18 December 2013 - Congratulations, you've been selected...

I've been awake for approximately 24 whole hours as I write this. I've been awake since yesterday morning, did a full 12 hour shift, then proceeded to teach a CPR class right after work. I was driving home when I saw an email with this attachment:

Despite my lack of enthusiasm on the outside, I was pretty ecstatic to see that email. Unfortunately, the date which I am scheduled happens to fall right in the middle of my Air Force Reserve Annual Tour, meaning I'll technically be orders. So as I was figuring out exactly how'd be able to be in two places at once, I got this second email:

Needless to say, I'm kind of confused. One email that gave me a congratulations and an interview date and another that says I got rejected, try again later. I don't know how to express all these feels. Anyways, I gave them a call, hopefully I hear back soon so I can plan accordingly. 

Either way, earlier this week, I got this email from U of South Florida:

Despite Kaiser being my first choice, I believe that only fools put all their eggs in one basket. Planning for success involves making contingency plans, so I guess come January I'll be flying out to Tampa for an interview. 

26 November 2013 - KPSAN responds.

Got this from KPSAN in the self addressed envelope today; that was much quicker than anticipated. I also dropped off an additional reference letter from a CRNA I shadowed for a few hours who happens to be a KPSA alumni. Will follow up with that to make sure it's in my file this week.

I've also sent out the rest of my application packets to National University, Barry U, and the U of South Florida. Now its basically time to sit and wait until I hear back. And so my watch begins. 

The future is here: Robotic anesthesiologists/anesthetists?

Earlier this year Johnson & Johnson released what they call a Computer Assisted Personal Sedation System (CAPS) codenamed Sedasys. This automated system does real time monitoring of your vital signs and provides procedural sedation during colonoscopies by administering and titrating our favorite hypnotic/amnestic agent, propofol. But since propofol is also used for the induction and maintenance of general anesthesia, who's not to say that it might progress to that, especially for low risk procedures?

Some anesthesiologists are already concerned with anesthesia specialization going to nurses, which is all well and fine. Ultimately, the goal for anesthesiologists and anesthetists is the same; providing safe, high quality anesthesia services with an aim for the best possible patient outcome. However, with health care reform on the horizon, we're also looking more and more into cost savings. But to machines? Sure it'll take out the human error factor, but machines fail too. One thing for sure though, it'll reduce the human touch of anesthesia care.

I, for one, welcome our future robotic overlords. As long it's not the one putting the scope in my butt. Just kidding, I'm still on the fence about this one.

More information here: http://www.sedasys.com/
FDA link can be found here.

First packet away!

Application, check. Transcripts, check. Reference forms, check. Miscellaneous documents, check. 

I originally intended to turn in my packet with 4 references including one from an alumni, but I've decided to keep to 3 and turn in my packet early. KPSAN application packet all compiled and to mailed tomorrow. Wish me luck!

Eric's Notes on Nursing

Nursing now days has so many formal rules. Here's a list of thoughts and informal rules of thumbs that I've picked up in my short time as an ICU nurse:

1. A good nurse lacks shame, an ego, and a conscience but has heart, soul, and the determination to never stop smiling. Even during codes. 
2. There's nothing to be nervous about; you're not the one that's gonna die.
3. You have to laugh at inappropriate things. 
4. Be and island of calm in a sea of chaos. 
5. Primum non nocere. Do no harm. Addendum: Primum non nocere sans documentum. Do no harm without proper documentation.
6. The IV access catheter is quite possible the most important invention ever created for the medical profession. Without an IV access, I am useless. 
7. Revatio rhymes with fellatio. 
8. All the crap learned in nursing school about patient advocacy and doing "what's right" and "by the book": out the window. Patient advocacy is all good, but protect your job and license first. 
9. Work when you're sick. Call in sick when you're not. 
10. Scrubs: Pockets are your friend. The more the better. ADDENDUM: As my experience in ICU progresses, I find that I have a need for fewer and fewer pockets, because I carry fewer things. And probably because I'm tired of finding crumpled up alcohol wipes in the dryer. 
11. Invest in comfortable shoes, even if they're ugly. You'll be standing on them for 12+ hours.
12. You should chart and document like how girls should pick clothes: just enough to cover your ass; sometimes less is more. 
13. Turn on the lights in the patients room or you might miss something on your assessment. Turn off your lights in your patients rooms so they go to sleep and stop bugging you. 
14. Learn to prioritize: take things one step at a time, accomplish the small and simple tasks first and get them out of the way. It leaves you time to tackle the bigger issues, like the drsg change on the sacrum of your 600 lbs patient.
15. There's always going to be that lingering thought that you forgot administer this, fax or document that, or call so and so for whatever reason. You are human and can only do so much; endose that shit to the next shift. Leave work at work; when you get home, the scrubs come off. 
16. A good nurse takes good care of their patients. A great nurse takes good care of their patients but does great documenting. 
17. Nursing will never be easy or stress-free; you will never be comfortable in your element. If you ever get to that point, you're not doing it right. 
18. Reorientate and negotiation doesn't work. Restrain your patients for, you know, their safety. Addendum: It's ok for med-surg patients to walk around. 
19. If 90 year old dementia grandma says she's going to buy you a pie, sometimes she's serious.
20. Best idea over: Obesity differential. You should get an extra dime an hour for every 10 lbs over ideal body weight if your patient is morbidly obese, and an extra quarter an hour more if they're immobile. 
21. Adventitious heart and lung sounds? No symptoms, no problems.
22. Got gas? Best place to release is to go crop dust in your comatose, intubated, C-diff+ patient's room.
23. The worst part about C-diff isn't the smell or the isolation procedures. It's getting bleach on your scrubs. 
24. The speed at which ER brings your admission is direct proportional to how stable the patient is. Severe sepsis with a suspected ruptured AAA on 3 vasopressors? Patient rolls through door while you're on the phone for report. Suicidal patient that just needs ICU for 1:1? Arrives at change of shift. 
25. You wouldn't donate blood if you knew some of the patients who would be receiving it. 
26. Your gut instincts is just as important as your physical assessment skills. 
27. If you work night shift, which inevitably you will, your phone's "do not disturb" mode is your best friend. Your manager WILL call you at 3PM after you just finally fell asleep to ask you to come in early to do overtime. 

