Tubed the Goose

Today I had airway in the OR...I missed an intubation for the first time. But I don't really consider it a bad thing. I had to miss sometime, and this patient was very difficult. I tried a different laryngoscope blade, because I've used the same one for my first 5 intubations and I wanted to try the other one. This patient had an excellent airway exam but once he was induced he turned out to have a very poor (Grade III) view, in other words, no cords to be seen anywhere. I tried anyway, tried to direct the tube where the trachea should be, but "tubed the goose" instead (intubated his esophagus, or 'goose'). The CRNA I was with tubed the goose after me, and the MDA ended up having difficulty too and used an Eschman stylet to intubate the patient. So I didn't feel bad for not getting this tube, AND I got to see what a Grade III view looks like, for the first time. The Dr. got on my case for trying a new blade so early, but we've been encouraged to try both blades the whole time by John, our airway instructor, and the CRNA also said I did fine and there's no problem trying a new blade, especially on someone who had a good airway exam preop. So I really felt okay about the whole thing. The patient was easy to ventilate between intubation attempts, so there shouldn't have been any pressure, and I really wanted to try again with the Mac blade, but the doc was feeling the pressure of the room, which was a case done by a surgeon who has a history of anger management problems, so the whole room is always tense for his cases. So she just intubated the patient, and that was that. Still, a good learning experience, and I got my first "miss" out of the way so I don't have to worry about that coming. I think when I do IVs on Tuesday I might stay for an airway when I'm done...we'll see.

Just got back from a swim a few hours ago. I got in 40 laps in 30 minutes. It was very tiring. But I felt pretty good. I kind of felt like running instead, actually, but I wanted to stick to my plan of running every other day. Twice a week weights...I'll do them once this weekend.

We got a long weekend, early! We're supposed to have class tomorrow, but one thing happened and then another, and all our classes ended up being cancelled. So I'm taking the train to Portland tonight, yay! It will be nice to be out of Spokane for a few days. I have major studying to do for our A&P exam on Monday, but otherwise I'm in good shape I think.

Milestones

Well, I had a lovely couple of days' visit with hubby. We visited the Buddhist temple on Sunday, and were able to spend quite a bit of time together for a few days. Yesterday we went down to the Rocket Bakery (a Spokane favorite) and had lunch together, and then I was able to study for a few hours while he worked. It was really nice. He headed back early this morning, and I'm hoping to be able to come out to Portland this weekend. I have an exam on Monday morning, but if I'm able to get my cards made early and get organized so I can study effectively in Portland, I might be able to do it. I'd like to hang out in Portland for a little bit, and go to the Portland Running Co. to get new shoes, and go to Saburos. We'll see how studying this week goes.

I had the big airway exam today. It's sort of a milestone in the program; you have to pass it with 90% or better, and it's long. John gives us 4 hours to take it, although I finished in 2. I always finish exams quickly, usually first. It's not intentional, I just don't write as much as others, and I think quickly. I don't get the best grades in class, but they are high enough to keep me strong in the program, and I don't really see any reason to change what I'm doing, so I don't. Anyway, the exam wasn't terribly hard if you studied, which I did. He told us what would be on the exam, in general terms, and it's all stuff we have to know, period. It was fair, but long, because it's mostly short essay answers. It's nice to have it behind us. I'm reasonably certain I got better than 90%, but of course you never know until you get the exam back. I had enough time left over to go home for lunch, and relax for a couple of hours before pharm at 3. Our class only lasted about an hour, and then I went to the gym.

After the rather poor last run with the shin splints, I decided to take a couple of days off from the gym altogether, so I didn't go Sunday or Monday. I looked on the Couch to 5K schedule and figured out about where I've been training at, and decided to follow it from that point on. I decided I was at about week 6 out of 9, so I did the first week 6 run today, and it went great. No shin splints, yay! It was a total of 21 minutes, broken into 5-8-5-3 minute chunks. I felt good and was able to hit a good stride (a slow one, mind you) and felt good during it. I did my full set of weights, and got done around 6. It was very chaotic in the locker room, so I came home to shower. The morning clouds have finally given way to a lovely sunny evening, so I'm going to throw some laundry in and go enjoy the day a little before the sun goes down.

The weight I gained back is VERY slowly coming back off, so I guess the plateau isn't officially over. I must need a fill. I have been letting more (sugary) snacks sneak back into my diet than usual, too. I'm shaking things up with my exercise, doing some cross training and such, and I have a fill scheduled on Thursday, so hopefully I can get things back on track here. The no-coffee thing is going okay. I have had an occasional cup when I can't stay awake in 3 or 4 hour lectures, but otherwise I've abstained. Even if the coffee itself doesn't affect the weight loss, certainly the sweetened creamer I use can't be good for it, and I like a bit more than I should really use. So it can only be a good thing to cut out the coffee. Thanks for the tip, Lori.

Wow: A fantastic resource

Anyone who is a newbie runner like me will appreciate this great resource, from the old Cool Running message board (it's been changed and apparently it's not as great anymore). This is packed full of valuable info for those who are totally new at this, like me, and maybe for some who have been running a while but don't know all the vocabulary or details. It's the Cool Running Newbie Wiki:

http://coolrunningnewbie.pbwiki.com/

Awesome info there. Enjoy.

Hmmm...maybe not

I tried the 2 minutes run/1 minute walk method endorsed by Jeff Galloway tonight. I ended up feeling sluggish, never getting a good cadence, and developing what seems to be anterior shin splints. I thought I had been doing pretty well in avoiding the beginner overuse injuries, but guess not. It could be something else, of course. I don't think it's a stress fracture, because there isn't a particular spot that really hurts, which is usually the case, according to my reading. My left is worse than my right, and it throbs, an hour after my run ended. I need to ice, and take some ibuprofen. And I need to hold off on running for a couple of days, which won't be a problem. I was planning to swim tomorrow anyway. I might not, and take tomorrow off and swim on Monday instead. We'll see how it feels.

