, without a secured airway.
LMA is also not a secured airway. Technically, nothing is through vocal cords. LMA is in the back of your tongue and it keeps your tongue from causing obstruction and allows you to breathe through that device. The same thing with an oral airway. It keeps your tongue out of the way. One looks a lot fancier than the other. I love LMAs. I’m definitely not downplaying LMAs. They’re great and they’re useful, but they’re not a protected airway. Don’t get too comfortable with the idea of having an LMA versus an endotracheal tube. Always assess what your patient needs, their history and assess their risk of potential aspiration- that’s always the key important step there based on what you need. You can also use maybe a double-lumen tube if you need to drop one into the patient’s lungs during surgery.
Anesthesia is about what's next. Anticipating what is next is what makes a good practitioner. Click To TweetRoutinely in our thoracic surgery or even in our mini AVR surgeries, where we would do a mini sternotomy for aortic valve replacement, we could do one lung ventilation temporarily during the case to allow the surgeon to have a better surgical field to work with. These double-lumen tubes are big but it allows you to clamp one side so you can clamp the right or left side of your lung and drop that lung. Some patients tolerate that well depending on what their own underlying base lung function is. Some don’t tolerate it for very long at all. It’s a back-and-forth game of operating, do your work, and then when they get so low, I’ll do my best to try to maybe give them some blow by for some apneic oxygenation situation where you’re blowing a little bit of flow into that down long to allow it to expand a little bit, but not interfere with the surgeon.
Sometimes that works. Sometimes it doesn’t. There are a lot of different challenges you can face in anesthesia. Different types of surgical cases come with different challenges and also planning and methods of providing anesthesia. During the case for induction, you want to decide what’s the blood loss expectation for this case. You’re planning ahead for that and you’re saying, “Do I need two big bore IVs? Do I need two IVs?” Maybe their arms are going to be tucked in a robotic case so if my one IV goes bad, not that I’m going to lose a lot of blood, but you still need a working IV. You can’t go through a whole case without a working IV.
Trust me, if your IV goes bad during the case where you have limited access to the patient’s extremities and feet, it is not fun. If you have no access to any limbs to start on the IV, then you’re talking about an EJ or an External Jugular IV. You always want to try to pre-plan for stuff like that and assess what you think you need and talk to the surgeon. Ask them, “What do you think your blood loss is going to be? How are you positioning this patient?” Keep in mind that if you have an IV from pre-op in your ante cube, which is in the crook of your arm, my least favorite place; all anesthesia providers would agree with me that that’s their least favorite place for an IV, because inevitably, if the patient’s arms bent in any way, now you don’t have an IV.
The Maintenance Phase
It’s essentially worthless. You have to think about those things too if they come back. I’ve also had plenty of patients come back from the pre-op with infiltrated IVs. You don’t want to be cramming a bunch of drugs into someone’s sub-queue. That’s why you go slow with your induction. You assess the IV before you even start induction, make sure it’s working. That covers an induction of anesthesia. I’m sure I left some things out, but that gives you guys a brief overview. If you were to go in for a shadow day, you would see some of these things. After the induction, you go into the maintenance phase. The maintenance phase can be quick, meaning you could have a ten-minute case.
It could take you longer to sedate the patient than the actual case itself. That does happen. That’s challenging for even an experienced CRNA, but I do think the more experience you get, the easier it gets because you’re better about planning ahead for that. Timing-wise, you’re better at anticipating things. Essentially, if I have a room that’s quick turnover, what I do to put my best foot forward is I get as ahead as I can, as far as I get drugs ready for maybe 2 or 3 cases down the road, or I look up those next three patients so I have an idea of what my game plan is. I even get my tubes ready and my two burrito sacks, where you have whatever size syringe you want to use and whatever equipment you think you need for the next case.
You have a little towel that you can hide in a drawer, and keep clean. You try to plan ahead, especially if you know you’re not going to have time during an anesthesia case to do that. If you’re in a case where you have plenty of time, I don’t worry about it. You do your induction. You make sure the patient’s settled, that’s number one. You always put your priority on the patient. You want to make sure you’re taking time to position the patient so they don’t get any nerve injuries.
