It’s tough for me to believe, but I just crossed over the 1-year mark practicing as a CRNA. Very surreal. The journey was truly worth the effort. Any SRNAs, young CRNAs, or those looking to transition to independent practice, feel free to reach out.

The following are my experiences as a new grad started joining an independent CRNA practice.

Life between graduation and starting work.

Keep it short. I filled the 4-week hiatus with marriage, a honeymoon, and driving a U-Haul 1,400 miles from the Midwest to the Southwest.

Weeks before graduation, we closed on a house that we purchased sight unseen. Would not recommend. I have some blogs on it here.  

So here we are. Ready to work. My objective was to start practicing as soon as credentialling came through, which ended up being 4 weeks. Not bad. I really think if anything, the state board approved my licensure so the Chief and my employer would stop annoying them.

Should I take time off before starting work?

I’m going against the norm by saying I don’t recommend waiting longer than the credentialing period for a few reasons.

First, my cash reserves were low after paying tuition and a down payment on a house. Mrs. TFC covered the wedding and honeymoon. She will be happy I gave her credit for that.

Let me clarify…we didn’t borrow money for any of this. All cash. Don’t spend your loans on a wedding, honeymoon, vacation, or house. Opt for a stay-cation if that’s what you can afford.

If you are living on loans, they are only growing and accumulating interest.

Secondly, I had 4 weeks off, 2 of which felt like work. The honeymoon, split between the East coast and St. Lucia, was ample R&R to reel rejuvenated.

The job

I heard multiple times, “you should not take that job out of school.” Many said to work in a trauma center for a couple years to gain experience. No. It was my plan all along to take an independent position immediately out of school.

I’m a small-town guy. I enjoy the autonomy and scope of practice at CAHs. And frankly, the money is a lot better than at the trauma centers. The compensation comes at a significant price, so to each their own.

I accepted a position at a CAH serving just under 40,000 people in the surrounding communities. Fully staffed, *doubt it*, this is a 4 CRNA shop where we work 3 weeks on, 1 week off. We practice to the top of our scope of practice regularly.

I say independent practice, but due to being short staffed the entire year, it’s more like two solo providers working concurrently.

In a 4-week period, we carry the beeper 7 days, and end with a 9-day break made up of post call days known as our “off week.” 13 callback weeks off annually.

We run 2 of the following rooms at any given time -- 2 operating rooms, 1 obstetrics room, and 1 endoscopy suite. Upon consultation, we roam to the cath lab, emergency department, 6-bed intensive care unit, or anywhere else we are needed.

Cases are typical CAH stuff with the occasional VATS and total pancreas.

The population is surprisingly acute. Minimal primary prevention. Rampant drug use and abuse. And more crashing cesarian sections than I care for. A few CRNAs in the Midwest warned me the patients would be sick, and they were right.

The summary – Lots of autonomy and responsibility, fair bit of call, minimal anesthesia support, very rural and undesirable location, solid compensation.

Independent as a new grad

I started with a 14-week orientation where I carried the beeper 24/7. This was my opportunity to gain as much experience as possible while I had backup CRNA.

The backup CRNA was to be available to answer questions and assist if needed, but really allowed me to practice my way. I was fortunate to have a supportive crew. Providers entering this setting without guidance are set up for failure.

Attitude

This is significant. I was/am excited about anesthesia. Passionate, obsessive, and fanatical – yes.  And I was ready to take on the challenge of independent practice. Hunger for learning is a prerequisite for success.

I willingly accepted a heavy orientation knowing it was one of the elements essential for success. School set me up well, but the more well-performed repetitions the better. There is only so much time to become proficient, so make the most of opportunities.

There are many folks who would not willingly stay within 20 minutes of the middle of nowhere for 14-weeks. Which turned out to be 17 because I transitioned to my 3 weeks on following orientation.

My First Month

It was tough. Like being at a new clinical site where I couldn’t find anything. I compensated by having all emergency drugs tabletop. Emergency airway within reach. Knowing the layout would come with time.

I prioritized patient safety by having emergency supplies within reach and remaining organized. This is always important, but even more so without backup.

The caseload wasn’t anything new. The mentorship guided me to choose an anesthetic that I could perform with two hands and a circulating RN to assist.

Airway for example. Independence lowered my threshold for endotracheal tube placement be that at the start of the case or with a questionable LMA.

Induction needs to be completed independently. I developed my flow from induction to taping the tube. The circulating RN is in the room and attentive but works on their own tasks to expedite the case.

I wouldn’t say there was doubt in my abilities, but certainly a sense of uneasiness. During school, someone is always looking over your shoulder. Or at least sitting in the break room. Not anymore.

At the end of the day, the mindset during the first month was about patient safety while working independently. That’s it. Do the case safely. Perform the block safely. Place the line safely.