What do I think happened? For one, the short bursts of running (shorter than I'm used to by now) meant I never got into a groove, and I could feel my toes hitting the surface sooner than usual. I think my calves didn't get warmed up adequately, which may or may not have anything to do with the Galloway training method. (Which I might be doing wrong, anyway; I ordered his book and will check it out before I blame his method.) I also think it's time for new shoes, which I was planning to get fitted for next weekend in Portland. Looking at my feet, my arches seem a little flatter than they used to a few years ago, now that I look at them. I was told I had high arches several years ago, but they don't look so high now. I have no idea what kind of motion my foot makes when I run--supinate? pronate? Who knows? I can't really watch my feet when I run. So the gait eval and fitting will be a good thing.

My plan, then, is to take a couple of days off from running and make sure that the pain goes away. Mayo Clinic recommends a number of things, including adding toe lifts and lower body weights, which I have been doing since January, so I'm not concerned about that. I'm already planning on more cross training, so that's good. I'm backing off a little on the distance. I'm getting properly fitted for running shoes. And tonight, ice and advil. Not that they hurt badly, they really just ache. But I want it to get better.

I didn't get to that yoga class...but I did make a cute bag for my yoga mat, so that counts for something. The scale inexplicably jumped a couple of pounds today--I don't freak out about a sudden jump that doesn't make logical sense, I just try to adjust my eating and watch over the next few days to see if it gets back to where it was. So I'm eating a bit less, trying to be a bit careful (although I had a cookie and some dark chocolate today...so maybe not THAT careful, hehe) and see if tomorrow is closer to what the past 5 days or so have been.

Now I go resume making A&P my beyatch.

Something new...makes me shiver with antici.....pation!

I hit the 0900 yoga class this morning. It was interesting. Even though I have done yoga before (ashtanga, vinyasa, "gentle") I've never done Iyengar, which is what Harmony Yoga does. This was also a new place for me, of course. On my way to the studio I thought about how many times I've been in the position of being new and awkward at something since mid-January of this year, when my new career as a grad student started. You'd think I'd be used to it by now. At least I am getting used to telling myself that the anticipation is worse than the actual experience and everything will be fine. So, I went. The teacher, Brit, a lady in her late 40s or early 50s, I'd guess, was fantastic--involved in everybody's practice, made sure she was checking in with those of us who were new to her class, and demonstrated every sequence before coaching us through it. Iyengar yoga is known for its extensive use of props--all the blocks, belts, bolsters and blankets that you may have seen in yoga studios but never or rarely used, they use them all. Prepping for class was sort of a mystery to me. In addition to 2 or 3 folded blankets, 2 blocks, a belt, and for some a bolster pillow, most people had a folding chair next to their mats at the beginning of class, which totally puzzled me. I grabbed all the other things, but not the chair. Just when I was trying to figure out if it was "optional" or "mandatory" for this class, someone came over and brought me a chair. Guess it's not optional. I've never really used props in a yoga class before--sort of the ego thing, "I don't need those things" kind of attitude I suppose. This yoga doesn't go for that kind of ego thing. Props are used to get the ideal alignment, and I went with it, and although it was perhaps a little more rigid than I've experienced with ashtanga style yoga before, I liked it. The one thing I missed was inverted poses, but this was a Level 1 class I attended. Tomorrow is an open house at the studio, and there's a late morning Level 1-2 class that I'd like to try out.

The rest of the day, I didn't accomplish quite as much as I had planned. I went to a coffee shop and studied for a little while. Then I went to a local fabric shop to get fabric for a new bag for my yoga mat. I actually saw the wife of one of the junior students there--it took us a while to realize where we "knew" each other from, but we figured it out. Then I went out to a movie (Forgetting Sarah Marshall, cute) and dinner with my girls from school. Tomorrow, I make A&P my bitch, as my classmate Connie would say. Sunday is more studying for the big airway exam on Tuesday.

I did check out some of Jeff Galloway's tips for beginner runners on Runner's World and on his website. Lots of great info for the newbie runner on there! I think I will buy his book (Galloway's Book on Running, I think, considered the "runner's bible") and check out his methods. In brief, he is a big fan of frequent walk breaks during a run, and insists that even top marathoners can train on 3 runs a week, including 1 long weekly run. His method would have me walking MUCH more than I am currently. I thought I was going easy, but his method would have me backing off a lot. He says his method prevents overuse injuries, and he's been running for 50 years now, including being an Olympic runner. He says he hasn't had an overuse injury in almost 30 years. So, based on all the reviews of his books and all the blogs that point his way, I'll give his method a try. Meanwhile, this gets me back to 3 days a week of running. What to do on the other days? Is swimming okay? Yoga certainly should be. 2 days a week of weights and running, 1 additional running day, 1 yoga day and a day of swimming? That would be 5 days. That sounds more balanced than what I've been doing, and hopefully would prevent me overtraining. Training for what? I don't know yet. Perhaps nothing, but perhaps...?

False Start

I got up at 0445 this morning to start IVs in SAU (surgical admit unit) which we students have been doing about every 2 weeks...got to the hospital, changed into scrubs, in the SAU by 0545, only to find that the surgery schedule is very light today and as a result, there were no IVs for us to start. All the SAU nurses were standing around looking for something to do--they are usually very busy early in the morning, getting ready for the first cases of the day, of which there are usually lots. So Cari and I stayed until about 0605 and then were dismissed. No IVs today. I'm glad I didn't put in my contacts this morning; I might take a nap.