That is common, especially when they’re paralyzed. They can’t move. They can’t tell you, “My shoulder hurts. My hands are going numb.” You have to make sure, are their hands supinated? Are they off their ulnar nerve, which runs right by your elbow? Is their elbow adequately padded? Is your ear bent in half? If they’re laying on their side, is your ear bent in half? Would you want to lay on your ear bent in half for three hours? No, you’d wake up and you’d be like, “What happened to my ear?” Even though the surgery pain is not that bad, my ear freaking hurts. The pressure on the eyes, people have come out with optic nerve damage from surgery before if you’re not conscientious of their pressure on the eyes. Are they on their head the whole case and you’re giving them tons of fluid? That’s not good.
You get orbital edema very quickly, especially if you’re essentially on your head for the entire case. In some cases, we’ll have the patient’s head down the vast majority of the time. Be aware of how much fluid you’re giving. Obviously, you want to still have urine output and make sure that they’re hemodynamically stable, but you have to be aware that they’re going to come out with swelling and you don’t want to have their eyeballs be popping out of their head when you’re done with the case. Yes, you go into the maintenance phase after you get them settled and you attend to the patient. That’s when you do things like chart, get ready for the next case, draw up any drugs, and even anticipate the end of the case.
When I go into my maintenance phase of anesthesia, I start anticipating, “What do I need for wake up? Is there anything I don’t have ready? Do I have my reversal ready? What reverse am I using? Am I using sugammadex versus Robinul or neostigmine? Why would I choose one versus the other?” I always tell my students I have an oh shit stick, which is my extra stick of propofol. You don’t necessarily have to always have that drawn up. It is nice to have it ready to go because you never know at any moment…what if they’re coasting along and you see no vital increase, meaning their heart rates and their blood pressures train track? The next you know, the surgeon does something that’s stimulating and now they’re moving on the table.
The surgeon is yelling at you and you’re like, “I didn’t even see that coming,” because they’ve been coasting along great. The oh shit stick is nice for that. I like to have at least a syringe labeled and propofol out ready to go so I can quickly draw it up and give it. It also comes in handy if they’re bucking on the vent, but don’t be afraid to get paralytic. If you need to get paralytic, get paralytic. It doesn’t take a lot to knock out those receptors. Even if you’re giving ten a rock, you’re not going to burn yourself by getting ten a rock even if they’re finished with the case. By the time they close and wrap things up and you’re ready to reverse and excavate, that ten of rock is going to be gone enough to where you can still reverse the patient.
Dosing-wise, you have to be aware of that and be cognizant that you’re not slamming them with 30 of rock at the end of the case and they start bucking because then you could potentially hose yourself and not be able to reverse them unless you use sugammadex. That’s something to think about. It gives you guys something to put in your mind if you have never experienced OR life and during surgery what the CRNAs do. The maintenance phase is catching up on charting. Sometimes, you have so much time that you have a decent amount of downtime and you always scan the room. I scan the room about every 3 to 5 minutes. What I mean by that is that if they have a Foley, I check for urine output.
Not that I document it every 3 or 5 minutes, but at least keep an eye on it, because you don’t want to get an entire hour into the case and have no urine output and not have even taken any steps yet to fix that problem. You always want to be aware of how things are going. I always try to tell my students that anesthesia is about what’s next. You want to try to put your mindset on what’s going to come up next and how can I be ready. Don’t get me wrong, sometimes you’re going to be wrong about what’s next because things can change rapidly, but it’s still anticipating what is next; that’s what makes a good practitioner in my opinion. Trying to stay ahead of the game, trying to anticipate your patient’s needs. In that way, you’re advocating for the patient the whole way through the case all the way to the recovery room.
Anesthesia is like an airplane. Take-off and landing are the most critical moments of the whole experience. Click To TweetDuring the maintenance phase of anesthesia, you’re assessing, do they have enough narcotics onboard? Are they comfortable? You do this by assessing their blood pressure, their heart rate, and whether the patient’s moving. Just because a patient move does not mean they’re awake. Even some surgeons don’t understand that. They’ll say the patient’s awake and you’re like, “No, they’re not awake.” To have an entire mac of gas and this may be way over your head, it’s okay if it is, I don’t expect you to know what this means, but one MAC of gas is essentially a good anesthetic, but at one MAC of gas, 50% of your patients will still move to painful stimulation, which means there’s no way you have any recall and you’re going to remember any of it. If someone stabs you with a knife, you’re going to have a reflex.
