What I Was Not Necessarily Taught About Anesthesia 3: read. laugh. learn.

By John Marble

Initially beginning as a humble idea that was literally 2 1⁄2 typed pages of words aimed at letting SRNAs know they are not alone in their angst, and later not really knowing how many books I’d eventually sell (if any), I only printed 500 copies of What I Was Not necessarily Taught About Anesthesia. Truthfully, I hadn’t any idea at all of what to think of it, then. At first several of my students bought it and were very complimentary; however, I attributed their positive responses to subservience in the face of someone (me) able [if I wanted] to make life a living hell for them. But finally, after opening my website to the public and selling a book to an SRNA in New Jersey on the very first day it became functional (with no advertisements or anything), I began to realize that [perhaps] there was indeed a market out there for genuine teaching, similar to the instruction of a preceptor, that takes into account all of the variables involved with learning anesthesia and helps to reassure the student that not only are they [most likely] on the right track, but also that they are probably in a better position than I actually was at the same point in my-own education.

“3 – read. laugh. learn.” includes everything that my first and second book did, only with more elaboration where it may have been previously obscure and/or ambiguous – in addition to an expansion of tidbits, caveats, pearls, and wisdom that I felt were important enough for the pupil of anesthesia to be further mindful of – all in the hope that the anticipation, recognition, and identification of such real-world situations, not to mention the appropriate responses, could somehow be presented to the student prior to their encountering such happenings in the reality that unfortunately lies somewhat outside of the textbook; which [for good reason] focuses immensely on the science of anesthesia, but unfortunately actually gives very little instruction in the ART of administering an anesthetic. Specifically, it has well-over 140,000 words, or [better yet] approximately 45,000 more than the “2nd Edition.” But, more important than any of this, and given the seriousness of what we do for a living, it both reminds and encourages us to snicker at our own errors, blunders, and/or lapses in judgment (assuming no patient harm, of course), lest any of us were to ever erroneously think that we were the perfect anesthesia provider.

• Language: English
• Publisher: John Marble
• Release date: Mar 31, 2020
• ISBN: 9780463595848

John Marble

John grew up in [South] Jackson, Mississippi, where he graduated from Forest Hill High School and attended Hinds Community College. From there he obtained a Bachelor’s Degree in Nursing from Southeastern Louisiana University and then worked as a critical care nurse for nearly four years. He later received a Master’s Degree in Nurse Anesthesia from Kansas University. He currently works in Southeast Louisiana.

Book preview

read. laugh. learn…

I have to be totally honest: I almost wish that I’d have written the first book under a pen-name ten years ago. I’m kind of an anxious guy in public and have never really been someone to seek-out the spotlight. And as it was, then, I never imagined that my little self-published book would’ve sold like it did; nor that I’d ever have to sit down one day to re-evaluate it, often cringing at some of the things I’d previously written, while correcting minor, but still embarrassing spelling/grammatical errors (my wife was and still is my editor). But doing so has also allowed me a chance to elaborate within where I’d been previously vague about things and to add more pertinent instruction regarding topics that I [unfortunately] didn’t think of when penning the 1st Edition, or for that matter now even the 2nd Edition.

But a 3rd Edition!? Look, I have difficulty finding the time to do pretty much anything elective these days with a wife, three active boys, and all the demands the go along with that; not to mention a job. And if I’m going to be completely forthcoming, I found updating this book for the third time to be exponentially more difficult than initially writing it for the reasons already mentioned and because I assumed there were now expectations involved and I didn’t want to offer-up a turd. So I held back. And once I finished and re-read it, I thought it sucked… Dry… No added humor… Blah… About as interesting as a textbook with fine print, tables, graphs, and an appendix.

And that’s when I stopped caring. Yes, readers want to learn. But they also want to be entertained, to anticipate turning the page, and to not want to put the book down. So I came to the inevitable conclusion that I can still be a professional and not take myself too seriously at the same time. And as soon as I did, the book started un-sucking, slowly but surely. As an aside, there’s something very gratifying about sitting in front of a laptop typing away and making yourself chuckle… often. As such, [once again] I have decided to forego a traditional title and instead name the third installment simply "3 – read. laugh. learn. – which I feel better compliments the easy reading" humorous undertones within, although admittedly about very real and significant subject matter, specifically that of importance in our chosen profession – including the knowledge, skills, issues, and circumstances encompassing the vast spectrum of anesthesia services that we provide.