Or I might go to a 0900 yoga class. I'm not sure yet. Yoga would be a good workout for today, after a day of swim and a day of running and weights. I'm trying to take it a bit easier on myself. Today I lost another pound, putting me at 176 for the first time since--hmm, I don't even know. At this point, every pound I lose puts me in uncharted territory. The last time I was in this neighborhood was somewhere between 18 and 19, when I was trying to ignore my weight because it was starting to get out of control. These days I realize that my skeleton carries a significant portion of my weight, and 176 on me looks more like 156 would on most. I'm lucky this way, I know. This is my reason for not shooting for a BMI of less than 25--I can't lose weight in my bones, so why make my lean body mass pay for it? Just seems logical to me.

This weekend is another long study weekend. I don't know yet if hubby will be coming back to Spokane this weekend. I'd like to think yes. But see we shall, hmmm? (doing my best Yoda impersonation)

Zoomin'!

Tonight I changed my workout a bit, and decided to swim instead of run. I've always enjoyed swimming, and technically I've always been a strong swimmer, but for most of my adult life I haven't been cardiovascularly fit enough to swim for long enough to call it a workout. So I started looking into swim fins. I always thought that swimming with fins would make me a wuss. But it turns out that the shorter, firmer fins they sell for lap swimming are designed to improve your workout and train for sprinting (among other things). So I got some Zoomers Z2 fins.

According to the literature that comes with the fins, these things were designed to load more of the workout onto the legs--when swimming, the arms are the most efficient source of propulsion but have only a small percentage of the body's muscle mass, while the legs are about 60% of the body's muscle mass but contribute very little to propulsion. The solution (according to the developer) is the short, firm swim fin: they improve the efficiency of the leg kick but because they are short, they do not overload the leg muscles. This should allow for use of a higher percentage of body mass in the workout, a higher level of intensity, and a longer workout. Working the legs a little more and the arms a little less allows the swimmer to be more deliberate about upper body form, have more time to breathe and get enough oxygen to sustain the exertion, and decrease shoulder strain (due to swimming in a higher position in the water, because of the additional propulsion)

My first run with the Z2 fins seemed to support these claims. I was able to swim 30 laps in 30 minutes, including all the pauses I had to take to catch my breath and let my heart rate recover. (Those are 25 yard laps, so I swam 750 yards; not bad for the first time swimming in about 6 months.) My legs are going to be SORE, I can already tell. Getting more propulsion and moving more efficiently through the water makes the workout more enjoyable, and I was definitely working out in the Zone--in fact I had to swim slower to keep my heart rate low enough to sustain it. I think these are a good investment for anyone who has similar problems that I had with swimming--simply unable to sustain a long enough workout, and feeling sluggish and slow in the water. My legs definitely did more of the work--I usually feel like I am sort of dragging my lower body along the pool, despite putting a lot of concentration and effort into my kick.

My weight loss plateau ended; I lost 2 lbs after the 12 days of no change. 3 changes were made just prior to the end of the plateau:

1. My husband came to Spokane, after about 2 weeks apart.
2. I stopped drinking coffee
3. I stopped working out.

I have no way of knowing if any or all, or none, of these things were related to ending the plateau. But I suppose all of them probably had something to do with it. I definitely was happier, more relaxed and less stressed with hubby here. The coffee thing, I still can't really find any actual literature addressing coffee and weight loss (caffeine has an appetite suppresant effect, but I don't know why coffee could make one retain or gain weight, although I could make some guesses, including the sustained high blood sugar finding.) Working out? I had been working out 5-6 days a week for a long time. Over the last 2 months, that has included increasing amounts of running. So perhaps I have been overtraining? It's been suggested to me before, but I've never seen it reflected in a plateau. (Let me say for the record that I know 12 days isn't really much of a plateau. But that was 12 days of the exact same weight, down to the 0.1 lb. The plateau lasted much longer than that, a bit over a month of being the same weight or higher, up and down in a 3 lb range.) With this in mind, I plan on (A) varying my workout more, and (B) reducing the frequency a bit. 2 days a week of weights, and 3-4 days a week of cardio. At least one of those days has to be something other than running on the treadmill. I also need to start bike commuting, but that means I have to get access to the bike lockup at the hospital, and so far I haven't been able to do that. Anyway, we'll see how this all goes.

Today we had an airway day in the OR. I was in ECT (electroconvulsive therapy) today. Yes, it is still done today. No, it is not barbaric. For one thing, the patients are anesthetized for the electrical impulse and subsequent seizure that is induced. That's why I was there, to learn how to do this, and manage the patients' airways while they were being treated. The patients do not feel the treatment, and have no memory of it. For another thing, it is very helpful for people who either can't tolerate antidepressant drugs or for whom they don't work. It's also voluntary; patients are only mandated to get ECT in extremely rare situations, when the patient is so debilitated that their life is in danger and they cannot consent to it themselves. They have patients who have been coming for years to get periodic ECT treatment, and they have gone from being institutionalized and completely debilitated by their depression to being productive, even happy members of society. It's unclear how the seizures help treat depression, but it has been known to work for a long time, and for some people it's the only thing that works. Google electroconvulsive therapy, you'll find some interesting information out there. There's a lot of misinformation that was spread by popular culture, particularly by the movie One Flew Over the Cuckoo's Nest.

So, anyway, the ECTs we did today were voluntary, of course, and it was quite interesting and not barbaric at all. We anesthetize the patients and then bag-mask ventilate them for the entire treatment (i.e. no breathing tube is inserted) which is about 10 minutes of masking, including the 1 minute for the actual treatment. It's not easy on the hands, but it's great experience for new people like me. When we were done, I still had a bit of time, so I was given a case to intubate (a gallbladder removal, or lap chole) and intubated my 5th patient. This one wasn't as easy or clear as most of them have been, but luckily I was able to get it without too much trouble. It was a long day--in the OR from 0630 to 1100, then in class until 1630. Then I went to study for a few hours, then home for a little bit, off to the gym, and now here I am blogging. All in a day's work.