It says, “Pull away.” Surgeons think that means the patient’s too light. That’s not necessarily always the case. It takes a lot more gas to get them to not respond to that noxious stimuli. That’s why in anesthesia you’re, you’re doing amnesia, analgesia, and areflexia. Areflexia is decreasing someone’s ability to move with painful stimuli. That’s why a lot of times, depending on the case, you need a paralytic to help you with that because maybe you can’t run them super deep on gas because if they’re super deep on gas, they’re going to have no blood pressure because gas itself is a basal dilator. You’re always trying to think like, “What’s the combination of amnesia, analgesia, and areflexia that I need for this case?”
All cases are a little unique and a little different, which makes anesthesia fun. It’s never the same. Even if you take two-lap choles, that patient will be different than the last lap chole. They may have different needs. Maybe one suffers from chronic pain. Maybe one is a redhead. It is true. Redheads do tend to require more anesthesia. It’s not always true, but it does tend to be true most of the time. It has to do with they have more of an enzyme cytochrome P450. It helps metabolize drugs. Throwing it out there, if you’re a redhead, you rock and you’re beautiful. That’s an interesting little tidbit. My girlfriend’s a redhead. I love her. In fact, she’s due to have her next baby. I hope and pray this baby has the reddest hair. I’m hoping.
Emergence
In the maintenance phase of anesthesia, part of the maintenance phase is anticipating the wake-up. Emergence, that’s another critical part of the anesthetic. Every surgeon wants a smooth emergence. No bucking and pain. It’s a lot of pressure like, “I’ll do what I can,” but you can’t always predict things or anticipate how things are going to feel. You do your best you can with the vital signs you have and knowing how painful the actual surgery is. Also, do they localize? Did the surgeon take initiative to put some local in there? That’ll play into how well controlled the patient’s pain is.
There are a lot of different factors that go into post-surgery pain control and having the patient not care that there’s a tube down their throat and cough when they start lightening up on the anesthesia. It can be challenging, especially when you have a case like a thyroid who has a neck incision or a carotid. The last thing you want is if they strain, they can get a hematoma, which could be dangerous and life-threatening. It can be tricky and high stress as a CRNA to do those cases without any bucking during the wake-up. You always do the best you can. Some places will practice deep extubation for those cases. It’s totally fine as long as it’s patient-appropriate, but it can also be risky.
You have to be certain that you can get them through stage two because they will go through stage two. If they go through stage two without an airway, you’re risking laryngospasm. You want to make sure you’re diligent about recognizing the signs of laryngospasm before they are blue sitting in front of you. Always be attentive to your patient. One of the things you can do is, you guys can’t see this, but I’m going to suck it on my throat a little bit. The increase on my neck dips in a little bit. If you see that in your patient, that’s an obstruction. Especially if you hear no air movement, that’s a complete laryngospasm.
If you hear some cooing, that’s a partial laryngospasm. That’s better than a full laryngospasm. If you get a full laryngospasm, you’re risking flash pulmonary edema, because, based on how hard they’re sucking in to get that breath, they could cause a negative pulmonary pressure to develop. It has happened. It’s one of the dangers of laryngospasm. That’s why you need to always have your succinylcholine ready to go to give in case of emergency to quickly relax them. You don’t want to paralyze them forever, but you want to try to break that spasm as quickly as possible. Based on whether you have a partial spasm, a complete spasm, and how bad you think it is, is in my opinion, how you judge if you give propofol, do you try to deepen them up, or do you go straight to sucks.
You don’t want to risk trying to get someone through a laryngeal spasm if it’s a complete spasm and they could be risking pulmonary edema. Give some sucks and break it right away to take that risk away of pulmonary edema. Wake up can be critical, challenging, and dangerous. Someone has always referred to anesthesia as an airplane. Takeoff and landing are the most critical moments of the whole experience because that’s usually when things can go wrong, which is in induction and emergence. Things still go wrong in the middle of a case, but statistically, most of the time, if you experienced a problem, it’s during takeoff and landing or induction and emergence. It can be a high-stress moment.
Make sure you’re giving your full 110% attention to not just your patient but what’s going on in the operating room. If people are not paying attention to you and what you need, you need to make sure you’re addressing that because even the circulator, you should be paying attention to and at your side. In that way, they’re tentative if you need extra help or you need a second set of hands. They’re going to be calling someone to get them to the bedside for you or be that second set of hands. I love my circulators. If you’re out there, high five to you. You guys rock. I don’t know what I do without you sometimes. Being there for me, even the little things like holding cricoid, holding that tube, or I’ve had them get supplies for me when I need them quickly if I don’t have it right by my side.