Initially beginning as a humble idea that was literally 2 ½ typed pages of words aimed at letting SRNAs know they are not alone in their angst, and later not really knowing how many books I’d eventually sell (if any), I only printed 500 copies of What I Was Not necessarily Taught About Anesthesia. Truthfully, I hadn’t any idea at all of what to think of it, then. At first several of my students bought it and were very complimentary; however, I attributed their positive responses to subservience in the face of someone (me) able [if I wanted] to make life a living hell for them. But finally, after opening my website to the public and selling a book to an SRNA in New Jersey on the very first day it became functional (with no advertisements or anything), I began to realize that [perhaps] there was indeed a market out there for genuine teaching, similar to the instruction of a preceptor, that takes into account all of the variables involved with learning anesthesia and helps to reassure the student that not only are they [most likely] on the right track, but also that they are probably in a better position than I actually was at the same point in my-own education.

"3 – read. laugh. learn." includes everything that my first and second book did, only with more elaboration where it may have been previously obscure and/or ambiguous – in addition to an expansion of tidbits, caveats, pearls, and wisdom that I felt were important enough for the pupil of anesthesia to be further mindful of – all in the hope that the anticipation, recognition, and identification of such real-world situations, not to mention the appropriate responses, could somehow be presented to the student prior to their encountering such happenings in the reality that unfortunately lies somewhat outside of the textbook; which [for good reason] focuses immensely on the science of anesthesia, but unfortunately actually gives very little instruction in the ART of administering an anesthetic. Specifically, it has well-over 140,000 words, or [better yet] approximately 45,000 more than the 2nd Edition. But, more important than any of this, and given the seriousness of what we do for a living, it both reminds and encourages us to snicker at our own errors, blunders, and/or lapses in judgment (assuming no patient harm, of course), lest any of us were to ever erroneously think that we were the perfect anesthesia provider.

And who knows? As long as I continue to encounter situations in the operating room that spark me to write, and assuming that students and anesthetists keep buying the book, perhaps in ten more years the 4th Edition might someday come out. I’m thinking… What I Was Not necessarily Taught About Anesthesia: Musings Before I Die. Now that has a nice ring to it. And the care-factor will most certainly be long gone.

preface…

The anesthesia provider’s choice of technique is extremely personal. Whether obtained from text, adopted from the observation of others, or acquired by trial and error, it is usually somewhat reflective of the underlying clinical environment that served as the foundation upon which it was built. Molded over time, it transcends logical explanation and technological advances, while inherently resisting change at any cost. It is widely evolved among the subcategories that separate practitioners, mostly dependent upon the geographical location of large teaching facilities, and subsequently dispersed regionally into outpatient surgery centers and private hospitals to wreak havoc on the truth. Eventually after observing and reluctantly embracing reality, it spreads its wings to fly while slowly leaving behind the outdated, largely inbred style of anesthesia that was once [albeit for a small time] both its origin and cultivator of existence.

The above paragraph describes my ever-evolving technique of anesthesia practice. Like many of you, I learned to perform anesthesia at a large teaching facility that, while teaching things I truly needed to understand, also incorporated many universal guidelines and unnecessary techniques into my anesthetic repertoire that I am still [to this day] resistant to letting go of. Oh… And in the process I was told that I was stupid and should not be practicing anesthesia more times than I could probably care to count.

On a related note, it’s both humorous and sad how many of the same people that informed me of this ‘fact’ also had no problem at all [whatsoever] with leaving me in the operating room alone for entire days, nights, and weekends, with nary any assistance or advice. Nevertheless, besides essentially being free labor for 2 ½ years, it simply was not a very fun experience – [of course] other than the humor involved (as you can probably imagine) with basically teaching myself the dos and don’ts of anesthesia.

The toughest part of learning this way [to me] was not the cognitive interpretation of the pathophysiological concepts that presented themselves or even the appropriate integration of anesthesia based upon the hypotheses that I may have deciphered from this information; nor was it the proper performance of the anesthetic skills that were expected of me as a student. Instead, it was the day-to-day struggle of learning the practical issues concerning anesthesia that are tightly and discretely woven within the framework of the operating room, all while trying to find a fair balance between exactly what I should and should not be focused upon.

