My First Year

I was one of the lucky few to spend an aggregate of 6 month of training at a hospital prior starting my employment there. I graduated in August 2014, took boards two weeks after graduating and spent 3 months relaxing before beginning work in December 2014.

Take A Break First

A word of advice to those who are close to graduation. Unless you have other priorities that need to be addressed immediately upon graduation (say, raising a family), I would say my biggest piece of advice to every new grad is to take some time off. Who cares about the money? I get it. You’re up to your ears with student loan debt or maybe you don’t have debt but are just cash poor. This is the advice I give to every graduating SRNA who comes my way.

So as long as you have your health, you’re going to have a long and ultimately prosperous career. Wealth is accumulated and it takes time to build those cash reserves. You’ve already spent 2 years living off of a budget or living off of loans. What’s another 2-3 months of time taken for yourself?

If you have a great credit score, get a credit card that has a 0% balance transfer fee and get a trip in before you start work because let me tell you, the days you being able to take 3-4 weeks, let alone 2-3 months, are OVER! This isn’t bedside nursing anymore where it’s a lot easier to call in sick and you don’t feel guilty. Trust me when I say I have to be on my death bed before I call in sick as a CRNA. It’s not as easy calling in sick as it was before (and I’m not advocating that one should do that as an RN especially if you don’t have to). I’m just saying you’re more hesitant to do so because you’re much more accountable to your peers now as a CRNA than you were as an RN.

That said, TAKE A BREAK! Go on a trip. Do a stay cation. Either way, don’t rush back to work because the work will be there. Trust me, it will be there…waiting for you…

What did I do? My girlfriend (now wife) and I took a month-long trip to Thailand. I put $6,000 on a Chase credit card that had a 15-month 0% balance transfer and ultimately paid it off in 3-4 months time when I began work as a CRNA. I didn’t pay a single penny in interest. So…think about it…there’s no rush to start work because it’s going to be harder now as a CRNA to get time off like you did as an RN.

Starting My First Year As A New Grad CRNA

Because I was lucky enough to have spent 6 months training at this hospital system, my transition from being an SRNA to CRNA was rather seamless. Mind you, as an employee at this hospital system, part of my responsibilities involves rotating to SIX different clinical sites where I provide anesthesia to a huge spectrum of patients in wide array of different clinical settings (off-sites, surgery center, main OR, L&D, etc.). It was and still is a great experience because I’m surrounded by individuals (CRNAs, attendings, and residents alike) who are all interested in pushing the field of anesthesia forward.

That’s the great thing about working in an academic setting. It’s being around individuals who are interested in ideas and exploring new ways of practicing. Sure, there are a few bad apples (CRNAs, attendings, and residents alike) who seem to make your life miserable (for whatever reason), but what work place doesn’t deal with those issues? On the whole, it’s been a boon to my intellectual pursuit in anesthesia by working in this environment.

What I can say about my first year was that there were a lot of ebbs and flows with how I perceived myself as a provider. What I mean by that is there were moments when I really doubted my clinical judgment especially when it conflicted with my attending’s judgment. I would have moments where I would be in a “rut” so to speak. I would have a difficult time placing arterial lines, placing epidurals or intubating. There were moments when I felt like I was the biggest hotshot…placing arterial lines, epidurals, and intubating.

The point is, I went through a series of ups and downs. After 18 months of practicing, what I learned is this: you’ll always go through a series of ups and downs as a provider, but what’s important is knowing how to manage the times when you’re feeling “down” as a provider. I’ve seen and talked to preponderance of anesthesia providers about their experience (both old and new) and they’ve all said the same thing. You’re going to go through phases as a provider. There will be times when you feel like you’re a more than competent provider and there will be times when you will find yourself questioning your clinical judgment. That’s okay.

The important thing to remember is to be proactive about your growth during the times you find yourself struggling. For me, since I’m lucky enough to work at an academic institution, it’s nice to be able to turn to my colleagues as well as the anesthesiologists for advice on how to improve my practice. Furthermore, I don’t make it a habit to blame myself if I’m unable to…say…place an arterial line. This job/career is an experiential one. You just have to keep at it and seek out opportunities to improve whatever challenges you may have.

And that brings me to another prescient point, which is FIND A MENTOR. Find someone that you trust and who can provide you with objective, but supportive feedback. The transition from SRNA to CRNA can be an abrupt one especially if you work in a setting where you’re required to act more independently than what you’re used to. Being able to find someone who you can turn to for help and feedback is especially important not only through your first year, but throughout the length of your career, because it provides you with a soundboard to brainstorm ideas with and to learn how to think through developing an appropriate anesthetic plan for your patient. Trust me, when you first start, you’ll be recalling Jaffe in order to provide your anesthesia, but over time, you’ll learn how to be more comfortable with coming up with plan on the fly and being flexible enough to change that plan as needed according to the patient’s needs as well as the surgeon’s.