The patient’s spasming and I’m trying to get positive pressure and my sucks are over on my back stand or I can’t easily reach it, they grab it for me. I can even say, “Give 1 CC.” I can even give them direction and they can help you in a pinch. It’s awesome teamwork. Again, everyone has an important role to play in the OR. That’s another thing too as an anesthesia provider, you work as a team. Every time you’re in a case with someone, everyone in that room has a role to play. Especially as an anesthesia provider, you can be a leader in that role of giving direction and delegation as to what needs to be done for the patient, even to the surgeon.
Don’t get me wrong, this should be a two-way street, meaning you’re not telling someone 100% of the time what to do, but you’re having an open conversation like, “This is what I’m experiencing. Let’s try to work out why this is happening because it’s not good for the patient. Is there anything that you can do to help me out or that I can do to change what’s happening so we can make this better for the patient?” There’s always room for someone else to come in there, help out, and help you essentially with the game plan going forward with the patient and the care. I talked about planning ahead for the next cases. Typically, you’ll get a morning break, which is a fifteen-minute break. That can be different.
I’m sure you’ve experienced it in nursing. It’s not always guaranteed to get a break, but some days are better than others. If you have time between cases, you better make sure you’re going to the bathroom, getting that drink of water, and slamming that cheese in your mouth because you’re not going to get a break. It’s too busy. They had two add ons and now the only free CRNAs are in rooms and all the attendings are busy. Keep in mind as an anesthesia provider, sometimes you have to have good bladder control. I’ve now been pregnant three times in anesthesia. I can tell you, don’t worry, it’s not going to make or break your career. If you had to, you can call out, phone a friend, “If you’re in between cases, can you come get me out?”
Take Your Breaks & Relieving
There’s always someone to help you. Don’t pee your pants. Sometimes getting breaks can be hard in this profession, but typically a fifteen-minute morning break sometime in the morning. If I start at 8:00 or 8:30, I’ll take my morning break ahead of time and cross myself off the list of people to break. It’s the courteous thing to do. If you don’t do that, don’t sit on your butt and do nothing. At least go around to other rooms and offer to help them get started. You never want to waste your time when you’re at work. If you’re on the clock, you’re there to work. You’re not there to sit and be on your phone. The people who do that routinely will get a bad rap.
That job is out there where you can get what you want. You have to decide what's important for you. There's not a job that can do everything well. You're going to have to give and take on some things. Click To TweetYou want to be that CRNA who’s more proactive and going around and checking on people, offering them breaks if you have downtime, “Does anyone still need a lunch break or a morning break?” If you have gaps in the day, try to be cognizant of who else you can help out because now you have plenty of time yourself. Make sure you’re thinking about those things. If you do have downtime and everyone’s cool, this is your time to drink coffee and socialize. Maybe you can work on some computer stuff. Sometimes we have continuous learning activities that we have to do. If you truly have downtime, then you have downtime. You just don’t take that downtime until you know 100% everyone else is okay.
Lunch is typically a half hour. That can happen anywhere between 11:00 AM and 2:00 PM. Obviously, most time you hope it happens closer to 11:00 AM, but depending on the day, it could be 2:00 PM before you’re getting your lunch break. It happens. It’s not ideal. That’s not what people strive for, but when you have one CRNA to give 15 or 10 breaks and every break is a half-hour, as you can see, that would take a long time to get through all the breaks. It depends on the day. You can work until 3:00 PM or 5:00 PM. If you work the later shifts, you will be relieving people. I did 10-hour shifts. I’ve done 12-hour shifts, 16-hour shifts, and 24-hour shifts. The 24-hour shift usually covered OB.
Typically, they were always free. They never usually were in a room towards the end of the day. At the beginning of the day, they were. After 3:00 PM, they can go rest for a little bit. Where I work, the 24-hour CRNA is usually the free person and they go around and give breaks. After all the lunches are done, they go lay down until 3:00 PM and then they go relieve someone. It can look different based on where you work, but the 24-hour CRNA gets some period during the day or evening to rest prior to the rest of their shift because you may not get a whole lot of rest as a 24-hour CRNA. It depends on the night. There are some nights where it is brutal and you’re running your butt off for almost the entire 24 hours.