Here’s the deal… As students, your mind will be filled with a plethora of knowledge about the human body and its reaction to anesthesia right down to the microscopic level. That’s all fine and dandy, because this provides a core knowledge base that is essential for every practitioner. However, and unfortunately in the process, the chances are that you’ll [at some point] become the recipient of well-intentioned advice from an instructor that, unbeknownst to you, [quite possibly] the sole reason they are giving you clinical guidance in a didactic setting is rooted in the fact they may not have been the best practitioner within the operating room domain [to begin with]. Instead, they may choose to teach young, impressionable minds that [unknowingly] hang on their every word. Note: Of course this excludes the majority of you who are instructors that are also competent providers. Moreover, 90% of what students are taught by anyone in either setting is probably based more on provider preference than actual medical fact (yes, I admit that I, too, am guilty of this).

Then, when you first enter the operating room, a new world opens up complete with more confusion and uncertainty at times than what may seem humanly imaginable. In my opinion, it is during these times that some of the best learning and retainment of knowledge takes place as a result of the aftermath of both things done correctly and mistakes made.

As you may have guessed by now, the majority of what I have learned as both a student and a nurse anesthetist is from making mistakes and then never wanting to repeat them again. But, before you judge me, please understand that I generally did not have a CRNA preceptor sitting next to me (or even in the same room) as a student prompting that ‘A stimulating part of the case is coming up’ or ‘Something of great significance is occurring right now, at this very moment’ – such as blood loss. Instead, it was after the patient moved or the blood loss was eventually noticed that I learned from the mistake and tried not to let the same situation happen again.

This book is geared to keep you from having to learn the same way that I had to; which brings me to the reason that I wrote it: I am currently a Certified Registered Nurse Anesthetist working at a regional campus for a large systemic hospital-based anesthesia group. Nurse anesthesia students often rotate through our operating room after spending quite a bit of time already at a large teaching facility, much like the one that once laid the foundation for my anesthetic technique. As I see it, the problem is that these facilities tend to enable the students’ fragile [and newly warped] anesthetic mindsets to morph into a strictly textbook attitude regarding various anesthesia techniques, while [at the same time] neglecting many of the character-building qualities that are essential in a profession where, quite frankly [psst! whispers…] confidence is everything.

After conversing with many students about their previous rotations, I have come to the conclusion that a disproportional amount of the clinical instructors at these facilities are not only reluctant to embrace a different technique other than the one that they have been practicing for years, but apparently some also become very defensive and belligerent when what they think they know about anesthesia practice is somehow threatened. It’s like this: I’ve come to appreciate that anesthesia is a lot like sex. If you’ve only done it one way, you’re really never aware that anything else exists. Granted, some ways might not be all that; but still there are other ways that might curl your toes like never before. It makes no matter when [in your own mind] you’re awesome because you figured it all out so long ago. But I digress… As a result it appears the students are somewhat lacking in a sense of empowerment regarding anesthesia-based-decision-making due to the constant tearing down of their confidence – I mean, God-forbid they ever tactfully question an instructor’s reasoning on an anesthetic matter?

Well, the truth be told, I kind of see myself in some of the student’s faces. Like me, they have been taught so much contradicting information from different anesthesia instructors (sometimes even the same one) that it is very difficult to determine exactly who is right or wrong. They also appear to have been mentally beaten down over the years by overzealous instructors hell-bent on attempting to impose their My way is the only way technique.

I only bring this up because [as a student] I was taught so many universal rules that are now outdated outside of teaching environments. In addition, any ideas or deviations that I may have had from the normal, more familiar anesthetic technique of the institution that I learned in were generally interpreted as an act of treason, rather than being embraced as dynamic thinking. I’m sure many of you can relate, but the confidence that I thought I possessed as a competent critical care nurse was crushed in less than one hour after my first day upon entering the operating room as an SRNA.

Please don’t get me wrong, most of the anesthesiologists who taught me were good; however, some were intent on demeaning me and my classmates in front of the operating room staff and [in my opinion] apparently got a kick out of it. Note: It was largely MD instructors that taught in the clinical environment where I learned… Oh and by the way, residents always got preferential treatment and SRNAs got crapped on. This lack of a teamwork approach is discussed later in the book.

