Episode 86

Episode 86: What Are My Favorite Types Of Anesthetics & Cases As A CRNA

Oct 12, 2022

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In today’s episode, Jenny Finnell shares her favorite types of anesthetics and the cases that go along with them as a practicing CRNA of eight years. She also discusses the easiest and most complex anesthetic cases she’s encountered along her journey. Jenny shares her love-hate relationship with OB, her love for open-heart, and her disdain for neuro regarding surgery. There is just so much to learn, and Jenny has a load of experience and wisdom to impart that can help you in your own CRNA journey.

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What Are My Favorite Types Of Anesthetics & Cases As A CRNA

These are my favorite types of anesthetic cases to do. As a practicing CRNA for 8 years, I’m going to share with you what my favorite anesthetics and cases have been. I’m also going to share with you what are the easiest types of cases and the hardest cases. Be sure to stick around to the end to know what is one of the hardest cases to do as an anesthesia provider. Let’s go ahead and get into the show. For those of you who are new, welcome to the show. I’m excited you’re here.

For those of you who have been around, you may know my background. You may not but I want to remind you that I’ve had quite a variety of practices at this point. I intentionally did that in my practice, especially early on. I was seeking out a wide scope of practice. I wanted to do it all and get my hands on everything. It came from me trying to figure out what I wanted and figuring out what my interests were.

Favorite: Open Heart

Surprisingly, when I was in school, I found that I loved open-heart, cardiac physiology and the pharmacology that went with it. I made that my goal to join an open-heart team shortly after I graduated from anesthesia school. Within six months, I was able to join an open-heart team. I did call and 24-hour shifts. During that time, I also got to do a lot of OB because the 24-hour CRNAs also had to be very proficient at OB. You were 1 of 2 CRNAs in the hospital overnight with 1 attending.

Those were the only people who staffed an entire Level 1 trauma hospital. You had to know how to do OB. You had to be proficient at doing open-heart for any class ones that came in throughout the night. That’s what I strove to do. I enjoyed it. It was fun and challenging. Maybe I’m a little biased in the fact that most of what I have to share with you as far as my favorite types of cases to do relates to my open-heart days but let me go into why open-heart is enjoyable. Know that this is my opinion.

Some people are like, “You’re crazy for thinking open-heart is the best type of anesthetic to do,” but if you share my passion for pathophysiology and pharmacology, you may find that you also equally will enjoy it. That’s primarily why I do enjoy those types of cases because it gets me thinking about the pathophysiology process and then the titration.

I love drugs. I don’t do drugs but I love giving drugs. I love the process behind pharmacology and pathophysiology. It gets my nerdy brain on fire, which you get to do pretty much all day every day when you do open-hearts. You get to physically see how medications work. You get to see it unfold before your eyes, which is incredibly rewarding and a lot of fun.

The reason why I like open-heart so much is that there’s a lot of titration. I always challenge myself to get my blood pressure to be exactly where I want it. That’s one point higher or one point lower. If they’re cannulating the aorta and you need that blood pressure to be right at 90 systolic, I would challenge myself to get right at 90 systolic and then keep it there for 60 seconds or whatever it would be, which was equally challenging.

You had to be good at titrating little microdoses of vasopressors, knowing exactly how they worked for that particular patient and mixing ephedrine and Neo in the right combination or maybe vasopressin or whatever it is you’re using. There’s a lot of titration, mixing and drugs going on. We often would have Levophed drips in the background and Cleviprex, which is clevidipine. It is a calcium channel blocker. We would use that.

A lot of people are probably more familiar with Cardene but Cleviprex is an amazing drug. I would also use it in the carotids I would do over Cardene. Cardene is fine but Cleviprex was something that I got comfortable using and titrating during my open-heart time. I routinely went to that during my carotids as well. One of the reasons why I loved it is because I got to mix drugs and get familiar and comfortable with titration. I also got incredibly comfortable using gas.

You’re probably like, “What do you mean by that?” Don’t get me wrong. There are a lot of places that practice open-heart that do not do this technique. I said this in the previous episode. Do not do this technique and assume all places do it this way because what I want to share with you too is every place that does open-hearts has its method and way that works for its facility and that the CRNAs are used to or accustomed to.