There are some nights where you maybe get six hours of sleep. That’s the best scenario possible, but I wouldn’t say that happens as often as the other scenario where you’re running all night. That’s going to be different depending on where you work. As a late CRNA, you’re typically relieving people. This is challenging to relieve people because you never know what you’re walking into. It can be stressful to relieve someone. You didn’t start the case, you didn’t position the patient, you didn’t make the plan, you didn’t dose the narcotics, but now you’re challenged with waking them up and maybe you would have done things a little bit differently so now you’re going to have to adapt to someone else’s method and wake someone else up maybe differently than how you would have because they did it differently.
You have to be adaptable, but I do think as a late CRNA, you get good at being adaptable because you never know what you’re going to walk into when you’re walking into someone else’s room. Everyone’s going to have their own way, method, likes, and dislikes. It could be more challenging and exhausting because the induction and emergence of anesthesia are the most labor-intensive parts. When you’re relieving people and you’re waking up, that’s a lot of work and then you relieve that case, then you go get another CRNA and then you wake that patient up. You’re pretty much waking up all these patients on cases that you didn’t even start. It can be exhausting to be a late CRNA because you feel like all you do in the evening is wake up other people’s cases. It can be exhausting and a lot of work.
Scheduling
That’s something to keep in mind. As far as the schedule goes, you guys can work any schedule you want. It depends on where you take a job. You have to stick those kinds of things out. You have to know what you want before you graduate from CRNA school, but I promise you that job is out there where you can get what you want. Is it more about location? Is it about money? Is it about acuity or what kind of cases you can do? Is it about independent practice? Is it about hours? You have to decide what’s important for you. Chances are there’s not a job that can do everything. That doesn’t exist. You’re going to have to give and take on some things. Where I’m at in my career is I care more about hours.
I want my schedule. If I get my schedule, I don’t care about everything else, essentially. To a certain extent, I can be flexible. As long as I have my hours, I’m good. I’ve worked 16-hour shifts, 24-hour shifts, 8-hour shifts, 10-hour shifts, 12-hour shifts, 13-hour shifts, 14-hour shifts, and literally everything under the sun. I’ve tried and obviously came to the conclusion that 8-hour shifts for me I liked the most. It allows me to see my kids in the evening. Maybe there will be a day when I want to work longer shifts where my kids don’t want to hug me anymore, but for now, they like hugging their mama. I want to be there for them. That’s just me personally. I have other mom friends who prefer to have days off with their kids.
They work twelve-hour shifts so they can have a couple of days off during the week with their young kids and take them to the zoo during the day on a weekday when it’s not busy or stuff like that. There’s a tradeoff. Being at work every day until 3:00 PM and where you always get your evenings with your family or would you rather miss some evenings with your family to have a full day with your family instead? That’s a personal preference. You as a nurse are experiencing that. You do 12-hour shifts, you can do 8-hour shifts. As a CRNA, there’s a lot more flexibility. Another issue I had as a nurse is I was working night shift. I hated night shift not because I hated the actual shift, but because my body hated it.
I know that’s common. I told my other SRNA that I remember going to the doctor and having all this blood work done. I thought maybe my thyroid was off or maybe I was anemic. I felt awful all the time and everything came back normal. It was a simple fact that my body hated night shift. I never could sleep well during the day. A vicious cycle of trying to take sleeping pills. It wasn’t healthy at all. I’m thankful that I don’t have to resort to that anymore. As a CRNA, other than doing the 24-hour shifts, I have never had to work a night shift. Typically, you won’t. They’re not going to fully staff nighttime. I can do surgeries all through the night, but at least you have the option at some facilities to do 24-hour shifts.
Some facilities may do sixteen overnight shifts, like maybe from 3:00 PM to 7:00 AM you can go in and work as a CRNA, or a twelve-hour night shift, 7:00 PM to 7:00 AM. They may have that option out there based on the facility. I have not experienced that myself because we use two 24-hour CRNAs to cover the nights and then the 16-hour shifts sometimes don’t leave until close to midnight. They help cover the late shifts OR cases. It depends. For the most part, you can get away from night shift as a CRNA, which is great.
I hope that gave you guys a good overview of typical CRNA life. I know there’s another hour that I could share with you guys. I will continue to do that on this show. I hope you enjoyed what I shared with you. Stay tuned for more. I hope to see you next episode.
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