Archive for Anesthesia


New Media

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This year is going to be a great year for our new incoming SRNA class here at USC.  We are all so much looking forward to the meet and greet coming up next weekend in Malibu.

What is planned for the coming season is to incorporate New Media and “On the Go” technology into the academic mix. Students today want to find information outside of the class room from their portable devices.  With this in mind I have been looking into a couple of new ways to keep students interested and focused.  A great quote I recently heard is, “Education is not filling a bucket, but lighting a fire.”  William Butler Yeats.

With this in mind, I have opened up a Twitter feed called SRNA Cafe focused on education for the nurse anesthetist student.  I hope that you find it useful.  Check it out and if interested in the content “Follow” on Twitter.

Another kind of cool on line way to create content and review material is to connect to make review cards for yourself.  One of the best methods I have ever found to study is to create flash cards.  The act of making the cards puts the information in another part of the brain.  These connections is what creates memory.  To create recall, frequent review to strengthen the neuronal pathways to that information is what is needed.  For me, making flash cards and reviewing them often works for memorization of data.

We do have a lot of data and information to memorize you know.  The scary thing about medical information is it keeps updating and expanding with time.  In the final analysis there is too much informaiton to know and keep up with.  We have to find ways of on the spot – where we are -access to current thought and research.  Most of this will come later for our students who are just now being introduced to the subjects.  There is much of the basics that do not change much and for now lets focus on that.

Good luck to all of the incoming SRNA’s no matter which program you are in.  Keep focused and above all have fun knowing you are entering one of the greatest adventures of your life.

Categories : Anesthesia
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There is a Fracture

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For those that are involved with orthopedic surgeons you will recognize a familiar theme here.  Some of my best friends are Orthopods and the other day we were all cracking up miming out this little scenario with one of the chief ortho guys.  Working in a teaching level one trauma hospital there is a lot of trauma and orthopedic surgery and the theme that the ortho guys sing is quite loud at times.

The following little clip is really hilarious.  Check it out.


Categories : Anesthesia
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Passed Board Exam!

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Well its official. I passed boards. The notice of board results can be seen at the AANA web site under Certification Verification. After taking that crazy board exam I was perplexed as to how I actually did on the exam so its been a long ten days checking for results each morning at the AANA web site. We are precluded from discussing the exam itself but I can tell you that the board exam from the CCNA is very probing and examines your knowledge and understanding of physiology and the anesthetic implications at very sophisticated levels. My exam shut off at 90 questions. From what I have heard from other people this is either very good or very bad. The board exam is a test that learns from your answers what questions to give you tailoring each test individually selecting questions out of the very large pool. Each test is different if I understand this correctly. This has been a long and difficult road climbing this mountain but the view from the other side is terrific. Just take a look at the view.

Currently Jennifer and I are in Shanghai visiting her parents for the Chinese Moon Festival. Each morning I would get up first thing and turn the computer on and go to the AANA web site looking for the board exam results. I know that sounds nuts but I just could not wait for the mail and the end of our trip overseas to find out the results of the board exam.

So what can I now recommend as study preparation for the board exams you ask. First I would not put off any review for the board exam but to study daily the entire time while doing clinical rotations. A through review of medical physiology is a must. My choice is the LANGE publication by Ganong, “Review of Medical Physiology” as a must read. This is not a large text but dense and will require several months of careful reading and rereading to gather the appropriate understanding of the specific anatomy and physiology that is required knowledge to do well on the nurse anesthesia board exam. Maybe I could give you a general example of how specific the board exam is.

One of the favorite subjects on the board exam has been the endocrine system and the interactions with anesthesia. The pituitary glad as you may recall is located in the Sella Tursica, a cave like bony structure and is histologically divided into three sections. In humans the intermediate lobe section is underdeveloped and rudimentary. The posterior pitutiary or neurohypophysis is the site of excretion of ADH (vasopressin) and oxytocin which are structurally similar. It is interesting to note that oxytocin has antidiuretic qualities because of the structural similarity of these two hormones. I digress. The point I am getting to is that the source of the posterior pituitary hormones in from higher structures in the hypothalamus, specifically the supraoptic and paraventricular nuclei. Nerve axons project from these structures and descend out of the “Blood brain barrier” down to the posterior pituitary where they are released when physiologically stimulated. A full review of this and all of the physiology surrounding these structures and the actions of all of the hormones along with the anesthesia implications is highly suggested. Ganong’s Review of Medical Physiology and the Anesthesia and Co-existing Disease book by Stoelting are both highly recommended.

