A Student’s Thoughts on Complexities of Nurse Anesthesia Program
David Kubicki, just months away from being a certified nurse anesthetist, laughs quietly to himself when asked to recall the longest procedure he has worked on to date. Turns out, it wasn’t that hard for him to remember because it had only happened the day before. As part of his clinical rotation at Fox Chase Cancer Center, he was scheduled for a standard day with a few operations, and arrived at the hospital for an 8 a.m. lung resection. What should have been a four to five hour procedure, ended up taking over 13 hours to complete.
“When the surgeon found that the cancer in the patient’s lung had spread farther than expected and the pulmonary artery started bleeding, the minimally invasive approach that was originally planned had to be converted to a full open approach. This required additional technology and more complex anesthetic interventions. We had to cancel two other operations to keep going,” he says.
A typical workday for a nurse anesthetist is, in David’s words, “a constant mind game,” and its an involved process making sure the patient receives safe anesthesia. For example, during longer procedures such as a liver resection (which can take upwards of ten hours), a body will lose a lot of fluid—whether through ventilation, blood loss, urine, and even evaporation—and, because the patient would have been fasting, he or she begins with a fluid deficit. Fluid management, a key responsibility of the nurse anesthetist, can be a delicate balance. He explains, “I’ve learned a lot about keeping track of fluid losses and gains. The loss is a calculation based on how long the patient hasn’t had anything to drink, their needs based upon body weight, blood loss, and real time laboratory results. We account for how long the patient has been undergoing surgery and quantify what we call insensible loss, which is evaporation from skin, mouth, lungs, etc. We also track blood pressure, heart rate, variations in ventilation, and urine output to formulate a best estimate of how much blood loss is acceptable for the heart and brain. Nurse anesthetists shoulder immense responsibility for a patient’s general well-being, and each operation presents different circumstances. We need to be prepared for anything and everything.”
For David, complexities like this mean there is never a dull moment, which is partly what drew him to the field. Before coming to Philadelphia in 2015, he spent six years in his home state of Ohio working as a critical care registered nurse in an intensive care unit at the University of Cincinnati Medical Center. More than a few of his nursing colleagues went on to nurse anesthesia school, so his early interest in the field began by proxy. Over time, he saw the way that nurse anesthesia practice builds on elements of ICU nursing such as exceptional bedside manner, competent teamwork, a keen understanding of pathophysiology and pharmacology, skilled patient assessment, recognition of the need for rapid intervention, hands-on technical skills, and, of course, all the other qualities required of a competent nurse. When David decided to take the next step in his own career, Penn’s Nurse Anesthesia Program topped his list. He reflects, “I’ve really come to understand firsthand the advantages of a Penn Nursing education. My training is exceptional. In Philadelphia, we have world-class clinical sites, such as OB rotations at Pennsylvania Hospital, the Level I Trauma Center at Cooper University Hospital, pediatric rotations at distinguished children’s hospitals, specialty cardiovascular and thoracic enhancement experiences…the range of opportunities is beyond impressive. And, the academics are equally fantastic.”
While hugely rewarding, David is the first to admit that, from day one, the program is extremely challenging. “We are always working,” says David. “If we’re not in clinical or class, we’re preparing for our next clinical day. As students, we receive a schedule of surgeries and/or procedures, as well as patient-specific information, for our next day’s assignment. It is up to us to make a plan for the operation, taking into consideration the patient’s comorbidities, potential emergencies, back-up plans, intended drugs and dosages, and a fluid chart that we’ll complete throughout the case. It’s a great way to learn, and helps us to stay flexible in the operating room.” As it happens, staying flexible and being quick witted is key. A nurse anesthetist won’t always have the opportunity to prepare, like when working in a trauma center. “You learn quickly to think on your feet. Things can change rapidly…you may be assigned to surgeries not anticipated, so you need to know how to provide a safe anesthetic for someone you might have only just met five minutes ago. Your mind is always going a thousand miles a minute, thinking about hemodynamics, pain management, infection prevention, intravenous access, and prophylaxis for postoperative nausea and vomiting. It’s one thought after another!”
David and his classmates have also had the opportunity to pursue specific areas of interest; in his case, regional anesthesia. “Now you can do ultrasound guided peripheral nerve blocks, where you use ultrasound technology to block sensation to, for example, an arm or leg, or other body part. You can visualize the needle with an ultrasound transducer to pinpoint an area.” This is becoming an area of expertise for David. Having used ultrasound a fair amount while working in the ICU, and now in school, he developed a lecture on ultrasound for difficult airway management and has presented at two conferences. “Some patients can be very difficult to intubate (the process of safely placing an endotracheal tube.) I’ve used ultrasound techniques advantageously to place the tube safely, and have been able to effectively share my experience with other nurse anesthesia students at Penn as well as with professionals in the field.”
With a May graduation date right around the corner, David’s professional life as a nurse anesthetist is about to take shape. While he and his wife, an ICU nurse herself, plan to return to Ohio, he has no regrets in choosing Penn Nursing and Philadelphia, his home-away-from-home for the past two years. Since his first class on maintaining one’s own mental and physical well-being throughout such a rigorous program, he has felt incredibly supported in both his professional and personal life. “The program is really hard and really intense – I can’t imagine a more rigorous or challenging program anywhere else – but it has been a great experience. If I had to go back and do it again to achieve the same goal, I would do it exactly the same way.” says David. As for his parting words of wisdom: “There is always something to learn, whether it’s about the patient, anesthesia, or yourself.”