Greetings,

If you have found this site after searching for stuff related to Nurse Anesthesia, you have found the right place. Well, you have found nearly the right place. I have moved to new software and am using WordPress at The Average Man where you may find that the story continues.

I also moderate the nurseanesthetist.org web site that is dedicated to all things pertianing to nurse anesthesia. There you may find comments and information from a variety of people involved in the field of nurse anesthesia.

I look forward to seeing you on the new sites. Have fun and be happy or you can consider the alternatives.

David Godden

The first half of our clinical rotations are coming after 6 weeks at LAC-USC hospital. Part of me is so exhausted and the other is jumping around so excited to be doing anesthesia at Los Angeles County Medical Center. This place is at the center of the Los Angeles Health Care system for the indigent and trauma cases.

Well, more study time tonight.

I have always been fascinated with what the Average Man is and does. Not that I would ever want to think of myself as average that would be too cruel. In the end though, we are all average or within the curve. Some may just fall somewhere near the edges a little more than others.

What strikes me the most is our commonality? We are so much the same and this is what I have been exploring these last few years. As you may know, The Extremist Blog has moved to a slightly new location on the server. I will have to go back and make sure all of the links are correct and working after the move. What is new is a total revamp of the site, "DavidGodden.com" into WordPress software.

As a tribute to this makeover and move I have decided to change the name of the Blog to something a little less pretences. The Extremist is still active but not my main face. In the end, The Extremist was an experiment in exploring the curves edges. What I face daily is that striving for excellence does not take away the constant struggle to move to the center. "Moderation is a difficult thing to find" This is also true. So if you enjoy confusion, extremism and the struggle to fit in and be "normal" I guess this Blog will have some value. It does for me at least.

Enjoy and realize that I will be posting to "The Average Man" from here on out.

This is a great picture. I am not sure where I found it but it fits. When you are feeling down and there is nothing to do, Read Blogs and Be Happy.

Or, if you read the sign correctly, Read Blogs Be Wise!

Have a great Week.

Uggggh! Test time coming this Monday and it's hard to start reviewing. My brain is tired after a long week of OR time at LAC-USC. "Focus, focus, hocus pocus .... What ever it takes to get down to business and do the work that needs to be done to do well for this exam". This is the self talk that goes on sometimes in the wee hours of the morning and long into the night. To become a CRNA is a lot of work, we all knew this when we started. Now is the crunch time.

How to stay focused. I don't know if that is a question or the answer. What I do know is that this quality of tenacity and sticking to a routine is what has guaranteed success so far and what it takes to keep going. Once in a while as a student it is necessary to just breathe deeply and smell the fresh coffee, hold the cup in your hands and enjoy the moment.

This makes me think about the different kinds of runners. The physical characteristics of a sprinter, the shorter thick powerful explosive energy build into their frames are wonderful for the short sprint. Take a look at the long distance runners and the body habitus is very different. The distance athlete has the lenthy thin muscles and ability to keep churning out the miles. These guys are not so good in the sprint but after 10 or so miles they are warmed up and can really start to glide along the road. Being in this nurse anesthesia program is like that too. You have to find your own rhythm, the routine of getting up early, finding moments to hours to study; taking care of all of the responsibilities and finding your routine is like this long distance runner. The longer these runners go, the better they get.

That is the key for me today. Find my own rhythm and stick to it. I am not good at cramming just before an exam; its the daily flow of reading and clinical practice that works best for me. Now, I just to maintain that rhythm, at least until Monday afternoon.

Today is the Chinese New Years Day. Last night my wife and I went to Temple as we do every year to honor Buddha and pray for our living and deceased ancestors. For those that do not know these traditions I have included a little summary of these things.

Chinese New Year is a celebration season that starts with the New Moon on the first day of the New Year and ends on the full moon 15 days later. The 15th day of the New Year is called the Lantern Festival; this is celebrated at night with very large light displays and children carrying lanterns in the yearly parade.