Brother, that was a mouth full. So which part of this do you need to know to pass boards? I am afraid that this is just a small example of the detail between structure and function that is requried. Its been overwhelming and the more that I study the more I realize that I know very little.

Good luck to all that are preparing for the board exam and don’t forget the small details. I guess it would be correct to say that knowledge at a superficial level will leave you really perplexed when you take boards while knowing the fine details will help you navigate your way through the questions. Again good luck.

Categories : Anesthesia
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The Beach Bunny

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Going to the beach is always fun. Having nothing to do these past weeks but study, I felt a little trip to the beach to get away from distractions was in order. I could set up a little folding chair in some out of the way place, bring my books and have a pleasant afternoon concentrating on the fundamentals of safe anesthesia care. My camera in hand, just because, and the fall weather in Southern California perfect, wandering down to the shore I spotted this homeless person. It could be a homeless person I thought due to all of the torn and shredded clothing but on closer exam I noticed the Gucci handbag. Maybe you will notice other things here as well that might tip you off that this is not a typical Santa Monica homeless person. Me, I just enjoyed the weather and my studies.

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CCNA Board Exam Prep

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“OH NO MR. BILL the CCNA exam is coming in a few days and even after years of study and preparation I do not feel ready”, the little voice whispers in the back of my head. What to do about those voices.

Just as all others that have come before and for those that follow there no way around this mountain except to climb each day a little further. I have kept a picture of K2 on my wall for many years and I keep whispering to myself that one day I will be over the crest. That day is so soon approaching that it is almost too much to comprehend.
Here is a plan for CCRN board exam preparation that I have used:

Attend a Review Course. I did the Valley Anesthesia Review, there are others?
Select a few concise books for reference.

  • Morgan and Mikhail Clinical Anesthesiology
  • Barash Handbook
  • Sota Omoigui’s Drug Handbook.
  • Valley Review Course material. The Sweat Book, the Memory Master and the Mixed Reviews.
  • Anesthesiology Review by Ronald Faust

I have read through the Sweat Book twice and the Memory Master a couple of times and The Mixed Reviews from Valley anesthesia I keep with me all the time. I read through these frequently.

The Faust Anesthesiology Review is a great one to look stuff up quickly for refresher. These past three weeks since graduation I have spent 6 to 10 hours a day reading and reviewing questions and looking stuff up quickly that I needed clarification on. I feel that I am ready for the exams but still have so much to learn. I just found out about another on-line review that could be helpful. It is called Prodigy Anesthesia. This is an on-line review and workbook type thing. I checked it out and it seems very good. Highly recommended for someone that has more than a couple of days before the scheduled exam. Thanks to everyone for the well wishes. Our class will get together for a big party once these exams are over so every one will know about our success.

Categories : Anesthesia
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Bob Naruse – Faculty of the Year Award

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The University of Southern California program of nurse anesthetist awarded Bob Naruse, M.D. the faculty award this year. Dr. Naruse is staff anesthesiologist at Cedars Sinai Hospital where many of us do our neuro rotations. It is here that I met Dr. Bob and became acquainted with the low opioid techniques for craniotomy surgery that are routinely used there. Today several of our classmates were able to present the award to him in person. Unfortunately I was not able to attend but sent my best wishes and called him on the phone as a follow up.

Our lives have been enriched by his mentorship and example of excellence in patient centered anesthesia care. Thank you Dr. Bob Naruse and we will all make you proud. What follows is a letter I received from him after today’s presentation.

Dear ‘SC Class of 2006,I must admit that I am truly touched by your award. Working with such a distinguished group of anesthetists made my job easy and fun. I can’t remember a class that I’ve enjoyed more than yours. I know that each of you will be outstanding anesthetists for years to come and I want to congratulate each of you for the great achievement of completing graduate school. I am proud of you.

Please pass along your knowlege, especially that which is not in the textbooks. I know that eventually your colleagues will be impressed with your airway management skills as am I. You each are better than at least 90% of all anesthesia providers(MD’s or CRNA’s) including my partners. We owe it to our patients.

Take care and best wishes in the future. Fight On!!!