19 September - KPSAN Counseling Session

Just a quick update. 

Had my initial counseling session at KPSAN HQ in Pasadena this morning. The vibe it gave off seemed like an interview more than a counseling session. The counselor reviewed my resume and transcript, asked me a bunch of questions. Typical questions, nothing out of the ordinary. 

There was hardly any feedback given unless you asked for it. I asked him if I was a strong candidate even though my GPA was lacking. I also asked if there was anything I could do to strengthen my resume and chance for admission. That said, they also weigh in all your extracurricular activities, volunteerism, and if you are part of any professional organizations and counsels. 

After the "interview" the counselor tells you whether or not to proceed with the application process. I got the ok to submit my application next month. We'll see what happens. 

Just a tip. They ask you to write an essay on the spot. After signing in, they hand you a piece of paper with an essay topic. Mine was "why do you want to be a CRNA?" There's no time limit on writing this essay but my guess is that it's part of the weeding process to see how much thought you've put into it before applying to the program. 

9 September 2013 - Ideas to Note

They say that in life, it's not what you know but who you know. I have recently found that who you know contributes greatly to what you know. My experience in the military to this point, though short, has allowed me to meet and encounter people from all across the United States and has exposed me to many world views and perspectives on life. Here are some ideas I picked up this weekend.


Knowing what you don't know is just as important as what you do know.

The take away here should actually be to know your limits. 

• Never be afraid to admit that you don't know the answer to something as long as you're willing to find it.
• Delegate tasks accordingly. Life is hectic as it is, so the delegation of simple or routine tasks is paramount to accomplishing what you are actually there to do in a timely manner.
• There's no harm in referring to a specialist or consulting someone who's had more experience. It can be harmful and potentially neglectful to try to solve a problem that's beyond your scope or knowledge base. 

Don't work without getting paid.
About a year and a half ago, I was put in charge of a large program that was running marginally at best. I was (am) a new lieutenant and had no idea what I was doing. Given our limited time to work on our projects, I had no choice but to put in extra time in order to learn the ropes, catch up on what was going on, and get it going in the direction I wanted it to go. Although we are given a salary, the amount of work and effort put in far surpassed any amount of monetary compensation afforded. Needless to say, this had a grievous effect on my morale.

And then I was told that I could be compensated for my work from home via telecommute. Although I had to jump through hoops for a minute amount of reimbursement, knowing that my extra effort at getting my program operational was recognized was a major morale booster. At least the beer money was anyways.

Riches abound when least expected.
Two thoughts here:

• There's always money somewhere, you just need to find it.
• If you like what you do, don't worry about the pay, because you'll probably get good at it. If you get good at what you do, they'll pay you more to do it.

The key to success in almost any situation is honesty and transparency.
A little bit of humility goes a long way. Be honest with your shortcomings and make it known that you need help.

• Forced review of a situation. Specific problems are presented, broken down, and identified. A big problem may be comprised of smaller, easily handled issues that could can be addressed internally.
• If you are not able to fix said problem, maybe someone else out there might have an idea that could help you.