We had a way that worked well and that we found worked out great for the patient. We often would titrate our anesthetic gases to quickly make an adjustment in the blood pressure. You have to be careful with that technique because if you’re not doing it carefully, you can have a lot of swings. We would do it so controlled that we knew exactly how to get the blood pressure down when we needed it. We would turn your flows up and down.

Was that bad for the environment? It’s probably bad for the environment. Since then, I’ve become very conscientious in my practice of my flows and keeping flows low to help prevent the destruction of the environment because anesthetic gases are toxic to the ozone layer. Knowing what I know now, I probably would have adjusted that practice if I was still practicing open-heart but we would routinely do it in a pinch if you had to.

You didn’t have a minute or 60 seconds to drop a drug and you had gas readily available. That’s why we would use it. It was not the first line but if we were in a pinch and we needed it quickly for whatever reason, we would use it because it was already there and going. It was easy to have access to versus turning your back, mixing up a drug, turning around and pushing it.

Typically, when we had drugs, we would pre-plan what we needed pre-mixed, whether that would be baby epi, which is ten mics per mL of epi, whether that be a Levophed drip or a Cleviprex drip. There are so many times when I would think the blood pressure for whatever reason keeps creeping up. It takes a while to get a Cleviprex drip out, string it all up and put it on a pump. You need the blood pressure down now, not in 1 minute or 2. They’re cannulating. You have to get it down.

Unless you had some diluted nitro or something like that, gas could get the pressure down. You have to make sure you don’t bottom it out. We use gas routinely to gauge and control our blood pressure, which I also found challenging and a lot of fun. The physiology of it all, understanding how the different chambers in the heart work, right-sided heart failure versus left-sided heart failure, pulmonary hypertension and A-fib are fascinating things.

You would physically get to see A-fib. You could see the heart flutter and go through V-fib, V-tach and all the different arrhythmias because they’re causing the heart to fibrillate before they put them on bypass. It was neat to see physically what that looked like in a heart and to see it quivering there. I thought it was the coolest thing ever. I love watching open-heart. It’s so fascinating to me that you can drain the blood out of someone’s body, put them on a cardiac bypass machine, put the blood back and then wake them up. They’re like, “I’m good.”

A CRNA and a doctor looking down in an operating room

Anesthetic Cases: Open heart is just so fascinating that you can literally drain the blood out of someone’s body, put them on a cardiac bypass machine, and put the blood back, and then wake them up.

It’s so cool. Partially, it’s my favorite because open-heart is the coolest surgery that even exists in my opinion. The patients can be incredibly sick too. It’s rewarding to know that you’re making a huge impact in their life and saving their life or the people that have a bicuspid valve, for example, and severe aortic stenosis. You can replace the valve. It’s the coolest thing ever.

Number one, open-heart is my favorite type of case. I work at a paeds hospital. I have not been interested in doing paeds heart mostly because I’m PRN at this point in my life. I’ll get into that in a different episode as far as things to consider when you’re looking for a CRNA job. I’ll discuss that later. I’m at a point in my life where my schedule is what is taking priority over my experience at this point. Don’t get me wrong. I still value my experience but what I prioritize in my life is my schedule.

Favorite: Thoracic Cases

I haven’t ventured into doing paeds open-heart. I like my PRN position. I don’t want to join the open-heart team. It is a big commitment to join an open-heart team. It typically comes with more calls and things like that. It’s not where I’m at in my life but I do think it’s cool and amazing. My second favorite type of case would be thoracic cases, lungs, lobectomies, VATS, things like that and thoracic.

The reason why I like lungs is that there’s the challenging aspect of managing an airway and doing a double-lumen tube. Those are a little bit more challenging to put in. You have to use a fiber optic scope to confirm placement. It was always fun to manipulate a little fiber optic scope. Getting good at using that made me feel good. If I ever had an airway emergency, I know how to use that scope. You might think, “That seems easy.”