Yours truly,
Bob Naruse
Da cedarsgasman

So there you have it. This week many of us are studying for CCNA board exams. My test date is the 20th of this month. Pressure, a little, confidence, a lot. I will let you all know how our class does.

Categories : Anesthesia
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Graduation Plans

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Dear All,

Your graduation is approaching rapidly. If you have not done so already, get together as a class soon and get some ideas going for a graduation celebration. Each of you will need to pitch in and assign yourself to a committee.

If you need to do a fundraiser, I highly recommend the USC Anesthesia sweatshirt, t-shirt, and hat sales from last year’s class. Thanks to the 2005 grads, you have a nest egg to start up a project such as this. Besides, there a number of people asking for these items, both local and international!!!

Let me know what you think.


May you always do for others and let others do for you.

Bob Dylan

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Correspondence can bring many things. Recently there has been a lot of mail, much of it from friends and family with discussions of life, projects and goals. I even had a request for money recently from a needy soul that could not be turned down. What I wanted to share today was a series of communications from this last week that has occupied my mind for several days. Maybe after reading these you too will pause and consider what a gift we have been given to serve and learn from our patients. Their contribution to us is tremendous and must never be forgotten. This is a sacred trust that I am appreciating with a new understanding. Thank you Jim for that. It starts with a letter from Jo. I find her vignette interesting and instructive but what comes later is beyond instructive. Let’s see what you think.

Hey David, here is a funny story,

As student nurse anesthetists we are fortunate to have some common sense especially since we have some critical care background and have actually touched patients. Anesthesia physician residents often do not have this luxury. They get thrown into an operating room because they have graduated form medical school and are expected to perform. While SRNAs are guided on how do things should be done in the operating room for a long time.

Recently I heard a story about a M.D. resident that was interesting. The surgical case involved a patient scheduled for a total knee replacement with an epidural catheter and an Laryngeal Mask Airway (LMA). A Nurse Anesthetist enters the OR to send the physician on a break. The patient is breathing 38 breaths per minute and chewing on the endotracheal tube. The physician states, “Oh that’s new this must have just started”. Propofol is then slammed intravenously and B/P drops precipitously and then the low blood pressure is then chased with ephedrine trying to bring the blood pressure back up.

There is a lesson to be learned here. You can’t blame the physician resident because many times when they are new in their training they do not have sufficient oversight. The patient obviously needed something other than slamming propofol – possibly a dose of narcotic and not hypnosis. The epidural was infusing but did the patient get a loading dose up front? These things may all effect how the patient was tolerating the surgery. What I have seen clinically is that when epidurals catheters are working well you need far less opioids and less volatile agent as the MAC is lowered. These patients usually wake up very comfortable.

The morale of the story is to feel good about the education that we receive as nurse anesthetists and feel proud to be apart of this prestigious profession of Nurse Anesthesia. Remember that 65% of all rural anesthesia is given by Certified Registered Nurse Anesthetists (CRNA’s). Some day you might be taking care of me or my loved one and I want the best and most competent anesthetist on the job.


At first I glanced over this note from Jo and scribble a few notes to myself while reviewing the many interactions that I have had with residents. Jo is a dear friend of mine – however I find that her reasoning incomplete. At least there is more here that is bothering me that I can not mine fully. She states correctly that patients with epidural catheters require lower MAC and less opioids then proceeds to disparage the hypnotic and suggest that the patient needs additional opioids? I began thinking that the idea of giving more opioid for a light patient is the wrong choice and her criticism of the resident could take a different slant. For me the propofol is not a wrong option but the lack of vigilance by the resident deserves comment. So ran my thoughts. To confirm my suspicions I ran off a note to a friend, we’ll call him ‘John’, a long time anesthetist back East. I was dealing with the trees and not the forest. My thoughts continued at that time this way:


…I was not there in the OR and all of this is second hand information but an interesting discussion about CRNA SRNA and Resident relations mainly. We all have our prejudices I guess. For me the physicians do just fine and receive extensive training. At times in the beginning of their training there may be things that happen that are not the best practice. Who is to say that Student Nurse Anesthetists do better really? Personally I do not find it profitable to compare providers but to look for a best practice regardless of the practitioner. John, I thought you might get a kick out of this story and look forward to your comments on the scenario. Hope all is well with you and that your scheduled surgery goes well. I am wishing you all the best from Los Angeles.