Because of my unfortunate experiences while learning, I now enjoy helping students regain their lost confidence in a stress-free operating room environment. My favorite question to the nurse anesthesia students that I teach is Why do you do things the way you do them? The most common answer is ‘because [insert name] does it;’ definitely not the in-depth pathophysiological answer that I prefer to hear coming from someone who will never be as smart again as they are at that particular moment, with so much information having recently been pounded into their head. I like to empower students to think for themselves and challenge misinformation. I, myself, enjoy being challenged and discussing why I do the things that I do.

Well, many of these students began encouraging me to write down all of the little tidbits of practical information that I would give them day after day in the operating room. I initially thought it was ridiculous; however, they assured me that it would be useful if I just wrote it down the way that I discussed it behind the drapes. Indeed, and after much ridicule over the years from many of my co-workers (who do not necessarily agree with everything that I teach), this is what has become of my initial product.

Personally, I would have paid a large sum of money as a student for this book that I have since written. It is mostly like a "Letter to Myself as an Anesthesia Student – full of stories and advice that manifests itself in appearance as if I am trying to prove to myself that I am actually me" fifteen years later. While focusing mainly on practical advice within, I’ve also tried to dispel many myths regarding anesthesia practice and contradict outdated techniques that seem to be universally taught to anesthesia students by well-meaning instructors. It’s also riddled with useful information, humorous scenarios (mostly first-hand), and a large amount of opinion regarding anesthetic practice in an easy to follow format.

As an already seasoned anesthesia provider, you probably won’t exactly agree with a large percentage of this book. You may even get upset when I describe a technique that you use every day as ‘outdated." But I guarantee that you will laugh out loud at the detailed descriptions of some of the same mistakes that we all make while learning to properly perform anesthesia.

As a student, both sides of issues will be presented to you in an easily understandable and retainable format. It chronologically gives advice starting in the preoperative setting. Next, it delves into what the anesthesia provider can expect from the operating room environment. And finally, it gives practical advice on the issues that one may face in the recovery room. It even discusses how to set up and navigate specific cases that have been known to be both difficult and stressful for the under-prepared anesthesia provider.

I hope that you have as much fun reading this book as I did writing it. Refer to it as a template for you to cultivate your own anesthetic technique while [hopefully] leaving out that which may not be necessary. At the same time, look to those anesthesia providers that you would most like to emulate and pick up ideas from each one, while consciously abstaining from the techniques and practices of the ones that chaos invariably seems to gravitate toward. And finally, remember that you are the ultimate decision maker of how you will eventually practice when out of school and working. I wish you the best of luck.

Sincerely,

John A. Marble, CRNA, MSN

I’d like to take this opportunity to personally thank both Brian Selai, CRNA, MSN and Mike MacKinnon, MSN, FNP-C, CRNA for each agreeing to contribute a section within this book centered around their respective areas of expertise.

one – introduction

Before getting started, I just want everyone reading this to know that what follows is not a self-righteous diatribe essentially stating my likes and dislikes as they relate to the practice of anesthesia; although it does mention some form of the word I 2,967 times. After all, I am by no means perfect and I make plenty of mistakes every single day.

On the contrary, I simply wanted to put together a book that [at the very least] would make students aware of the situations and decisions they will be faced with each day when exploring the new frontier of the operating room. It is NOT meant to be an anesthesia textbook. Instead, it is geared towards preparing the student in an attempt to get the most out of their clinical rotations, while hopefully helping to establish a routine well before they are out and practicing in an unsupervised setting. Additionally, it encourages them to start thinking outside of the box while learning anesthesia and to [tactfully] challenge overt misinformation, especially that in which its universality is seemingly severed outside of teaching institutions.

Though essentially extrapolated from my own clinical endeavors, I am convinced – and preliminary critical reviews by my peers have indicated – that the average student will gain more relevant clinical knowledge by reading this book [just once] than reading over and over those claiming to possess the secrets of our profession. And even if the student reader disagrees with 90% of it, they are still exposed to the real-life situations presented within and are made aware of all the possibilities and alternative methods that can be utilized in order to avoid particular consequences. I whole-heartedly believe that I did not and that students will not get the gist of this information from typical anesthesia textbooks or reference manuals.