The Chinese calendar is not a Western Invention as you may have guessed and is based on a combination of lunar and solar movements. The lunar cycle is about 30 days in length. I say about because it averages to 29.5 days. In order to "catch up" with the solar calendar the Chinese insert an extra month once every few years (seven years out of a 19-yearcycle). This is the same as adding an extra day on leap year. This is why, according to the solar calendar, the Chinese New Year falls on a different date each year.

The Chinese New Year's Eve and New Year's Day celebration are family affairs. It is times of family get together, reunion and thanksgiving. The celebration was traditionally highlighted with a religious ceremony given in honor of Heaven and Earth, the gods of the household and the family ancestors.

The sacrifice to the ancestors, the most vital of all the rituals, united the living members with those who had passed away. Departed relatives are remembered with great respect because they were responsible for laying the foundations for the fortune and glory of the family. To the Chinese these things are primary. I have enjoyed participating in these celebrations because my wife is Chinese and I have become such a part of her family.

The presence of the ancestors is acknowledged on New Year's Eve, last night, with a dinner arranged for them at the family banquet table. The spirits of the ancestors, together with the living, celebrate the onset of the New Year as one great community. The communal feast called "surrounding the stove" or weilu is symbolized by family unity. This diner honors the past and present generations. In my own way I was able to remember my own parents and the contributions that they have made to make my life what it is today.

So, celebrate with us and remember your roots. It couldn't hurt.



David and Jennifer

This past week I spent time in the trauma OR room and Friday was spent in the hot Burn OR for two cases. We are adding up our cases, tallying our statistics on Medatrax, so that we can have a full experience as SRNA's. The life of a student Nurse Anesthetist is too full. This week however, I had time for reflection.

The great thing and the bad thing about statistics is that they are so impersonal. It's like hearing in the news that there were fewer traffic fatalities this holiday season, only 8 highway deaths over Christmas week down from 12 last year. Interesting unless you are related to one of the unfortunate tragedies. The trauma OR room is like that too except you get to see the results up close, too close really.

There was a case this last week that had me thinking for days; actually I have not stopped thinking about it really. Just another small statistic probably not even making any news but terrible never the less. An out of town woman was hit by a car and made it to the emergency room after being thrown 10 feet or so as the report reads. She was rushed to the OR for neuro-surgery after her level of consciousness decreased and her CT scan revealed active intracranial bleeding. I am use to taking care of these unfortunate victims in the intensive care units but this was my first experience with a large trauma in the OR.

It was pretty much a rush with 3 surgeons, an anesthesiologist the chief CRNA and myself helping out. As a student I basically took orders, started an arterial line and functioned at the head of the bed with the Chief CRNA behind me. We were all very busy. This person had multiple injuries, pneumothorax requiring a chest tube, fractures limbs and the head injury which was severe. What I keep thinking about now is this poor women and her family. At the time we were busy with her anesthetic and there was not a moment for reflection.

The surgery went well actually and the pressure in her brain was relieved. After the craniotomy her blood pressures settled down and we were able to keep her stable with titratable medications. As far as the general anesthetic was concerned, this also went fairly smoothly. She will need additional surgery for her other injuries but they can wait till the morning.

I went to see her in the ICU the next day. She was still intubated, sedated and seemed to be doing alright. She had woken up and moved all of her extremities but the nurses told me that they were not able to assess her neurological function yet. Seems reasonable and hopeful. Her family was coming from out of town. That all seemed so sad for me that this all happened. The one good thing is that she would have died had it not been for the quick abiltiy to detect her bleed and releave it. Maybe this strikes home to closely. Perhaps I will comment on that someday.

Monday, Monday
So good to me.
Monday, Monday
It was all I hoped it would be.

Oh Monday morning
Monday morning couldn't guarantee
That Monday evening
You would still be here with me.

Monday, Monday
Can't trust that day.
Monday, Monday
Sometimes it just turns out that way.

On Monday morning
You gave me no warning
Of what was to be.
On Monday, Monday
How could you leave
And not take me?

Every other day
Every other day
Every other day
Of the week is fine, yeah.