The response I received back has been lingering in my mind for the past few days. When I started the web site my goal was to try to put together something with content that would be both instructive and entertaining while showing what it is like to be a nurse anesthetist student. John goes beyond my expectations.

Hi, David

I have many thoughts tumbling through my head at this stage of my career. As to the story your friend related, I find your take on it to be the more reasoned. Yes, the average SRNA is probably much more oriented to the care of the patient, by virtue of the nursing background. This stereotypical SRNA is also more clinically astute because s/he’s been on the front lines, watching actual patients get better or get worse and die, so s/he has earned to look at everything, make no assumptions, and always to keep that “sixth sense” activated whenever s/he is responsible for a patient. Those hard-earned lessons from the ICU on a 12-hour night shift do stand the SRNA in good stead.

And it’s probably true that the average MD trainee at whatever stage of her/his training is probably less experienced and clinically seasoned; more educated in basic sciences than the average RN (notice I said “more” educated which doesn’t necessarily equate to “better” educated). But a friend of mine long ago put it this way: “Good nurses know a lot about medicine while good doctors know a lot about nursing”. When I look back to the people who had the most influence on my developing anesthesia career (and it’s STILL developing) I find nurses who took it upon themselves to be very educated (and very WELL educated) and physicians who had that common sense and humanitarianism that is stereotypically viewed as the hallmark of nursing. What each had in common was a curiosity that motivated their learning, a humility that taught them that their learning would never end, and an empathy for the suffering patient who was at once her/his sacred responsibility and greatest teacher. The other thing they had in common was my enduring respect; you see, I’ve seen callous CRNAs and empathetic and truly altruistic physicians. We must be careful not to be guilty of that error which we decry in others: judging an individual by the letters behind the name and not the character attached to the person.

As to your friend’s assessment of what was needed, we all know that anesthesia is a complex specialty. From first principles, the patient should never have been allowed to come to such a state, under the care of an anesthesia provider, that the patient was chewing the tube and breathing 38 breaths per minute. The rescue of the patient from that unacceptable state can take many forms, some better than others. The bolus of propofol was a “fast” answer. Fast is important, but one must be careful not to overshoot lest one have to engage in the “dueling drugs” scenario as your friend described chasing blood pressures all over the place. You made another astute observation: “I wasn’t there…” This is a very mature approach to analyzing anecdotes about cases; you know that not everything that happens can be reduced to marks on an anesthesia record, and that even the most careful observer is biased to some extent.

I have a feeling that neither you nor your friend would have gotten yourself into the situation of needing to rescue the patient from inadequate anesthesia. In a couple of jobs I’ve had in the past, we’ve had trainees rotating through the anesthesia department. Now, I’m always careful about generalizations, and the following observation is given with the very large caveat that generalizations are poor tools to explain things. That said, I noticed that there were in general two “styles” exhibited by anesthesia trainees. One style was more “high tech” and the other more “high touch”.

One manifestation of this was the manner in which the trainee monitored the patient. Some stood with their backs to the patient and watched a bank of monitors. These tended to miss things that a more experienced onlooker would see evolving before they manifested themselves on the monitors. These were the “high tech” ones. Many were very intelligent — far more so than I — and usually more educated as well. As a generalization, these were doctors. Others gave their primary attention to the patient, and looked to monitors as a secondary information source, to validate their clinical impression of the evolving anesthetic. Most of their time was spent seated or standing in close proximity to the patient, their backs to the monitors. Sure, this has elements of a false dichotomy, but by and large, these latter were nurses. They didn’t treat numbers, they treated patients. And they usually “picked up” things before the “things” became “problems”.

Sometimes the “high touch” crowd couldn’t even characterize what it was that was about to go wrong. Usually the “high tech” ones could recite the “book learning” about what had just gone wrong. If you haven’t found this out already, in anesthesia it is frequently the case that we are too smart too late. You’ll also know the daily reality of something I once read: Most great discoveries are presaged not by the exclamation “Eureka!” but by “Gee. That’s strange….”