It’s not as easy as it looks because when you’re adjusting it and twisting it in different directions, you have to be able to identify your anatomy incredibly well and then adjust the end of the scope. It’s the opposite of what you would think. When you pull down, it goes up. When you push up, it goes down as far as the end of the fiber optic scope. You can get easily disoriented when you’re inside the lungs. You’re looking at the different types of lobes and trying to find tracheal rings and things like that.

I got to use that quite often during my double-lumen tube placements. I got good at using a fiber optic scope. That leads me to one of the things that I like about doing open-heart and thoracic cases. There are tons of hands-on skills. In an open-heart, I would do A-lines and a big-bore IV. I love starting fourteen-gauge IVs, which is so much fun. It’s so gratifying. I enjoyed that but there are a lot of hands-on skills.

A surgeon and a nurse standing over a patient while in surgery

Anesthetic Cases: There are a ton of hands-on skills when doing open heart and thoracic cases.

In the lungs, we would do thoracic epidurals. Those are fun to place. It’s a different challenge than placing a lumbar epidural. Doing a thoracic epidural was different. You’re going to the same space but the technique and the anatomy are different. It was a nice challenge. In the lungs though, airway management sometimes could be a big challenge. It’s to make sure the lung is staying deflated so the surgeon can operate and that you’re able to oxygenate and ventilate through one lung.

The thoracic cases could be a lot of work but there are a lot of fun hands-on skills that come with it. The physiology of it is a lot of fun. Those were also typically cases where extubation was crucial. They had to earn that extubation. There were usually already people who were respiratory cripples and had a lot of disease processes going on. Waking those patients up was challenging but we would extubate those patients and take them over to recovery. That’s the fact that they were healthy enough to be able to be extubated and taken to recovery or sometimes to ICU depending on the case. I enjoyed doing lungs.

Favorite: Vascular

Number three was vascular. Can you see a theme here? It’s heart, thoracic and vascular. I did do that for a good chunk of my career. Naturally, that’s what I was interested in. I loved vascular. I thought of physiology, the titration of drips and fluid management. Open-heart fluid management is huge too, although you don’t run them and give them a lot of fluid in open-heart. You tend to run them pretty dry.

In vascular, abdominal aortic aneurysms are a massive amount of fluid management. You have a cell saver at the bedside. You’re giving blood products, cryo and FFP. It’s understanding all of that, reading ABGs, interpreting tags and titrating vasopressors. You’re dealing with a lot of acid doses and acid-based shifts in a big vascular case because they’re going to be clamped and creating that acidic environment. When they unclamp, it’s the surge of vasodilation from all the acid buildup.

You’re dealing with that and dumping acid right on the heart. You’re making sure that the patient stays stable through that and giving calcium and bicarb. It’s constant. It’s a lot of fun. You’re like, “That seems like so much,” but it’s fun. Don’t get me wrong. There were plenty of those cases. Some of them went straightforward. We were like, “This is easy AAA.” There were other ones where I was sweating buckets. I didn’t sit down for the whole case. I was running.

Multiple times, we had 3 or 4 different CRNA providers in the room at one time. It’s an all-hands-on-deck thing. Those weren’t nearly as common but most of them went pretty straightforward. They weren’t as scary as you may think but every now and then, you had someone who needed a lot of additional support and help to get through the case clear and free.

Favorite: Carotids

Carotids are incredibly challenging. They’re equally fun because they are hard. I liked carotids. Sometimes they were such a pain though but it was a nice challenge. I enjoyed anticipating. They tend to be patients whose blood pressure swings. It’s from one extreme 200 systolic to 40 systolic. It’s like, “Boom.” That’s why they have vascular disease. Their compliance and vessels are non-compliant. They have a bunch of plaque build-up.

They’re stiff. They can’t expand and collapse. They don’t have the ability to auto-regulate the way a healthy person would. Their blood pressure seems to be all over the place. They could be incredibly challenging to manage blood pressure-wise. They’re also hard to wake up because you can’t over-narcotize them. They’re not going to have lots of pain, yet they can’t cough because gosh forbid they get a hematoma on their neck and then a deviated trachea. Now, it’s an airway emergency.

It’s challenging to wake those patients up because you can’t have them cough, yet they have to be awake enough to where they squeeze your hands, stick out their tongues and wiggle their toes. It’s challenging to get someone with a tube in their mouth to be calm and do those things. They have this big incision on their neck. They’re usually holding pressure on the neck.