Lastly, JOURNAL! I’ve kept detailed written accounts of cases that were difficult and problematic for me. I’ve sought out anesthesiologists and CRNAs to help me brainstorm how I could have performed better and I’ve kept a journal of my experiences. Nothing beats this strategy because you’re taking a systematic approach to learning and retaining information. Our two years of education only prepared us to deal with the basics of anesthesia. Your real learning starts now as a CRNA and you will undoubtedly come across a wide variety of clinical situations you’ve never faced before in your first year. And that’s okay! That’s a good thing because you’re learning! Make use of that opportunity by detailing your experiences and writing about how you would’ve changed your anesthetic plan.

So, remember, during your first year as a full-fledged CRNA:

  1. You’ll experience a lot of ups and downs. That’s okay. This is normal. Be easy on yourself and be open to new experiences. Your learning begins now.
  2. Find a mentor! Find someone you can trust and turn to when you need help and constructive feedback.
  3. Journal your experiences. One of the most effective ways to reinforce your learning and one of the few posts in this blog that I will not hyperlink a study to support this notion because it’s self-evident. C’mon now.

Private Practice

Perhaps I was in over my head, but at about the 6 month mark as a new grad CRNA, I decided to venture into private practice and boy, was that an education unto itself. The experience reminded me of doing off-site anesthesia in that the personnel are different, you’re alone, and your access to resources is rather restricted. Worst of all, you’re by yourself. Oftentimes, you’re the ONLY anesthesia provider in the building! Basically, you have to exercise a heightened sense of vigilance when in private practice.

No one has your back. You have no one to turn to and there’s an overwhelming sense of pressure to move cases along. This is why experienced CRNAs advise individuals ought to have several years of experience under their belt before venturing into the wild west of anesthesia.

Apollo Drager, this ain’t. A blast from the past this machine is.

The biggest challenge is learning how to say no. You are going to be put in a position where you may come across an ASA 3 and you’re wondering whether or not you should be proceeding with a procedure. I don’t have any straightforward advice to give, but you have to be able to take into consideration what kind of case you’re doing, the surgeon you’re working with, and your access to resources at the facility.

To give a real world example, I often come across many patients with OSA and HTN at these outpatient surgery centers. My limit for refusing a case is anything beyond an EGD/colonoscopy for these kinds of patients. Basically, anything that requires me to perform a general anesthetic on ASA 3s is my limit. I refuse to do them even at the risk of not being invited back to the surgery center. That’s okay though. It’s important to remember that it’s not worth the risk to your patient or you to do something that can potentially have devastating results. The reason why I’ll do EGDs/colonoscopies on ASA 3s in these centers is largely due to the fact that the gastroenterologist basically churns and burns through these cases. A typical procedure usually lasts anywhere between 5-10 minutes. I’m okay with that kind of risk because I know what I can get away with so as long as I’m judicious with my anesthetic.

However, if an ASA 3 patient is scheduled for a shoulder arthroplasty and is expected to be in beach chair position, I won’t do it. Not worth the risk. First off, the patient already has some severe systemic disease. Second, this patient is supposed to be in beach chair? Sorry. It’s just not worth it to me.

Some of these sites that I’ve worked at don’t even have a glidescope, which is scary! To be fair, the ones that don’t have a glidescope often carry an intubating LMA, but still, you get the idea. Your access to resources is severely restricted. It’s not the same as working within a hospital setting, whether academic or community. As such, you have to be able to be flexible with your anesthetic plan and make do with what’s made available to you. But, as I’ve already discussed previously, you also have to know when you need to be firm in your resolve to not go through with a case.

Overall, I find private practice to be a rewarding experience because it’s so different from academic medicine. I’m left to my own devices which is both a good and bad thing. It’s a double edged sword. While you get to practice independently, you also have to realize that you alone are responsible for whatever consequences that might arise and it can be an unsettling feeling especially when you’re taking care of ASA 3s in an outpatient center. That said, would I recommend private practice for the new grad? Probably not. However, I think it’s a matter of what you feel comfortable with and some people don’t care to do private practice. And that’s okay! I pursued it because I think it’s a great way for me to improve my clinical skills (from technical as well as judgment). Certainly, I’ve been involved in a few close calls, but that’s the nature of our profession. Whether you’re in a hospital or an outpatient surgery center, you’re going to run into scenarios where you need to know how to get your patients out of a dicey situation. If you think you have something to gain from private practice and feel confident that you’re able to practice independently, then more power to you. Try it out, but understand the risks with venturing out on your own.

Final Points To Consider If You Decide To Moonlight In Private Practice:

  1. Know when to say no.
  2. But also know when you can straddle the line and proceed with a case.
  3. Bring your own emergency drugs and airway equipment because you never know when you might need it!
  4. Maintain a heightened sense of vigilance!