All streaks must come to an end

The streak is over. I dropped 1.2 lbs, finally. Maybe it was the coffee? Going without it this weekend wasn't bad. I'm on my way to a 4 hour A&P lecture, so I might break down and get some during a break. But so far I'm doing okay.

Not much to add this morning. We tried to go to the Buddhist temple yesterday morning and check out their service, but it was the day of their semi-annual Food Bazaar, so we bought some treats instead, and went to the Perry Street Cafe for breakfast, which was underwhelming. Hopefully we'll both be here next weekend to attend the service.

Eat like a 3 year old

Day 11, same weight. Wonder how long this can go? Even 0.1 lb change--EITHER DIRECTION!--would be reassuring. But, I will roll with it.

Today's rule is: Eat like a 3 year old. Hungry? Eat. Get full? Stop. Not hungry, food's there? Push it away.

Also, I'm going to cut out coffee this weekend. Some bariatric docs swear that you have to stop drinking coffee to lose weight. Elsewhere I've heard that the caffeine is an appetite suppressant, as long as you don't load up your coffee with too many calories. But I'm on a plateau, and I have to change something. On Monday I suspect I won't be able to get through 4 hours of A&P lecture without some coffee, but this weekend I can do it.

I didn't get to yoga this morning--it was 2am by the time I got to sleep, and my 8am alarm was NOT happening. Turned that bad boy off and slept until 10. I love having no classes on Fridays. I know this will end soon, and I am enjoying it for now. Today I have a lot of studying to do, of course (don't I always?) so I am getting to it shortly. That Friday 9am yoga class probably will never happen--who am I kidding?--I sleep in on Fridays. I'll have to find another one. Yes, the life of a childless anesthesia student. It does have its perks. I know most of my classmates, who have children, got up early today and are already studying, rather than enjoying a slow wakeup with breakfast and the Interwebz.

More later, I think.

Sushi and books...

My weight has been exactly the same for 10 days now, down to the 0.1 lb. WTF? No change at all. Actually I didn't even weigh yesterday. I knew it would be the same. But I weighed all other 9 mornings, same time, same Bat channel. Today I didn't work out because I did yesterday, it kicked my ass, and the day before I ended the evening with a round of about 10-12 Sun Salutations at home. I haven't done any yoga for about 3 months, and all those Plank poses killed my arms. Clearly I need to do more of those. I plan on taking my first Iyengar class tomorrow morning at Harmony Yoga, at 0900, if I get to bed soon enough. That will have to be pretty soon....

I have a long weekend of studying ahead of me. We are on the autonomic nervous system in Pharm, and I don't get it...and it's a BIG important part of anesthesia, actually it's about 90% of what we do when you come down to it, so I need to really understand this stuff. I don't think it's going to be impossible if I just hunker down and pick it apart until I really understand it. Physio, we are doing a bunch of stuff that I need to understand better. I have a big 4 hour airway exam coming in less than 2 weeks. Today we asked the juniors about it, and they said to start studying now. So there's that. And my final project for Adult Ed, which is not anesthesia related and is kind of fun, but will need some attention nonetheless. We are supposed to do some in-depth learning on a subject that we don't know much about (and isn't anesthesia related) so I am studying sushi. Although I love to eat sushi, I didn't know much about it. So there is a lot to do for my power point, and my paper, both of which are due on Tuesday morning.

I did get my pharm exam back that I took on Monday. I was nervous because I left the test feeling really great about it, and the rest of the class thought they bombed it, which totally made me second-guess my instincts about it. I had no idea if I was on target with my personal assessment and really wanted to know. Well, I ROCKED the exam, got 52 out of 50-- I missed 2, but got 4 extra credit points, and I think I got the best grade in my class. :) So that was very exciting and uplifting! Especially since I did most of my studying on Saturday and just decided not to go over it anymore on Sunday, because I felt like I knew it. And I did. I'm very happy about that.

Today I bought some things for my sushi presentation: some nori, some sushi rice, pickled ginger, etc. And then it occured to me that I ought to try making some sushi, since I'm buying all this stuff anyway and I'm supposed to be learning about sushi. So I did...I prepared the rice, I got some sushi grade tuna at the market, and followed the steps and made a maki tuna (maguro, I guess) roll. Let me tell you, I already had a lot of respect for the itamae (sushi chef) but I have much more now. I made an extremely simple roll and it was not pretty when it was done. It tasted pretty good--I would be disappointed if I bought it at a sushi bar (by flavor alone, even if it looked pretty--it just wasn't that interesting) but it was definitely edible. The tuna was tasty (I don't know if I'll trust Spokane again as a source for sushi grade fish, but this experience will let me know) and my sushi rice wasn't bad. I should have taken pictures. Maybe tomorrow...I have quite a bit left.

Back to studying...but first, I am very excited that my hubby is coming to Spokane tomorrow night! Multiple issues have prevented him from making the trip over the last 2 weeks, and it's been very hard for both of us, but I'm thrilled that he will be here very soon. I can't wait. Hurry hurry! :)
p.s. Snow predicted tomorrow. Was 65 degrees today. WTF?

Making the Connection

Just now, I wandered into the kitchen, looking for a snack. I looked in the fridge--all healthy food. I looked in the freezer, not really paying attention to what I was looking for. I thought of looking in the pantry, and then had the thought, "There's nothing good to eat here." Then I realized it: I'm not hungry! I told myself, "Your goal is to get hungry! How can you get hungry if you eat before you get hungry?"