You’re trying your best to time that extubation to not stir the giant or the beast and know based on your end title agent where they’re at with the stage-two delirium and emergence delirium thing. Don’t stir the giant until you know they can have some ability to think, “I’m in the operating room. I woke up from a surgery,” versus disinhibited and crazy, “Where am I? I don’t know where I’m at but I feel threatened. I’m going to fight.” You don’t want them to wake up like that. Those were a challenge.

We did open-heart, thoracic and vascular. Those are my favorites. I’ve done neuro, OB and kids. I am a paeds CRNA. That is my favorite population. I don’t know if it’s the phase of my life that I’m in but I love babies. I enjoy working with kids. Sometimes it’s sad. Don’t get me wrong. Sometimes I’m becoming a more paranoid parent. In working with the kid population, you see dog bites and burns. You see crazy stuff like cancer and things like that but I love working with kids. It’s enjoyable.

Least Favorite: Ortho

If I can love someone else’s kid for a little bit even if it’s for a few minutes going to sleep and waking up, that makes me feel satisfied. It’s rewarding. If you would have asked me years ago, I probably wouldn’t have said paeds was my favorite population but it’s becoming my favorite population at this point in my life. I’ve done EP lab. Let’s shift gears a little bit and talk about my least favorite types of cases.

It’s funny because for the longest time, I’ve always said neuro but I used to say ortho a lot. I’ve started to think that I don’t dislike ortho. I’ll get into maybe what I don’t like about it. I don’t mind it anymore. It has not made my least favorite list anymore. The reason why ortho used to be on my least favorite list was that, and this is me being who I am…I don’t like the banging, the blood splattering everywhere and the chainsaws. It seems so barbaric. They take this hammer. They’re like, “Bang.” I get it but holy moly.

That’s why I didn’t like ortho. It disturbed me. Equally, I don’t like watching BKAs where they chop off someone’s leg and carry it across the room. You see this leg being carried across the room. You’re like, “They chopped off this leg.” I don’t know why. I don’t mind open-heart and seeing a beating heart open in a chest but seeing a leg being carried across the room or having someone bang on someone’s body part with a giant hammer to where they’re rattling over the bed is disturbing to me.

Least Favorite: Neuro

That’s why I don’t like ortho but they do the cases anesthetic-wise. We will get into that in a little bit but that made my easiest list. My least favorite is neuro. I’ve never liked neuro. I don’t know if that will ever change. I still don’t like neuro. It’s not that I mind it. I’ll do neuro. I don’t mind doing backs and things like that but it’s not what I would want to go in and do. I don’t like brains, which is weird because I like hearts but I don’t like brains. I don’t like seeing brains. It’s all wrinkly and gooey.

It’s the fact that there are no nerve endings on it. You can be awake. They can touch your brain. You will be like, “I’m fine.” It weirds me out. I did an awake crani in school. I haven’t done one since but it was crazy. We sedated the patient to crack the skull and get the skull off but then we woke them up and ran them on a Precedex infusion. They were talking with their skull cut off. It was insane. They weren’t wide awake but they were awake enough to interact and do things they had to do for the case but I was like, “No, thank you.” It freaks me out. I’m not crazy about neuro.

I don’t know if any CRNA enjoys proning a patient but I sure as heck don’t enjoy proning a patient, especially when they’re 400 or 500 pounds. You’re like, “I have to flip this person on their stomach.” We deal with their bellies and hindering their preload and making sure that everything is positioned. It’s hard to do because they’re so big. You deal with drool, slob and boogers. They’re slobbing all over the floor. It’s not my favorite thing.

It doesn’t mean you’re always prone in neuro cases but a lot of times, you’re prone in neuro cases. That’s why it’s one of my pet peeves. I don’t like prone. I also equally don’t like when they put their head in tongs, which are these big bolts that go on the side of the head. They have their head hanging by this giant heavy device. I’m like, “Be so careful with their neck.”