The only good thing that came out of Jo’s experience is that you are talking and thinking about it and learning from it. The occurrence of inadequate anesthesia in this patient — the failure of our specialty, the patient’s trust betrayed — became, if you will, a “chance experiment” in the laboratory that is your learning. No Institutional Review Board would ever have approved of the situation into which this patient had been allowed to deteriorate, even for the pragmatic good of your learning. But it happened. Remember, “stercus contingit”. You have been handed a learning opportunity, purchased at a very high price by your patient. Learn from it, get all you can out of it. And, as you progress in your career and teach others, remember the debt you owe to that patient, in whose care an error was made, allowing you to learn from the remediation — and yes, even the “cover up” — of the error.

Here is where I have a huge problem with many physicians with whom I’ve worked. There’s an attitude of entitlement. “I earned this degree. I got out of training with six figures of student debt. I am owed”. No. Wrong, wrong, wrong. They are who they are, they know what they know, and they have what they have, because of an unending string of patients who held still for their first clumsy attempts at the laying on of hands, who suffered at their mistakes as they repeated lab tests and painful procedures, who died at their imperfect hands — at all of our imperfect hands. David, I submit to you that this is a debt that can NEVER be repaid; the currency to satisfy such a debt has never been minted, nor could it be.

I recently had a physician make some comments to me in passing. I think he meant to encourage me; I’m not sure. He commented on my skill at regional anesthesia, especially in the massively obese parturient with whom we’d just dealt successfully. I described how I’d evolved in my skill to a peak several years ago, and how I’ve had to refine my skills as my senses and strengths change. I used to palpate everything, and my sense of touch was my paramount one. As I age, my tactile sensation has diminished, and I rely more on vision. And even that is failing as I approach my seventh decade of life. But I continue and I do my job well and carefully. He expressed surprise when I told him how old I am — that surprises everyone because I’m blessed with a youthful appearance. Then he told me that he doesn’t intend to work past the age of sixty, not at all while I intend to work until it would no longer be safe for my patients for me to continue to do so. I’ll know when that is, and a carefully selected group of people with whom I work will validate that judgment. Only then will I pursue a lesser career, and I will leave with reluctance and with regret for that huge unpaid debt, with gratitude for every patient who has taught me what I know. For now, CRNA doesn’t describe so much what I do as who I am.

PS: My surgery has been put off until the 22 of this month. Several things have to be in place for it to take place, one of which is some sort of fibrin glue to be used in the repair. I am blessed to have tissue that doesn’t act its age, and a “sports medicine” orthopedist who normally limits his practice to athletic injuries in genuine athletes. He’s agreed to apply his skills for an old man who fell on the ice, whose “athletic” prowess is confined to paddling canoes and kayaks to photogenic places, or slogging along on a mountain bike or cross-country skis to places that aren’t crowded, and whose major competition is against entropy — and gravity. His method includes aggressive rehabilitation. It will return me to my “playing field” sooner, and ease the overwork my absence will impose on my partner and our already thinly-stretched locums. That’s important to me.

Thanks for your kind good wishes. I’ll keep you posted. In the meantime, work is busy, and that’s great therapy.

Categories : Anesthesia
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Road Trip

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David in the ORToday I am happy to submit for your appreciation a true story. In some tales you hear the line the facts are true only the names have been changed. That applies to the “Road Trip” which was written as a sort of autobiographical recount from a long time CRNA (Certified Registered Nurse Anesthetist). I hope that you enjoy this example of what it is like to be an anesthesia provider behind the scenes doing the every day work of an anesthetist. In reality this is something about being a rural CRNA keeping your finger in the dike, working hard to keep your skills up for when it really hits the fan; something about being “on deck” for half of your life knowing that in fact for 65% of rural hospitals, CRNAs do this “Road Trip” night after night. Enjoy. For those that wish more information about CRNA clinical practice I refer you to the professional organization at the national level – the AANA.

Road Trip

“Damn, damn DAMN!” He thought. Two seconds ago, he’d been rushing across the hospital parking lot, thinking about all the things that could go wrong during an emergency anesthetic for a 400 pound patient, and all the things he’d have to do to make sure that none of those things would go wrong. Ten minutes ago, he’d been writing some last-minute Christmas emails and thinking about yet another New Year resolution to send cards next year.

As the initial shock and anger began to wear off, the hard reality of the slick, cold, gritty black ice of the parking lot began to make itself felt. His right arm hurt like a son-of-a-bitch, and when he tried to flex it, it wobbled uneasily, but bent very nearly as it should. “Nothing broken”, he thought as he picked himself up gingerly off the pavement and fumbled for his ID tag to let himself into the back door.