I had bariatric surgery over a year ago. I've lost nearly 60 lbs. Why am I still having to figure this out?

I'm glad I'm getting a fill. This, plus working on my mental game, should help the thoughts of food when I'm not really hungry. Here's what else is going on: I had IVs this morning at 0545, which didn't go as well as I wanted. I only got 4 out of 5 of my IV attempts, and all but one required more than one try. I hate that. I had 2 long classes, and have been thinking about the presentation that I have to do next Tuesday, that I haven't started working on yet. And in pharmacology we started a new section of content, on the autonomic nervous system, which is extensive and complex and painful to listen to. And all of my classmates thought yesterday's pharm exam was our hardest one yet, which makes me doubt how I felt about it (which was pretty good). So I guess you could say my emotional state is slightly anxious, a bit unsettled, a bit stressed. I'm also hormonal, which never helps, and bloated. And lonely. It's a good thing there's "nothing good to eat" here! Sometimes we help ourselves more than we realize. Listen up, WLS wanna-be's: keeping the junk out of the house can help you stick to your goals! It does work for me, anyway.

Over and out.

hungry like the wolf

Pharm test today went well--I think I did fine. That is a relief. I have IVs in the morning, so I'll be getting up at 5am to be in SAU in scrubs by 0545. That means I can't work out too late tonight...gotta get to bed at a reasonable hour.

I made an appointment for a fill in 2 weeks. It's with the PA, a guy named Brian. I really could care less if I see the surgeon or the PA for a fill. My experiences with PAs have been entirely positive so far, and a fill isn't exactly brain surgery. (I guess I should be knocking wood, after saying all of that.) It isn't so much my hunger (which is there, at about 3 hours after I eat), it's more the constant thought of food and rummaging for food that makes me think I need another fill.

I spent most of my adult life trying to avoid feeling hungry. I'm trying to have a new relationship with hunger, not see it as such a bad thing. Dr Judith Beck (The Beck Diet Solution, a cognitive behavioral therapy approach to weight loss) advocates doing a hunger experiment: Try to go a day without eating. I did it for most of a day, and found that after that intensely unpleasant hunger feeling goes away, so does the actual hunger. It comes and goes, but it's not as bad as that initial feeling of strong hunger that you get about 20 minutes after the little beginning hunger feelings start. So, here's a new way of thinking: What if I make my goal TO GET HUNGRY? I can eat, when I am hungry. The point here is to avoid eating when I'm not hungry, so telling myself that the goal is to get hungry seems like a sort of no-brainer solution. Another no-duh thing I've found recently about hunger is when I go to work out a little bit hungry, that hunger goes away fairly soon after I start my cardio routine. The blood leaves the stomach and goes to the legs and lungs and heart. So getting some real exercise when a little bit hungry seems like a pretty good idea--as long as I have eaten a meal that day (and I rarely exercise in the morning, and NEVER before I eat), it won't hurt me at all, and will probably reduce my calories.

Last night, I did my full workout including 22 minutes of running, followed up by 4. Yes! It felt good to get back in the groove. I did all of my weights, and got pissed enough about the leg press situation that I finally spoke to management. See, there are lots of 20ish young guys who like to leave their 100s of lbs on the leg press. Sometimes they are doing a different set and plan on coming back to the leg press. Other times I think they just think it's macho and cool to let everyone see their 400 lbs sitting on the leg press. I get SO pissed. They are 100 lb weights, and I'm sure I'm going to herniate a disc or drop one on my toe when I have to unrack them. (The biggest weights I put on are 45 lbs--I use 2 of them and 2 of the 25 lb weights.) When I know who left it on there, I ask them to rack them for me--I play up the chick thing, because they should be SHAMED into racking the weights, dammit. Who is so lame that they don't rack their own weights? So I talked to the management about putting up signs. They told me no one has ever complained about it before (is that possible?) and the upper management folks are anti-sign, but they'll ask about it. It actually sounded a little more hopeful than that. The manager was an older woman, and she agreed with me that we shouldn't be expected to rack someone else's 100 lb weights. There are little old ladies that use the weights for rehab and such and they certainly can't take those things off. So I am hopeful that there will at least be a sign up. But there is nothing there to tell people what they should already know is a common courtesy--you rack your weights. You don't get to commandeer the leg press for the 30 minutes it takes you to do your circuit the way you like it. There is one leg press, and you need to be a man and take your damn weights off. We'll see if anything comes of it.

So, I think I'll go make some dinner, finish proofing my paper, mail the tax returns (ahem), and then go run at the hospital around 6:30. Then home and to bed by 9.

Nothing but weight loss today...

I'm going to try for a strictly WLS post now. The past several posts have been all about anesthesia school, and while this is an all-consuming part of my life now (as WLS was around this time last year), there is still this weight-loss thing trying to go on. So here goes...

My weight has been exactly the same for a week, down to the 0.1 lb. I'm not sure if I need a fill or I just need to be more careful about my eating. Certainly tonight was not a careful night...went out for sushi with some classmates, which was great fun, but I ate a bit more than I should have, and had a drink, then we went for another drink elsewhere...While this isn't the end of the world, I rarely drink (don't need the calories) so I always question myself when I do, especially when I'm trying to make the scale move. But we needed the study break, and I am so tired of weekends being about nothing but studying for the next exam. So I do wonder what the scale will reveal tomorrow.

Today was an even nicer spring day than yesterday, with a high around 70 and lovely sunshine. So nice! I got on my bike for the first time in probably 6 months and blithely assumed that I could zip up the South Hill since I can now run for 20 minutes! Ha! The bike uses different muscles and a different kind of energy. I'm glad I wore my heart rate monitor, I was able to see how hard I was pushing myself to get up the hills. Wow. If the hills had lasted another 15 minutes I could have used it all as a substitute for my run (which I did not get to today...). Hm. Anyway, went up to Manito Park and studied in the sunshine for a while. It was really nice.