Typically, when you prone someone with the Mayfield tongs, then the surgeon takes the head while you flip. They do the same thing when they go supine. They’re the ones who control because you have to be so careful with the patient’s neck because their head is bolted into this device that’s into their skull. It’s heavy. It’s a big piece of metal that they secured to the bed. Their head hangs suspended in this bolted device. It’s crazy. It’s barbaric.

You’re probably like, “I never want to go and have surgery on myself.” I don’t know if I want to have surgery on myself either but I’ve seen a lot at this point. Neuro is not my thing. I don’t like the 180 degrees away from me. It’s a problem but I’m a control freak. I like feeling like I have control. When their head is 180 degrees away and they’re prone in Mayfield tongs, I don’t feel like I have as much control.

If you estimate my patient, I’m going to be angry. Don’t step on the wires. Do your due diligence and tape things up out of the way but a lot of time and effort goes into positioning. Their head is dangling under the drapes 180 degrees away. You’re like, “I hope everything is okay underneath there.” You can go intermittently check but that’s equally not super convenient to do. You’re crawling underneath the drapes with a flashlight.

Least Favorite: Electrophysiology

I like them supine with their head near me or at least face up even if they’re 90 degrees away or 180 degrees away. If their head is at least sitting on a pillow versus being suspended and hanging in tongs, I like that a little bit more. Enough about neuro. Going on all day has never been my favorite. EP is not bad. EP cases are easy, which is electrophysiology. For those of you who don’t know, A-fib ablations, SVT ablations and things like that are easy.

There’s a lot of work in the beginning. You usually do an A-line or big-bore IV at a minimum and intubate but then after that, you sit there. They’re honestly boring. Maybe you will do isoproterenol or something like that to try to elicit an arrhythmia but for the most part, you don’t do a whole lot. You give heparin and protamine at the end. You sit there but there’s so much radiation. That’s why it made my least favorite because you get blasted. I’m like, “I don’t want cataracts. I like my eyes. Thank you.”

You see that all the EP docs have these special lead-protected goggles. I’m like, “Can I get a pair of those, please? I’m here doing anesthesia all day long in these cases.” That’s why it made my least favorite list because I don’t like being around that much radiation. That’s why ortho is not also one of my favorites, although the radiation on an ortho case is pretty minor compared to what you would get in the EP case.

I don’t like X-rays. I don’t like dealing with C-Arms and also neuro when they bring in the O-ring. It’s like a CT scan. You have to step out of the room because there’s that much radiation. No, thank you. I always have this fear. You come back to a room after that happens. You’re like, “Is there still radiation scattering off the walls everywhere and bouncing into my brain?”

When they bring in the circle or the OR CAT scan, you have to leave the room. You try to get the patient ever so slightly perfect as far as what their pressure is and everything like that but then you have to step out. Once it starts going, it can’t stop. You’re watching in the window. You’re like, “I hope their pressure hangs.” There’s no stimulation. Usually, at that time, their pressure’s like that. You’re like, “Hurry up.” That’s another reason why I don’t like neuro. In EP, I don’t like the radiation.

Least Favorite: Obstetric

Number three of my least favorite is OB. I had a love-hate relationship with OB. I loved it when I loved it but I hated it when I hated it. The hate part of it outweighed what I loved about it. Sometimes you have a beautiful day up there where everything is wonderful. You give amazing epidurals. They’re so grateful. They cooperate with you. They’re a beautiful family, “This is amazing. I’m so excited for you. Congratulations. You get to do C-sections. It’s the same thing.”

It’s beautiful. I love babies. Bringing a baby into the world is the most amazing gift. It’s a miracle but then I would have days where I had the opposite experience where no one was grateful. There’s a lot of dysfunction, sadness and sorrow. It could either be all rainbows and sunshine or nothing but storms and clouds. The storms and clouds stuck with me. It was this love-hate relationship with it.

Bringing a baby into the world is the most amazing gift, but there are days when there's an opposite experience. It could either be all rainbows and sunshine or just nothing but storms and clouds. Click To Tweet

Here’s the other thing too in OB. I’ve been through so many dire emergency things in the anesthesia realm and OR but when you’re dealing with this emergency in the OB world, you have two lives at stake. You have the baby and the mom. Either one is bad. You’re responsible for two people. The mom is your priority as an anesthesia provider because, without the mom, the baby will die. It can get ugly fast in a second. The baby loses its heartbeat. You take it out. They’re blue. There are chest compressions. The mom is not doing good. It could go icky fast.