I must warn you that I generally have an opinion about everything and I’m not afraid of writing it down on paper; but please note that I did NOT say that I am right or correct about everything. Of course I’m taking a risk here, for I am not a scholar. What I mean is that I will rarely break things down to a cellular level while attempting to explain the concepts within this book – as it is far from anything scientific. Furthermore, I really do not believe that it will be well-received in certain anesthesia circles. Consequently, I feel the need to inform you that it can either be used as a template by those desiring the avoidance of unnecessary techniques or perhaps as toilet paper by those that it may rub the wrong way (no pun intended). You may think to yourself that I am dead-on in my approach to a certain aspect of anesthesia practice while reading one section, but then the next one may cause you to curse out loud and throw the book in disagreement. If you ever meet me, you may want to kick me in the crotch before shaking my hand. However, regardless of your viewpoint, it is my belief that you will have fun laughing out loud at the mistakes that I’ve made and the conclusions I’ve reached over the years. And if you’re not careful, you may even learn something new in the process. Have fun reading it and let me know of your feedback (both good and bad) via e-mail at [e-mail] or by posting a review on the book’s Facebook® page.

two – general information

1. Organization, organization, organization…

Oh dear God-in-Heaven. As I embark upon revising and editing this book for the 3rd time, I’ve now read through several topics I initially wrote about in 2007-2008 and concluded that while many things have stayed the same, A LOT HAS CERTAINLY CHANGED about both my practice and regarding the specific operating room I have worked within over the nearly TEN YEARS(!) that have since passed. For starters, I’m a lot less anal about organization. Please don’t get me wrong here: Organization is still very important, especially when just starting out. But DANG – I think I might have been a bit of an over-achiever in this regard. Also, we now have Pyxis™ machines in every single room with most drugs now right at our fingertips.

BUT please understand that I think I’d be doing you a disservice with some of these topics if I just completely erased my thoughts from 4 to 5 years out of school and replaced them entirely with nearly fifteen years of I don’t care so much about THIS anymore because I happen to be more comfortable with my intuition, knowledge, experience, and skill-set – not to mention having worked with many of the same surgeons for well-over a decade.

So what I’ve decided to do for many such instances within this edition is to highlight any NEW and/or CONTRADICTING information with the book-ends of ***. Such as ***This is new information added after I came to the conclusion that erasing and replacing the old information would be performing a disservice to the average reader that likely has much less experience than I currently have.*** So, without further ado…

The most helpful skill to learn as an anesthesia provider is how to be organized. I could have been spared so much heartache while learning the ins and outs of anesthesia if someone would have let me in on this little secret years ago. The simple fact is that you could be the best anesthesia provider in the world; however, if you are unorganized, you will [most likely] never reach your full potential and/or get the recognition of being a good provider.

It takes an extra five minutes each morning to do this. And in return, your room will always be left in good shape for any of your coworkers who may inherit it later in the day or [even better] when doing an emergency case late that night or while on call. Now, keep in mind that the vast majority of the people that you work with will probably not be as concerned with the way they leave their room for you. Furthermore, these are the same people that will most likely be the ones to take full advantage of the way your room was set up and not return the favor at all, whatsoever. That’s okay. BE DIFFERENT, DON’T BE THE NORM.

Also, you will start to notice that some anesthesia providers seem to attract chaos, despite the acuity of the patient and the case at hand, mostly because they are unorganized and ill-prepared for what the anesthetic brings their way. As for these providers, a glimpse inside of their operating room during a carpal tunnel release may unfortunately bring to mind the often frenzied environment of a challenging coronary artery bypass graft: Specifically, syringes thrown everywhere and the focus on trying to catch up rather than being on the patient. That’s okay. Just remember: BE DIFFERENT, DON’T BE THE NORM.

***Holla! Nothing new to add so far.***

The following advice on setting up has helped me, personally, be more prepared and a much better anesthesia provider. It is not meant to be an absolute must do as much as it is a template for you to cultivate your own suitable anesthetic technique. So, here is what I do to get and stay organized each morning…