The reality of winter in the northland hit him, and he reflected that you could take the boy out of California, but you couldn’t take California out of the boy, and that, as long as he had lived in the North Weeds, he still had to remind himself that the footing could be treacherous. Then the reality of the life of a rural CRNA came back to the fore, and his mind tore itself away from the pain, and back to planning for the care of his patient

“Murphy”, he thought, “was an optimist”. What had started as a simple in-and-out look through a scope at the lining of his sedated patient’s stomach had turned into a desperate emergency. The high-resolution screen of the video system hooked up to the modern gastroscope had told the tale for the entire crew to see – a crimson geyser sprayed from a tiny hole in the lining of the man’s stomach. Under the magnification of the fiberoptic system of the scope, it looked horrible. “We have to open”, said the surgeon. Just like that.

“No plan survives initial contact with the enemy”, he remembered from somewhere in his past. That spout of blood was trying to kill this man, and the entire crew stopped and looked at him there at the head of the table, and he suddenly felt very alone. Quickly, he ran a mental checklist for a “rapid sequence IV induction”, a procedure that would quickly and safely exchange the patient’s fuzzy panic for calm sleep, and exchange the poor man’s labored breathing for the efficient mechanical swishing of a modern anesthesia ventilator pumping life-giving oxygen into the man’s lungs along with general anesthesia – the mysterious miracle that has been called “death with a return ticket”.

Years of practice and training informed his quick and efficient movements. Everything was laid out exactly where he knew it would be because everything was ALWAYS laid out where he knew it would be. Years of working alone in operating rooms where everything that could go wrong frequently did go wrong had prepared him to prepare. Even in preparation for the most seemingly trivial procedure, everything that might be needed was there. He knew that, sooner or later, everything that might be needed would be needed. Decades ago, he’d learned that, while there might be “minor surgery”, there was no “minor anesthesia”. In a series of steps that would have occupied several pages of some systems analyst’s flowcharts, but which took only precious seconds, his patient was asleep, a tube safely and surely in his windpipe, his blood pressure and pulse stabilized. With a terse nod to the surgeon and the man’s family doctor who’d been urgently summoned to help, he said “Go”. The incision was a small white rent in the yellow of the iodine-stained skin for a split second, and then drops of blood became a thick red line as the doctors went to work. He scanned all his monitors again, satisfied that his patient was responding as he should. Only then did he reach for the phone.

His partner of several years was home, and he breathed a sigh of relief as she answered the phone. A second pair of educated hands would be a life-saver – perhaps literally tonight. “Damn — I’m a one-armed bandit”, he thought to himself silently as he grunted with the effort of hanging another bag of IV fluid with his arm that did what it was told, but reluctantly and painfully. He could have finished this case alone, but he didn’t have to prove that to anyone, least of all to himself.

Within minutes the other CRNA had come. No questions asked no protestations that it was her night off – because it had often been the other way around and she knew it would be again. With a brief exchange of questions and answers that a visitor might have mistaken for a foreign language, he brought his partner “up to speed”. The doctors, heads nearly bumping over the deep incision into the man’s massive abdomen, murmured in a language all their own and the technician and nurse half-listened, preparing and handing instruments in a frenzy of movements that spoke of years of having done this. A hundred collective years of training and experience came together over the man’s blue-draped body, homing with a grim intensity on that “bleeder”, conspiring to cheat Death yet again.

The two CRNAs worked together in the small area between the head of the bed, the cart full of drugs and equipment, and the anesthesia machine. In a space barely big enough to turn around, they divided the tasks and worked together with a silence broken only by an occasional syllable or two; they both knew what had to be done. Within minutes, another large IV needle was in a vein in the man’s arm, and a slim needle had been run up an artery in the man’s wrist to monitor his blood pressure. With each task completed, their pace became less frantic but no less intense.

Finally, the doctors looked up. “Got it”, said the surgeon, and for the first time, he took a deep breath. “We’re closing him up, and you guys wake him up and we’ll transfer him”. The CRNAs looked at each other, and each knew what the other was thinking. This desperately ill man would “wake up”, all right, but it would be tomorrow, miles away, in an Intensive Care Unit, of which this tiny rural hospital had none. They also knew that the same freezing drizzle that had turned the skating lot into a parking rink would have kept the helicopters parked safely in some hangar somewhere, and that it would be a long and careful trip in the back of an ambulance.