But whenever Monday comes
But whenever Monday comes
You can find me crying
All of the time.

Monday, Monday
So good to me.
Monday, Monday
It was all I hoped it would be.
Oh Monday morning,
Monday morning couldn't guarantee
That Monday evening
You would still be here with me.

Every other day
Every other day
Every other day
Of the week is fine, yeah.

But whenever Monday comes
But whenever Monday comes
You can find me crying
All of the time.

Monday, Monday,
Can't trust that day.
Monday, Monday,
Just turns out that way.

Oh, Monday, Monday,
Don't go away.
Oh, Monday, Monday
It's here to stay
Monday, Monday
Oh, don't go away

By Wilson Phillips

It is one of those Mondays. Maybe you don't remember the Momma's and the Papas but I seem to recall hearing this in the distant past some Monday. Just turns out that way, Mondays do. This Monday was not a day of crying but for going to school; Nurse Anesthesia school didactic and its here to stay.

Cardiac risk factors in the non-cardiac surgery patient are the topic of discussion today. This is a little complex for me so we turn to the ACC/AHA guidelines for a little help. I was able to find this document without too much trouble this afternoon. Here is the question, "do we go ahead with this ankle fracture surgical repair in this 55 year old Hispanic woman with a history of diabetes and hypertension and recent MI." Oh, she had a myocardial infarction 4 months ago and currently has intermittent angina. Her blood pressure this morning is 165/90 and her medications include metoprolol, isordil, metformin and aspirin. She is able to climb two flights of stairs without getting too short of breath.

So what do you think? Are we ready to go to the operating room to fix her broken ankle? OK, we do this case being a little nervous with her potential to re-infarct again. Blood pressure and heart rate are well controlled during the anesthetic using opiods and short acting beta blockers. Cool, case one down.

The next case is an Armenian gentleman aged 54 who is scheduled for a fem-pop bypass graft (he has vascular disease even at this age), a heavy smoker for the past 30 years and a family history significant for coronary disease in both parents and an older brother. During the history he tells you that he is not able to climb one flight of stairs because his legs hurt too much so he can't comment on whether or not he gets short of breath. No cardiologist has seen him. Do we take him to surgery today?

The ACC/AHA guidelines for Cardiac Risk in the non cardiac surgical patient can help with these kinds of decisions. Now maybe you thought this was all fun and games but when your butt is on the line and you have this guy's future and health in your hands it makes you think twice, maybe more than twice.

As a student we are thrown into these situations and we have a clinical supervisor breathing down our necks asking us questions while we are trying to get organized and straight in our heads if we even want to take this guy to the OR. "So little grasshopper, why didn't you call me last night with this information you worthless piece of student dog meat". Oh No Mr. Bill!

Some of us are not getting very much sleep mulling all these things over trying to figure these things out, finishing up the anesthesia plan of care for the next days and studying for exams. This is not to mention that some of us have husbands, wives and children that need a little, I mean little attention once and a while. Maybe it's the worry about how to keep our patients safe that bothers me the most. Even after all the study and diligence to make sure that every base is covered, there maybe just maybe something that will get overlooked that could make a difference. It keeps me thinking late at night.

Sometimes I wake up at 2:30 in the morning with my mind ruminating on the case that was a little difficult that last day. Wondering why I missed a couple of important points that my clinical instructor was "pimping" me about. I knew that stuff, why did I blank when he asked me all those questions. Maybe it was because I was trying to do something in the OR and my mind could not jump rope and chew gum at the same time, who knows.

All in all I am having a great time. Everyone is kind and understanding for the most part and it's usually just me that is making life really tough. We are our own worst critics.

OK, did you think about our Armenian fellow. He is not going to surgery today. This is based on the ACC/AHA guidelines. He has intermediate risk factors and is scheduled for a high cardiovascular risk surgery and needs cardiology consult. Seems reasonable now while I am sitting at the desk with all of the data in front of me but in the heat of the moment it's not so clear sometimes. I guess that's why we are in training and have seasoned clinical anesthesia around to make sure we don't fall in the ditch.