On death and dying

Sometimes it's depressing for me to work around so much death and decay. It's hard on the mind, body, and soul. One of worst feelings for me is having to take care of a patient everyone knows is actively dying except for his/her family. Money and denial are strong motivators. 

Working in the ICU, I see a lot of things happen on a daily basis to the human body that really shouldn't be happening. It's my personal belief that some of the things we do to our patients for the sake of "doing everything we can" fall into the category of cruelty. I believe in protecting human dignity and that is a difference between saving a life and prolonging suffering. Here's my thoughts on dying patients:

1. People die, it's a part of life. 
2. But if you fuck up, you just killed someone.
3. You have a job because someone is trying to die; your job is to not let them.

Remember this line from the ANA Code of Ethics: "The nurse should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death. However, nurses may not act with the sole intent of ending a patient's life even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations."

What we can and can't, should and shouldn't do is so contradictory. 

-----

On a related note, I've learned a couple things that aren't in the books in regards to keeping your dying patients alive or recognizing that they're about to crash on you. There's no evidence based practice behind these, they're just things I've noticed. 

1. The less you touch your patients, the less likely they are to die. Yes, I know you're supposed to turn your patients often to prevent pressure ulcers and skin breakdowns. But when you see a patient desaturate for 15 minutes or go bradycardic and see rhythm changes from being turned 30 degrees, its time to stop touching them for a while if you want them to live until your shift ends. 
2. The poop of death. The final release. The phenomena of terminal defecation. Excreta ultima. If you've seen it, you know it happens. That massive dump that happens right before a patient codes. I think it has to do with massive K+ loss followed by sine waves and fibrillation, but what do I know. 
3. Patients on long-term vasopressors are going to feel cold. Don't warm them up. The cold is from the vasoconstriction in their periphery, which will eventually lead to tissue breakdown. But if you warm them up, you'll cause vasodilation which is going to drop their blood pressure. Take your pick. 

The prerequisites

Most schools I've looked into have the same basic prerequisite requirements. If you've been working as an RN in the ICU, most of this stuff you should have already.

• Bachelor's degree. Usually BS in Nursing, but some are ok with a related or science field.
• GPA of 3.0 or higher. Keep in mind that this is a minimum requirement. I've seen GPA requirements as low as 2.75 but in reality a competitive GPA is probably around 3.75.
• Most programs will require one or more of the following: 
• Statistics 
• General Chemistry
• Organic Chemistry 
• Biochemistry
• Physics
• Anatomy and Physiology 

• Minimum GRE scores (2012+) of 297 to 300. 
• RN licensure. This should be unrestricted and have a spotless history.  
• Between 1 to 3 years of experience in critical care. Some places will consider ER, PACU, and OR.
• CCRN and/or other additional professional certifications
• BLS, ACLS, and PALS Certification
• A rich sugar mama to support you through 24-28 months of schooling cause you won't be able to work. 

So where do I stand in all this? 

• Bachelor of Science in Nursing, from a state college
• Undergrad GPA = 3.27. Hardly competitive for most programs, but I've taken graduate level nursing courses in pharmacology, pathophysiology and a couple others with a GPA of 4.0. 
• The only other extra courses I've taken are statistics and general chemistry. I also have a introductory general general/organic/biochemistry course. Anatomy and physiology were done as preqs for my BSN program. 
• GRE scores: Verbal=157, Quantitative=153. Waiting on my analytical writing scores. 
• About 3 years of experience in critical care
• CCRN is completed. Also have TNCC in addition.
• BLS, ACLS, and PALS under my belt. In addition, I'm also a BLS Instructor and working towards becoming an ACLS instructor. 

Good news today from Kaiser!

I got this email from the Kaiser Permenante School of Anesthesia earlier today. 

When I applied for shits and giggles back in 2011, I got a phone call and was rejected outright. An email saying "...you meet our minimum requirements..." is a step up. Yeaaa buddy.

Introduction

I know what this blog sounds like. It sounds like a blog about farts. My girlfriend claims that the flatus produced by my bowels is some of the most rancid she's ever smelled. It's safe to say I that is one part of my life I've mastered.

This blog is here so I can vent about being an ICU nurse. I'm not really the politically correct type, so you'll find some pretty blunt and uncensored "confessions of an ICU nurse" type things on here. Like how if I'm gassy at work, I go into my demented C.Diff positive patient's room to crop dust.

It's also here because I'm trying to become a Certified Registered Nurse Anesthetist, or CRNA to those unfamiliar. This blog is to help me keep track of what I've actually done and my progress.

If you're reading this, you're probably a nurse or looking towards becoming CRNA too. Hopefully you can give or get a little insight along the way.