I prepare two (2) styletted endotracheal tubes (7.5 for the average female and 8.0 for the average male). Use a 7.0 for smaller stature females and 7.5 for smaller stature males. Then I prepare five syringes and needles with labels (one 30cc propofol, one 10cc succinylcholine, and three 5cc syringes for fentanyl, midazolam, and Zemuron® [rocuronium])… And for those that somehow have not figured it out yet, each and every Zemuron® (rocuronium) bottle that I’ve ever encountered already has a red sticker on it that you can peel off and place on the syringe, itself. There is no reason that a medication sticker dispenser should ever have such a ridiculous number of Zemuron® (rocuronium) stickers in it (which I have seen) that you cannot even find anything else. Consequently, unless you are using a multi-dose vial, there’s also not any reason that you should ever have to write a label for a Zemuron® (rocuronium) syringe. I am surprised at the number of people who have been doing anesthesia for years that do not know this little fact. This information alone will save you much time over the course of your anesthesia career. Okay, returning focus… I then cover [or wrap-up] the two tubes and the labeled syringes with a towel and DO NOT TOUCH THEM. That is my gift to whoever may use my room later-on that day or the next. Remember: BE DIFFERENT, DON’T BE THE NORM.

***[Face-palm]. Wow. I was quite a piece of work. Well, I guess it’s time to start breaking it down. While I still feel like styletting two endotracheal tubes is prudent, I couldn’t care any less if it’s an 8 for a male or a 7.5, nor a 7.5 for a female or a 7.0 - unless the patient is smaller in size and stature. It’s simply not that important in the grand scheme of things and a complete waste of brain cells. Also, the syringes… You know – the gift to your coworkers? Please understand that this was written in the days well-before accrediting agencies zeroed-in on anesthesia as the primary cause of Hepatitis outbreaks, butt-abscesses, global warming, meth labs, and puppies dying; while also before it was mandated by the federal government for every operating suite to be staffed with an over-zealous super-circulating nurse that apparently receives tax deductions for reporting under-shirts and tie-back scrub-hats not covered with an operating room-issued bouffant. If that weren’t enough, it was also before we had Codonics™ label-makers in every room – and ironically before we were nickel and dimed for every anesthetic choice we seem to make on the patient’s behalf. Anyway, just know that it’s a different environment presently.***

Next, I make the same syringes and needles with labels and set up the appropriate size endotracheal tube (You might one day prefer no stylet; but while learning, I suggest that you use one) with ***two one oral airways (8.0cm and 9.0cm)*** and make sure to have at least a Miller 2 and a Macintosh 4 blade available.

I then prepare phenylephrine and ephedrine at the beginning of the day. If the patient is on an Ace-inhibitor (which most are) and especially if on a combination of an Ace-inhibitor and a Beta-blocker, you will probably need them. And for the record, phenylephrine costs 40¢ and ephedrine costs 89¢ a vial, so don’t give me the lecture about it being expensive and wasteful to do this. Furthermore, a 100cc bag of normal saline costs the hospital that I work within 81¢. So, take the 81¢ bag of 100cc normal saline and draw up 9cc from it to mix with the 89¢ vial of ephedrine. Next, mix approximately 0.9cc of the 40¢ phenylephrine vial (Note: It does not have to be exact) with the remaining 91cc of normal saline. There. You are now prepared to safely treat hypotension the entire day (remember not to reuse syringes and needles) for a whopping $2.10 cost to the hospital – which will not hurt them at all to eat, considering the one in which I work charges the patient $150.00 for one of the 81¢ 100cc bags of normal saline. Translation: 184 bags of this stuff can go uncharged for every one bag that is charged without the institution losing one red cent. Note: If you work within a facility that individually charges for these items out of single patient specific medication boxes, then you may want to attempt doing what is previously described in a different way.

***Again, please know that when I wrote this book nurse anesthetists weren’t yet supplying the local meth houses with all of our unused ephedrine. Having finally caught up to us, we now have to treat it as a controlled substance. Trust me, there’s very little that will piss you off more than having to jump through hoops in order to obtain a drug that was once readily available in ample quantities, only to later spend precious time in search of someone actually qualified to waste it. Anyway, ephedrine and phenylephrine were once both readily available in a standard-issue drug box and are still very cheap; however, and especially considering that it’s now very common for pre-made syringes of phenylephrine to be obtainable by simply opening up a drawer in the Pyxis™ machine, it’s no longer advisable to suggest drawing up these medications before the induction of general anesthesia.***

And finally I grab the appropriate forced-air warming blanket for the case and put it out to remind me so that I won’t be putting it on after the incision and under the drapes when the patient is already hypothermic. It has been my experience that when I am not sure if I need one, I always in retrospect had wished that I had put one on the patient. Plus, it is already out and in an organized manner, so it is not a burden at all to remember. I use forced air warming in approximately 90 percent of the cases that I start.