I think next week I will call for a fill appointment. I don't like to rely on the band so much for portion control, but it's been a little out of control lately and I think a fill will probably help. My hunger is sort of coming back, more than I used to have. I'm also going to have to look at the little things that I've let sneak into my meals. Coffee for one thing...I'm getting a little heavy-handed with the creamer, and that has to stop. I actually tried drinking it black today, but I'm not quite that hardcore yet. I'm fine with my weightloss slowing down now, with 18 lbs to go and grad school in full swing. But I'd rather it didn't stop altogether. I need to get back to the regular groove of working out (spring break got me a little out of whack, even though I did work out most days of my break) which helps everything else. Tomorrow: I go to McDonaldland and do the full workout. Maybe a bike ride too, if it's nice again. I'd also like to take some pictures in the Japanese Garden to post here, if it's as nice tomorrow as it was today. Of course, I also have lots of studying, and laundry, and cleaning. Not everything will get done. But the workout must!

Education

I've been trying to be a good student today, working on my pharm exam which is on Monday. At some point I was looking up student nurse anesthetist blogs (perhaps wondering why I was doing this on such a beautiful day?) and found some interesting complaining going on from MDs. Nurses and MDs are always going to be at odds for something, if not at an individual level than certainly at the group professional level. MDs as a group seem to be constantly amazed that a "mere RN" can do as much as we can with "almost no college education." They talk a lot about how we only need 2 years of college to be a nurse--which of course isn't true even if one does get an associate degree instead of a BSN, because of the prerequisites required to get into the 2 year program. But about half of us have bachelor's degrees. Anyway. For the physicians, everything begins and ends at how much college education one has. Without as many years of college education as a physician has (which can be argued, is only about 50% useful to them--their bachelor's degree was probably in a science and geared towards med school acceptance, but it is not medical education) one obviously can't be allowed to do work that is "important" or be compensated anywhere near what an MD is compensated.

So this blog discusses the "problem" of CRNAs being paid more than family practice physicians are paid. Its author, California Medicine Man, points to another blog by a guy called KevinMD that outlines the outrageousness of this problem:

CRNAs (Certified Registered Nurse Anesthetists) make almost as much, if not more, than primary care physicians - with 2 years of college education. This post from a forum wonders how:

• CRNAs make 224% as much as RNs and 156% as much as advance practice nurses (NP). According to the allnurses.com website, 58% of nurses are certificate nurses only, ie. have no advanced degree beyond a RN. It is not clear whether all these nurses were trained in 2 year certificate programs or whether some may have been trained in 18 month programs . . . Most of these CRNAs with a diploma RN and a certificate CRNA are still in practice and therefore have only 2 years of college education, period.

Some are even wondering if FPs can go back a re-train as CRNAs:

• 
  I wonder what would happen if a FP tried to apply to CRNA school. Certainly the degree they have qualifies them over a mere RN degree. Then they would go to work as a CRNA. From there it's hard not to see them lobbying to have full anesthesiologist status.

CMM points out that in fact, CRNAs don't have just 2 years of college education. CRNA certification requires education for 2-3 years at a masters level, which requires a bachelor's degree (which, by the way, is actually a health care science degree, not a general science degree like MDs). But the point of practicing as an Advanced Practice Nurse is that our experience in nursing is valued in lieu of additional college training. And, since when is the amount of time put in a university a direct correlate to amount of compensation that can be expected? In a lot of MD's minds, years of college=dollars earned. CMM goes on to explain that this isn't about education but the law of supply and demand. Isn't that terrible, that family practice doctors aren't as valued as CRNAs, so they get paid less, when they are educated for 4 years longer than a CRNA? (This is playing a bit fast and loose with the numbers. He quotes 7 years of college education for the CRNA vs. 11 years for the FP doc. The last 3 years are residency for family practice medicine. They are paid while completing this residency. And we already discussed the first 4 years.)

That last bit by KevinMD (actually just quoted by him, I think it's actually from a student physician message board) is why CRNAs and MDs will never truly get along. How simple, a FP doc just bypasses anesthesiology residency by applying to CRNA school, because "Certainly the degree they have qualifies them over a mere RN degree." And then "it's not hard to see them lobbying to have full anesthesiologist status." First, no CRNA program (except maybe the ones owned and run by MDAs, but I doubt even them) would accept a family practice doctor into their program. The programs require being an RN, having a BSN or its equivalent, and having nursing experience, almost always at least 2 years in critical care. Being a FP doc doesn't meet any of those requirements, much less exceed them. CRNAs have a strong lobby and professional consciousness, and they would never allow an MD into their program so he (not she) could leapfrog into practice as a MDA. A FP doc does not have the bedside critical care experience necessary to start as a student nurse anesthetist, and would be behind the 8 ball from the beginning. He might have the intellectual knowledge, but not the experience. How many PA catheters does a FP doc place, and interpret? How many times has he managed a septic patient? Oh yeah, none. And then there is the issue of the ASA (the American Society of Anesthesiologists). They would NEVER allow anyone, not any kind of MD, to become a board certified anesthesiologist without completing a 4 year anesthesiology residency. Period. The ASA argues that CRNA education is inferior to anesthesiology residency, anyway, so no grandfathering would ever occur with their blessing, because that would be admitting that CRNAs and MDAs are essentially interchangable. The ASA vigorously opposes that position.