Preceptor/Mentor

The orientation was a way for staff to mold my way of thinking to the style of independent anesthesia. The mindset of being on an island. One must be prepared, capable, and conservative.

There is a line between confidence and arrogance that some may fall trap to. During my critical peds rotation, someone said -- I have been doing this for decades and the day you feel comfortable with these sick kiddos is the day you need to walk away. That’s how I feel about my current practice.

Required Skills

We practice to the top of our scope regularly. All skills at any point in time. That means you may start 3 central lines in a week, then not place another one for a month. The caseload may warrant 4 brachial plexus blocks in a day, each at a different site along the plexus.

You have to be ready with all skills at all times, especially on call. During my first month, I had easily accessible resources that provided a quick refresher for something I had not done in a while. I carried the same notebook from clinicals. No shame in utilizing resources.

The skills contributed to the intensity and duration of the orientation. Our facility had a fair number of opportunities and my mentors assured I was available for each and every one. Heavy, but I’m really glad it happened this way.

Regional Anesthesia

Proficient regional anesthesia is an expectation. We perform the basic upper extremity, lower extremity, and truncal blocks for ortho, podiatry, and general surgery. Plus, we block patients not fit for general anesthesia, be that acutely ill or dabbling in recreational substances.

All of this with a dinosaur ultrasound machine. The C-Suite won’t budge on a new one.

It’s a bit anxiety producing knowing you are doing a full ortho case under a supraclavicular nerve block, 1mg of midazolam, and verbal anesthesia. No eyes to verify the spread of local anesthetic other than your own.

I performed a great deal of blocks as an SRNA. But it’s another type of pressure to be independently placing blocks that need to be absolutely spot on.

No general anesthesia to hide your inadequacies. More reason to study up and seek out the reps. Again, there is no shame in referencing books, apps, or videos prior to nerve blocks or any other skills. Prepare in whatever way gives you comfort.

The first Saturday after starting, I convinced my wife, Mrs. TFC, to be an ultrasound test subject. I grabbed a handful of towels and began scanning every nerve block location I would even consider blocking. I scanned the right and left side, head to toe…Twice.

That’s what I needed to feel comfortable with a Jurassic era ultrasound and the required regional techniques. Highly recommend.

Central Lines

Central lines were not common for SRNAs in the Midwest. This was one skill I worried about. Guess what, I studied up and welcomed the opportunity. Little did I know, I would place 1 per week like clockwork.

Sometimes on a trauma. Sometimes in the ICU. With ultrasound proficiency, central lines are typically straight forward.

It is a real confidence builder knowing I can reliably establish my own central access. It’s the vascular cricothyrotomy. Another tool in the belt. The more tools you have, the more dangerous and marketable you become.

Epidurals

The Tuohy needle is a good friend to have, both for OB and ortho. I poked quite a few backs in school – mostly spinals. Epidurals aren’t difficult, but the ever-increasing body habitus doesn’t make them easy to learn.

During the first month, the thought of a wet tap came up way too often. Just stick to the fundamentals and your confidence will grow. I promise the self-doubt will fade.

One year in, I would willingly take a Tuohy needle over a spinal needle. That’s what I used (in combination with a Whitacre needle) on a 170kg patient who needed a lumbar puncture. The good ol’ 22-gauge Quincke just wouldn’t do it.

PICC Lines

Unfortunately, we place PICCs. Basically, ultrasound IVs. Not cool enough to warrant a second paragraph.

Back to my mentors…

The mentor aspect of lines and skills boiled down to prioritization. You don’t have all day to perform skills, so make it happen. Epidurals during the day are placed between cases. If it takes an hour, the team won’t be very happy with you.

They taught me to skip the fluffy prep stuff and get right to the skill. See the kit a couple times and once familiar with the contents, work on speed.

 They said, the tape, stickers, and dressing don’t matter if you can’t get the epidural. So spend your time doing the procedure by immediately prepping, draping, and placing the epidural. All effort goes to the skilled portion.

Same with central lines. Prep. Drape. Scan. Stick. Simple. Should be poking within 2 minutes on a person with normal anatomy.

That mindset helped me a lot with my timing. It means I start epidurals between cases without slowing down the team. I can induce, intubate, and place a central line within the first 10 minutes of being in the operating room.

I hold myself to a high standard. I strive every day to perform skills safely, effectively, and quickly. The trifecta of success.

I’m not tooting my own horn about how good I am. I’m an inexperienced CRNA. There are plenty of folks who perform these skills with far greater proficiency. This is just the mindset I used to transition from SRNA to solo provider.

The weeks averaged out as follows:

·         55-60 hours worked.

·         15 nerve blocks

·         5 epidurals

·         2 spinals

·         2 PICC lines

·         1 central line

Preops

No MDA to complete these now. I worked to develop a preop spiel that corresponded with the paper preop assessment charting. Clunky at first, but I quickly found something that worked for me. Important for perception and acquiring trust.