It can feel like the room is spinning around you and you can only do so much. It’s not my cup of tea. Here I am. I’ve had three babies. Every time, I’m terrified because I know too much. I’m like, “I know way too much,” but equally so, it can be rewarding. Don’t be deterred from doing OB. This is my personal preference as to why I don’t like it. I’m sharing with you but you may be like, “You’re crazy. I love OB. I love the rock and roller coaster ride of OB.”

Easiest Cases: Robotics, Ortho, Plastics

Let’s go into what are some of the easiest and what are some of the hardest anesthetics that I’ve ever provided. Let’s go into the easiest first. The easiest cases in my opinion 100% are always robotics or general lap appies and lap choles. They’re usually pretty straightforward. There’s nothing too exciting, especially robots because they’re slow. You have to dock and undock.

It’s still slow but is relatively quick for a robotic. I’ve worked in other places where robotics are painfully long. I’m in a place where it’s pretty decent for a robotic but it’s still slow. It’s fine. I don’t mind cases that are not happening. It’s a nice break from the craziness that you can experience. It’s funny because some people are like, “Being a CRNA is 90% boredom and 10% sheer terror,” which is true to an extent but the boredom is nice because it’s a mental break from the stress.

The boredom is really nice because it's a mental break from the stress. You need cases like that; otherwise, you would be fatigued and probably hate your career. Click To Tweet

You need cases like that. Otherwise, you would fatigue and probably hate your career. Would you want 90% sheer terror and 10% boredom? No. It’s not a bad thing but they’re pretty straightforward. Unless they puncture something unexpected, it doesn’t usually go too unexpected. The only time it can be challenging is if you are on their head. They’re bigger. You have a harder time ventilating them. That can get challenging.

They have so much new technology though that has made ventilation so much easier as far as the type of gas they use and the different systems they use to gauge the pressure that they need to keep the abdomen inflated for the surgeon. It has gotten so much better than it even was a few years ago. It’s becoming way better as far as being able to ventilate a bigger patient that way but that can be a challenge. Don’t get me wrong.

If they develop crepitus because they have been insufflated for so long, they will eventually start accumulating CO2. That can happen. The shorter the robotic case, the better. You don’t want an eight-hour robot. That’s miserable. 1 hour or maybe 1.5 hours are okay. When you have a 3 to 4-hour robot, those can be painful but usually straightforward. There are general lap appies and choles.

When you start as a new student, you’re probably going to be put in a lot of general rooms because they are easier cases to manage. You may not feel like that. If you’re like, “Those don’t feel easy,” it’s because you’re new. Give yourself a little bit of a break here. I’m talking about years of experience. They do that on purpose because you don’t want to go into an open-heart first or a neuro case first.

EP would be relatively easy but still probably overwhelming. OB would be overwhelming. They do tend to put you in cases like robots and general cases when you’re new to the OR as a student because it helps you get the repetition. You need to get the repetition in to get the comfort level. You need to start advancing into other more challenging aspects of providing anesthesia.

You need to get the repetition in to get the comfort level. You need to start advancing into other more challenging aspects of providing anesthesia. Click To Tweet

Ortho made the easiest list because it is relatively straightforward. Don’t get you wrong. A 99-year-old hip can be a complete nightmare but for the most part, if you’re doing a fracture of any kind, it’s pretty straightforward. There’s not usually a lot of blood loss. It’s easy. Sometimes you get to do a spinal and a MAC or a Twilight anesthetic with a spinal.

A dentist and a nurse anesthetist talking with a patient in a dentist's chair

Anesthetic Cases: Ortho made the easiest list because it is relatively straightforward and easy.

Ortho made my easy list as far as it’s not hard to provide anesthesia for ortho cases most of the time, especially if you have a peripheral nerve block like if you’re blocking the shoulder or the arm of some kind. It makes your job easy. They’re not going to have pain afterward. You have to keep them asleep so they don’t have a memory of the procedure. It’s pretty straightforward.