I don't mention all of this because I think it's a reasonable possibility that it could happen (although I'll bet someone has tried). I just use it to illustrate the amount of hubris that many in the medical community have with regards to nursing. Physicians are highly educated, and many of them are extremely knowledgable and outstanding clinicians. Not all are; they have a spectrum of ability and intelligence just like any other profession, and it's not as oriented towards the top 5% as most people think. But they make the mistake of valuing formal education, its amount and where it came from, over actual knowledge, intelligence and expertise. This dismissive attitude towards nursing specialties, and nursing in general, is evident nearly everywhere. This kind of thing gives nurses a big chip on their shoulder. Would you like working with this sort of thing hanging over you all the time? It's a wonder that nurses play as nicely as they do. The professional CRNAs that I have seen navigate this minefield with a remarkable amount of grace.

And, for the record, CRNAs are paid more than FP doctors because they are more in demand and they are sued way more often than FP doctors. They carry much higher malpractice insurance. And the burden of responsibility is higher. FP docs do have a lot of responsibility, and I don't diminish their expertise or importance one bit. But they would not trade the level of responsibility or the insurance premiums if offered.

Thus endeth the sermon.

Eye of the Tiger?

I got to the gym very late today--nearly 9, and they close at 10. So I had to do an abbreviated workout. I only spent 30 minutes on the treadmill, but I ran for 20 minutes straight, which is a new record for me! So I didn't worry too much about missing my last 6 or so minutes of running that I would have done in another leg. I didn't have time to do all of my weights either, but I did most of them. I was not quite as sluggish as yesterday, but not great either. I think my overall energy is just down, period.

But you know, running for 20 minutes was a struggle, and not just physically. Running is a constant mental game, at least for me. I'm constantly making deals with myself. I know that if I want to go for 15 minutes, say, I have to mentally break it into smaller blocks, and give myself permission to bail out before I get the whole thing done, knowing that I will talk myself into doing the whole thing, and usually 1 minute more, anyway. I don't go into a "zone" when I run. What do people think about when they run? How do you do a marathon? Don't you get bored? I have times when I notice that I feel really good while I'm running, but it is still a mental challenge for me. My brain needs something to distract itself. Sometimes listening to podcasts instead of music works, but if it doesn't have my total attention I have to go to one of my workout playlists instead. But either way, I'm watching my time, watching the clock, watching my heart rate, constantly watching something. I'm not in any kind of zone.

I'd love to hear what other people think about when they run, or what their brain DOES while all that is going on.

Meanwhile, my weight has been stable for 4 days--no change at all. Which is fine, I guess. It's better than gaining. (Hah, that reminds me of Bull Durham...when Nuke LaLoosh comes onto the bus and tells Crash, "Man, I looove winning...it's, like, better than losing.") My pants, though, are getting baggy. Here's another thing that I never noticed happening when I was heavier: I spend so much time "between" sizes now. What's up with that? The size 8 jeans are getting baggy, so I bought size 6. Cool, huh? But they are clearly too small still...they go on, but are skin tight. I know jeans (ones with stretch, which seems to be most jeans now...certainly the ones I buy!) loosen up about 1/2 a size after wearing, but it's still a big discrepancy between the size I'm wearing now, and the next size down. When I was big, I guess clothes didn't really fit as exactly. Stuff was always either loose or tight, and that's how life was. Now I want my clothes to FIT. But it's not just that. I could lose or gain 10 lbs and the size 16 jeans would still fit (or size 18, depending where I was along the spectrum...). It took a much bigger weight swing at the higher sizes to affect whether I needed a different size. Does that make sense? That it takes less weight change to need a new size now, but I can spend so much time too small for one size and too big for the next? I find it weird. Anyway, the size 6's are waiting for me. Within 5 lbs, they're mine.

Oh yeah....

I forgot: my run. I did 16 minutes, walked 3 minutes, then another 10 minutes (with 6 minutes of warmup and 6 min cooldown). It was really hard today. I think maybe I need to have a carb-y snack before my workouts now, to get a little energy, especially on these days when I'm dragging. Tomorrow I have to go do my weights, as well as run. But I'd already had a long and intense day by the time I worked out, so I wasn't too worried about skipping the full workout today.

Bedtime now!

Out of Gas

My classmates have been talking about the same thing that I've been thinking: our brains are tired. We're not as fired up about 5 hour study sessions as we were a couple of months ago. It's almost like that brief little spring break just sapped away our remaining energy for studying. But I doubt it's spring break that did it. I think we've done a lot in the last 3 months and we need to assimilate it for a little bit. Unfortunately, we don't really have time for that.

This morning we were in the OR for airway management. From now until we start clinicals in the fall, we will have airway management in the OR every Weds morning. These mornings are a little chaotic. They start out at 0630 in the CRNA office which is located in the OR. So we have to get there early enough to change into scrubs and hats and be ready to get our assignments. The practice is large and busy; there are 28 ORs in the main hospital, 6 more in the outpatient building, and not all of them run, but almost all have a case starting at 7am. There are 8 senior students already assigned to rooms (on Wednesdays the juniors don't have clinical, which is why it works for us to go do airways that day) plus the 8 of us freshmen. This morning was a good example of what happens: about half of us had our assignments changed at least once, which isn't terrible, but a little hard to sort out in the morning. My assignment was changed once before I even arrived, then was changed again because they put me in with John, our clinical instructor, who was doing a "request" case (someone he knew requested him to do the anesthesia for a case; those cases don't have students in them). So I was changed again, to work with one of the senior students, which was great. We were in a room where a surgeon known for very VERY speedy cases was working. Our first case was an ileostomy take down, a fairly quick procedure in general, but the surgeon was completely done 17 minutes after I had intubated the patient. That is FAST. The paralyzing drugs haven't worn off by then, and any other drugs you've given are still working enough that the patient doesn't want to breathe when you need them to breathe, so you can get them to PACU and start the next case. We waited in the OR for about 15 minutes with the patient, after the case was over, until she was breathing and responsive enough to extubate her. The intubation (only my 2nd) was quite easy, but she had prominent front teeth and I was very afraid I would chip one of her teeth with my laryngoscope...but I didn't, yay for both of us!