One general anesthetic, with everything, to go.

The ride was long and bumpy. Each breath for the patient came from a plastic football-shaped bag, squeezed by his beat-up sore arm. He thought it would never end, but like everything else in his career, it did.

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A Letter From a Friend

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Gina and David at ArrowheadToday I received such a sweet note from Gina my friend from USC that I had to post it. We have been in the nurse anesthesia program now for about a year and a half together and in the last couple of months have not seen much of each other. All of the students are scattered about doing specialty clinical rotations currently and only get together for Journal club once a month.

At one point last year Gina and I were together at Arrowhead Regional Medical center and we became quite close.

Here is her note:


Got your message today and sorry I missed your call. I’m just now trying to get my Medatrax caught up for the week. Wondering how you’re doing these days. It is strange not seeing one another every week, but that is progress, isn’t it? We’re very close to the finish line, or so it seems. How are things going in OB? Any problems getting your numbers? Dr. Gold seems to think that is a concern there. I was looking over the schedule to see where you are and it appears as though you have a nice few months ahead of you. Of course that last month at LAC is going to kill you. You know what I say; better you than me!!

Children’s is worlds better than I had imagined. It is clean and efficient, much like Arrowhead, which you will like. The attendings are for the most part, into teaching. The morning conferences and Grand Rounds are a nice review. The hours are not as long as I thought. The anesthesia is simple and it is not a rotation I would recommend trying to get too fancy with. Of course my objectives for the rotation are very simple; 1) don’t kill anyone and; 2) get to the point where I am reasonably comfortable when a baby or child shows up in my OR. And to that end, I think I’m getting there. It’s good and important experience. Of course the bad side is that you are dealing with kids who have really horrible diseases, who endure pain daily, who are scared when you take them away from mommy, and who wake up crying. The parents are weary and desperate. My heart is broken daily. I hug my son a bit tighter these days when I get home.

Tell me how you are doing and where your thoughts are these days. Any thoughts about where to work when all this craziness is done?

I look forward to seeing you Monday, my dear friend. Be well.


So there you have it! Gina would probably laugh out loud if she knew that I posted her letter she is such a stickler for details. One thing is abundantly clear – she is a great soul. I did reply to her mail and include it here for historical purposes.


Thank you for the great update. You are a great soul and appreciated very much. Your wisdom comes through everything you say. Its like the old saying about the trees and the forest except that no matter what you do I see the forest of wisdom in who you are. Maybe I am just an old philosophical fool but it makes sense to me anyway.

For the latest on me you can always check out my revised web site the “Average Man” at the new URL

You may get a kick out of this site actually. Many have asked me why I chose the moniker of the Average Man. When I try to answer the question the topic of the “Ordinary” man always comes up when I am thinking of “Exceptional” man – used in the universal sense. When they are thinking of “Ordinary” I am thinking of the potential that is in every one of us just waiting to be exposed. Most people don’t get it but those that do are the ones I speak to. As an example, I did a search in Google for an “Average Man” and came up with a site for Gandhi in which I found this:

Mahatma Gandhi was an average man – at least, that is how he regarded himself. He laid no claim to be either a saint or a mahatma. He declared with humility:

“I claim to be no more than an average man with less than average ability. Nor can I claim any special merit for such non-violence or continence as I have been able to reach with laborious research. I have not the shadow of a doubt that any man or woman can achieve what I have, if he or she would make the same effort and cultivate the same hope and faith. Work without faith is like an attempt to reach the bottom of a bottomless pit.”

These words were not the expression of a pretentious modesty. They reflected Gandhi’s fundamental conviction that each one of us can achieve that which he had achieved – and more. For Gandhi, life was a permanent experiment with truth. He walked his talk – and where his walk did not coincide with his talk, he changed either his walk or his talk.

“I claim to be a simple individual liable to err like any other fellow mortal. I own, however, that I have humility enough in me to confess my errors and to retrace my steps. I own that I have an immovable faith in God and His goodness and unconsumable passion for truth and love. But, is that not what every person has latent in him?”

So Gina dear friend maybe you will be able to understand what it is to be an Average Man and know who I am. Most likely due to the fact that you certainly have touched the center of your own latent potential. Certainly I claim no greatness just the average goodness that is in us all.

Your friend David.

Categories : Anesthesia
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