***I still do this till this very day. In fact, I place my induction drugs and paralytics on top of the folded-up blanket. And when I’m done using the syringes, it reminds me that it’s now time to put on the forced-air warming blanket.***

Place all of these items in an organized manner suitable for yourself. I personally do not prefer to use the desktop of the anesthesia machine for any of my supplies because I like to have a place to rest my head during long, boring cases. Ha! No, the top of my anesthesia cart (***now a Pyxis™ machine***) is plenty big enough for all of these items to be methodically placed. I will place the forced-air warming blanket (still in package) on top of the towel that covers my set-up gift (***[insert eye-roll]***) for the person that inherits my room. I then place the endotracheal tube on top of that. From there I ***group the vaso-pressors together at the top corner of the cart and*** methodically place the other syringes, blades, and airways so that they are in the same place every time I am in need of one of them.

If you do not have the time to set up (Note: It will take you longer than 5 minutes when first getting your routine down), use the downtime in your cases wisely in order to complete the setup. This is also a good time to prepare for the next case. I have plenty of downtime [***without computerized charting***] in a laparoscopic cholecystectomy that takes only thirty minutes (skin to skin), while still managing to converse and joke (tactfully, of course) with the others in the room.

***We now have Epic™ computerized charting (btw: I personally love it!) and my jokes can be less than tactful these days.***

Remember, organization is number one on my list for a reason. Once I made an attempt to get organized, things quickly started to fall into place and anesthesia became much more enjoyable to provide. I only wish that I had started to get organized sooner, rather than later. Instead, I went through two and a half years of misery in school and another year of turmoil while out and practicing. If I had only known then what I know now…

2. Anesthesia has a way of humbling you

Humility is like underwear: essential, but indecent if it shows.

Helen Nielsen (author)

You will always learn something new every day - no matter who you are or how good you get at performing anesthesia. You will have been successful at 300 consecutive intubation attempts – some after others had already unsuccessfully tried – but still be caught off-guard by a patient that you anticipated being a routine induction. Patients will mysteriously move on 3% sevoflourane, laryngospasm or obstruct while awake, or be resistant to an absurd amount of narcotics. The best advice is to not expect, but be ready in the event of the unexpected.

You already have two styletted endotracheal tubes available for an emergency re-intubation. Oral airways are readily accessible. With proper preparation you are ready for just about any situation that you may encounter. When not properly prepared, you are vulnerable to these situations.

Also, do not take any credit for executing the maneuvers that you perform day in and day out. If you accept or even acknowledge any acclaim for instances that might have gone better than expected, then you must also shoulder the responsibility when the consequences of your actions (or inaction) clash heavily with circumstances beyond your control - many times leading to less than enviable results, not to mention lots of questions and inevitably second-guessing of oneself. And even though you might just surprise yourself with your capabilities if/when in fact you do get in over your head (especially the first time), the simple truth is that you are a trained professional who is supposed to be able to function in both controlled and uncontrolled environments. And trust me, the Lord knows that you do not want the added attention should the situation that you are currently in happen to be one that is extremely trying and could potentially lead to patient harm.

Having said that, [on average] there will not be an emergency and your days will [hopefully] be pretty laid back after you initially figure some things out. As anesthesia providers, we generally do not get paid for the things that we do day in and day out. Instead, we get paid for what we are capable of doing, should the need arise. We may even get teased [occasionally] by other medical disciplines for our perceived lack of work and stress. Do not be fooled. It is pretty much guaranteed that not one of them would ever want to be in your position when you are tested by a trying situation, despite the hours you work or money you make.

And finally, there will be mistakes made. There will be things overlooked, medications withheld or mistakenly given, and inadvertent injuring of the patient despite perceived vigilance. The key is to learn from the mistakes you make when they happen.

A man’s errors are his portals of discovery.

James Joyce (novelist)

FYI#1… If someone happens to establish an artificial airway (LMA, endotracheal tube, etc.) that you could not, please praise that individual. Do not get upset or harp on it too much because that is not what matters. What matters is that you did what had to be done in the meantime until the airway was finally established. Maybe one day you will be able to return the favor to this particular provider or for someone else.