The last of the easiest types of cases are plastics. Don’t get me wrong. Some plastics can be challenging but for the most part, plastics are easy too. You keep them asleep. You don’t have tons of pain afterward. If you do a nose job, you might run a Remi drip but it usually allows you to wake up pretty smoothly. I’ve done a lot of plastics when I worked at the surgery center. Those were usually nice days because they were straightforward. There are boob jobs, liposuction, tummy tucks and all that stuff. Sometimes you were proning those patients depending on where they’re taking all the stuff from but it’s a pretty straightforward general anesthetic. That made my easy list.

Hard Cases: Thoracic, Lungs, Heart

Let’s get into the hard types of cases to do. I already hinted toward a few of them. One of them is the thoracic. Those are hard. Lungs are harder than hearts because they’re shorter cases. Hearts are nice. You’ve got the pump period where you’re taking a nice little breather. You’re like, “They’re on the pump. I’m off. I get to sit here for 40 minutes, get my grip around coming off pump, prepare drugs and do whatever I need to do.”

During an open-heart case, you get a break when they go on the pump because you’re having a baseline gas on but the perfusionist does everything else at that point. You may occasionally give some insulin or something like that but otherwise, they’re technically doing all that on the pump. You don’t have to do much when you’re on the pump for the most part.

For hard cases, lungs are hard because they’re shorter cases. You’re doing a lot as far as managing ventilation. There were some lungs that between doing the thoracic epidural and the double-lumen tube confirmation placement, you have to always double-check and make sure the lung is down. Clamp it off. Unclamp it. Clamp it off. Suction goobers out of there and make sure they’re not getting blocked with secretions.

There’s one hand on ventilation, on and off the vent, and blood pressure because when you’re inflating and deflating the lungs, you can cause little shifts in preload. It was a lot. They’re like, “We’re done.” You’re like, “I haven’t charted anything.” You get the epidural pump in the room trying to set that up. Usually, by the time the surgeon is done, you’re like, “I’m sweating back here. I haven’t done any charting because I’ve tended the patient the entire time and done all the other things.”

Those can make your head spin. Even with experience, the lungs would make my head spin from time to time, not all of them but some of them were crazy. We were pretty much hands-on the entire time because we were having to deal with desaturation, trying to come up with a long and down with the lung, giving some P, putting some oxygen down through the tube, desuctioning, confirming placement, unclamping, reclamping and getting the epidural pump going. They’re like, “We’re done.”

Lungs can be hard. I’ve done a lot of other randomly hard cases. There have been some vascular and neuro that have been incredibly hard in the sense that there’s a lot of fluid management and hemodynamic instability. I shared with you what I thought. For the most part, most cases are not routinely hard, although lungs seem to be consistently routinely hard.

Hearts could be hard on occasion but some hearts were beautiful. I’m like, “I love this.” It’s a nice mixture of challenge and ease, especially when you get into a routine with it. Lungs, every now and then, would sucker punch you. You’re like, “It’s freaking hard.” TAVRs are the same thing. I did a lot of TAVRs. Some of them were beautiful. Other ones were a lot of work for whatever reason like instability. The valve didn’t get placed right. The patient had to get intubated and put fully to sleep versus on a Precedex infusion.

Every case has the potential to be hard. Let me leave this with that. No matter what you do, it could be plastics ortho or robots. Sometimes you have a hard time ventilating a robot. Any anesthetic can become hard. Don’t ever think that just because you’re scheduled for a general day that you’re going to have it easy. The patient could make it hard. Keep that in the back of your mind and stay on your toes at any moment.

It’s probably where a lot of our stress comes into play in this profession but it equally becomes one of those things that you enjoy because it keeps you vigilant and connected to what you’re doing. It keeps you thinking, engaged and present in what you’re doing. This is not a job where you can zone out. You’re always engaged but that’s enjoyable and rewarding.

Becoming a CRNA by far is the best thing that I ever did with my career. I’m honored and grateful to be here sharing this with you. I hope you become a CRNA. If you’re already in CRNA school, I hope this episode was insightful for you. Thank you so much for reading. I appreciate you so very much. You all have a wonderful time. I will talk to you soon.

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