I was just thinking that no one asks how old I am any longer. I credit that change to a well-managed preoperative visit. I’m in my late 20s for reference.

Ordering preop workups took a bit of time. Especially during chart reviews where I was responsible for every provider’s workup. Ultimately, trust your instincts.

This was a lengthy conversation topic with everyone I worked with. What are your criteria for labs, EKG, ECHO, etc.? How strict should we be with an EKG within the 6- or 12-month recommendation? I searched for reliable resources for their input on the topic.

Ordering scans such as an ECHO is difficult when the CAH does not have an ECHO tech during the day or at all. New things to account for. If a study is unavailable, assume the worst.

Months 2-3

After the first month, I felt I could stand on my own. Not yet one of the cool kids, but proficiency was coming along nicely. Now I needed help unadvertised aspects of anesthesia such as the following:

“Are we placing PICCs after hours?”

“Is it appropriate to place a nerve block on med-surg?”

“What is the best way to handle this OB patient dilated to 9cm requesting an epidural?”

“What about cardiac clearance?”

“How are we handling out-of-department calls?”

As an SRNA, you did as you were told. Now you are the one making the decisions. Some answers are straightforward. Others vary by facility.

It is important the anesthesia group decides a collective answer to commonly asked questions. Nothing worse than hearing, “But Jimmy, CRNA would do it.” Be a united front.

Week 15: Off Orientation

At this point I merged into the call rotation and was credited as being a functional member of the team. Despite being wet behind the ears, I felt pretty confident with anything that came through the door. I was confident during my call shifts. I was confident in my skillset.

Having an emergency action for anything and everything brought me a great deal of peace. Sure, there are always those atypical situations that appear solution-less. But my orientation provided me with enough atypical situations.

I had multiple interventions for any situation. Multiple tools and tactics for each intervention.

Float CRNA

When we had/have three CRNAs, two run rooms and the third floats i.e., run the board, preop patients/add ons, cover OB, and be available for emergencies.

Being the float is interesting, but kind of boring on slower days. It is a different type of anesthesia prioritization. More of a 10,000-foot view.

Months 6-12

During this time, we were running the anesthesia department with just 2 of us. That means both of us took a room. We took call every other night and every other weekend. And the volume started to pick up as new surgeons came aboard.

This was an important stage of my development. There was enough volume to perform all of the skills regularly enough to solidify some degree of proficiency. Enough to reasonably hold my own.

During this period, I continued to research techniques and apply them as appropriate. I am a self-proclaimed opioid-sparing provider. Opioid-free for gynecological cases and high PONV risk patients. Nerve blocks when appropriate.

OR Staff

Be good to the staff. And I mean everyone. In a small facility with limited resources, you never know when you may need a hand. And you don’t have many hands to choose from, so keep your options open.

I mentioned previously that the circulating RN is your best friend in the OR. They are your lifeline to emergent airway supplies. I perform some blocks myself, but it never hurts to have someone else to inject the bupivacaine when your echogenic needle is close to valuable real estate.

Present Day

I have been practicing CRNA for 12 months but have worked 3,000+ hours and carried the beeper 230ish nights for a CAH supporting 40,000 people.

And I was fed most of the nerve blocks and lines during a significant portion of that time. I say this because confidence comes with repetitions. Repetitions come with time.

CAH Life

I understand not everyone is about working as many hours as possible. If you are into entertainment and eateries, rural is not for you. The stress is high. The call is frequent.

If you want a cush 40 hour per week job with 2 overnight shifts per month, nothing wrong with that. Solid lifestyle job that pays the bills and allows time for the kids.

The beauty of being a CRNA is the accessibility to work anywhere in the nation. Sure, the day-to-day may be different, but we can’t have our cake and eat it too.

I had specific job criteria found here. I wanted a job that would train me to be dangerous, so I can provide a complete service. A one-man wolf pack. I wanted a job that paid well, so I can retire early. Mix that with being a small-town guy and a CAH is the perfect option.

Would I recommend it?

If your criteria align with what you just read, I absolutely recommend it. No need to have experience at a trauma center. Those skills don’t translate. The major cases aren’t something we do at a CAH. You need a solo provider mindset, not a care team mindset.

The prerequisite for success is the desire to learn. Hunger for proficiency. That internal flame.

I was the only SRNA to sign at a CRNA-only site out of my graduating class. This appears to be the norm. If you are serious about independent practice, go for it.

Unfortunately, after drinking the elixir of solo practice, I don’t think I can transition to an ACT model. I enjoy the freedom and flexibility to deliver the anesthetic that I feel is best for the patient. Success or failure at my hands and my hands only.

I wouldn’t change a thing. Thanks for reading, especially if you stuck it out for nearly 3,000 words. Best of luck in your practice and don’t hesitate to reach out.