Now, let’s imagine that the shoe is on the other foot and you have established an airway for a colleague who had previously failed. If that’s the case, then please do not gloat or pat yourself on the back too much. Not only will you appear to be a self-righteous idiot, you will more than likely miss your next routine intubation. The anesthesia Gods have a way of keeping us all humble. Do not tempt them!

"Egotism is the anesthetic that dulls the pain of stupidity."

Frank Leahy (late Notre Dame football coach)

If I must boast, I would rather boast about the things that show how weak I am.

The Apostle Paul (2 Corinthians 11:30) [New Living Translation]

FYI#2… There’s a state of mind somewhere between cocky and unsure of oneself that every anesthetist’s mindset should hover at on a daily basis, while also still managing to display humbleness. And although this might sound somewhat contradictory, it’s really not at all. For instance, if [before going in to do her epidural] you were to hear [from the nurse] something like … the new labor patient in room number 2 has scoliosis and was stuck ‘5 TIMES’ for her last epidural and then enter the patient’s room with that piece of information and whatever subsequent doubt in your mind, the [by all means] I can almost guarantee that you are going to struggle. However, if you go in confident, yet humble, and with absolutely no expectations either way, more often than not you will surprise yourself.

FYI#3… You will hit a lot of home runs in empty ballparks over your career. But I’ve found that’s better than striking out in front of an audience. What I mean is there will be instances in which something you did likely prevented a bad outcome or perhaps even saved a life. Several years back I took buddy call with a new-grad CRNA and an anesthesiologist who was less than a year out of residency. We got called-in on a Saturday morning to do an emergency I&D of an abscess on the lateral part of the neck of an 18 month old. The patient went to sleep and was intubated easily by my buddy, so I left the room as the surgeon was walking in. I was gone about 10 minutes when I walked back in to find the child blue, apparently unable to be mask ventilated, and now the two of them were busy diligently trying to re-intubate. Apparently there was a half-arsed taping job done and the toddler had been extubated when the surgeon turned his head. Bradycardia soon followed. And as one of them lunged for the cart to draw-up succinylcholine and atropine I was offered the chance to re-intubate, which I attempted and completed successfully. Of course the child soon pinked-up and the heart rate quickly returned to baseline. And what did I do? I said nothing at all and calmly walked back out of the room. I basically hit a home run in a mostly empty ballpark, as I had done before and have since done. But I’ve also had help to bail me out of certain situations, too – especially back when I was a newer CRNA. They, too, pinch-hit for me and bailed me out. DO NOT be the person who flips his bat, trots around the bases, and gloats when this happens. The anesthesia gods will throw at your head the next time you step in the box. Again, you and I are trained to do this. Yes, it’s extremely unfair that we’re expected to bat 1.000. So occasionally it’s okay for a pinch-hitter to step in.

3. Character qualities of an anesthesia provider

Every experience that you endure is geared to make you better at your profession. Thank God for every patient that you have as each one [for the rest of your career] will be a learning experience. Yes, this includes the obese patient with a difficult airway and a family history of malignant hyperthermia.

We, as anesthesia providers, deal with life or death situations every day. Yes, it is usually second nature for us and sometimes we may not think too much about what we are doing day in and day out. But make no mistake: The patients that you put to sleep every day will die if you or someone else is not there to manipulate their airway and/or the anesthetic. An accountant won’t harm anyone if he/she messes up a client’s taxes and a sales representative will not observe anyone turning blue if they fail to make a sale. However, a little too much of something here or there from us can definitely result in dire consequences to one of our patients. Consequently, you may come across providers that might seem a little too paranoid about all of this. But then again, you’ll see others that never show any concern and get caught off-guard quite frequently. Somewhere in the middle there is a good balance to have between a lack of concern and paranoia.

This all tends to settle with time. Irrational paranoia means you have an unreasonable fear about things that don’t happen; however, with experience we develop rational fears about things that actually DO happen. I guess a moderate amount of concern should always remain in the foreground of every monotonous and habitual act that you perform.

Having mentioned all of that, I advise you to be useful and excellent in all that you do in regard to being an anesthesia provider. Do not settle on just being average. Yes, wallowing in a pool of mediocrity everyday will get you by and your pay will be the same; however, you will never get the true joy out of performing anesthesia that a competent provider encounters every day. In fact, your days will [most likely] be doused in oblivion as you remain preoccupied with mostly trying to catch up while a whirlwind of practical