My second patient was pretty interesting...an older (60s) man who was developmentally delayed and nonverbal, nonambulatory, obviously full time care when he wasn't in the hospital. He was having another GI procedure (one slated to take a little longer than the first one). He had no teeth--for the anesthetist, this is good because you can't chip any teeth with the metal laryngoscope blade, but bad because it is a little harder to breathe for the patient using a mask and bag, because you can't get a very good seal on the face. He looked like we might not be able to move his head very much, which makes intubation much harder. So we had some helpful tools available "just in case", but as it turned out I didn't need them, because his neck and head were much more mobile than it appeared at first. His airway anatomy was fairly unusual, but obvious enough that I could intubate him pretty easily. Woo hoo, my third intubation! Someday it won't be as nerve-wracking as it is right now, but I can't forsee that being anytime soon. Still, that is why we have these airway days for weeks before we are expected to do everything else.

We don't only perform endotracheal intubation on the airway management days. Some cases use a laryngeal mask airway, which is a slightly less invasive and simpler device (there are pros and cons for using them and it's decided which to use based on what the requirements of the patient and the procedure are). Other cases we don't "secure" the airway at all, but just mask (bag) the patient for the whole case. Nowadays that is just for very short cases, like ECTs (electroconvulsive therapy), but they used to mask patients for hours during surgery. Now there are so many ways to do anesthesia, and so much to do while the case goes on, they rarely mask for that long anymore. It's hard on your hands. Naturally, some cases are done with spinal blocks or epidurals, or even just deep sedation and local anesthetic, or peripheral nerve blocks and sedation, for certain cases, but at this point they want us focusing on managing airways, so we are doing general anesthesia cases where we have to do something with the patient's airway.

These airway days are nerve-wracking, but fun. It's so nice to actually work with patients and do what it is we came to school to learn. It's hard in a lot of ways to be a student again and a complete beginner when we are all used to being experts in our previous environment, critical care nursing. But when you learn how to stow away your ego for a while and learn from all the people who are experienced and knowledgable and willing to teach, it's a great experience. Of course, we know all of the things that can go wrong when trying to manage an airway, even one that no one expects might be difficult (when they turn out to be difficult, that can be the hardest, because you aren't as prepared mentally), and knowing those things makes us all scared witless at this point. But we always have a CRNA on one elbow and an MD anesthesiologist on the other one, making sure the patient is safe and we are doing the right things. If something goes seriously wrong, we bail and let the experts handle the situation. They will let us learn how to get out of a bad situation as long as the patient isn't in danger, but if things get out of hand they are right there to make sure things are done right. It's a good learning environment.

I still have so much to learn in my other classes before we start clinicals this summer, though, so I've gotta get my mojo back.

I'm back

Spring break was brief, but great. I am back at school now, and we had A&P today at 8am. During the break I found it impossible to study, and now it's still hard to tackle my to-do list, which includes studying (for all my classes) and non-school items.

I ought to change my ticker; I am one pound higher than my ticker says, but that is better than the 4 lbs I gained and lost. (Water? Who knows?) I'm just happy to be back in the 170s, though, and now the daily restaurant dining is over, so it should be easier to get back to my losing ways. I can't decide if my fill is adequate or not. Some days I feel like I can eat everything, or I get hungry quickly, but in the last few days things have seemed sort of okay. I haven't made another fill appointment yet (my last one was about 3 weeks ago I think) but I will soon, I think. In theory I only have 2.5cc in the band now, but I'm curious to see what is left in there with the next fill. As for exercise, I did manage to go to the gym 5 times during my week in Portland, which is great, even though I only did weights one day. Today I did my full routine back at McDonaldland (aka the Spokane Valley Y) including my full weight routine, and running for 17 and 9 minutes, a total of 26 minutes of running with only 2 minutes of walking in between. And my training heartrate is getting lower...my resting HR remains 84, but my max after running for 17 minutes was 162, which is lower than it used to be. I'd like to get my speed up (I'm only running 12.5-13 min miles right now) but I'm aiming for longer periods of running, ideally getting up to doing 30 minutes consecutively, first.

I caught part of Talk of the Nation on the radio today before going to the gym. The topic was willpower, and specifically, the relatively recent finding that willpower is a finite thing, and that essentially we have a "budget" of willpower to spend. When one is exerting willpower to stick to a reduced calorie diet, for example, it is often much harder to stick to a seemingly unrelated task, such as staying on a budget. The show was based on an op-ed piece in the New York Times, called Tighten Your Belt, Strengthen Your Mind, which highlights research by several scientists in recent years.

This topic stirred up a number of thoughts. A lot of us (myself included, sadly) who lose weight find ourselves shopping more than we should. I'm sure there are many reasons for this, including the pleasure-reward aspects (rewarding ourselves for our weight loss, and being able to fit into smaller, cuter clothes; the neurochemical "pleasure" response that we are no longer getting from overeating or eating food that is now restricted; positive reinforcement; simple desire to show off our successes) and probably others (that I can't think of at the moment...ummmmm). But I would imagine that this could be another aspect: we are continuing to exercise our willpower in sticking to a new eating plan, and perhaps (hopefully) an exercise plan, and find it difficult to resist this other thing that requires willpower.

Yet, there are a couple of flaws there. For one thing, doesn't the amount of willpower required actually change over time? Is it easier or harder to stick to the new eating plan after a year or so of fairly continuous adherance? I think there might not be a simple answer to this. In some ways it is pretty easy to continue what I have been doing for the last 13 months. It's habit, and I have a few tricks in my bag that make it easier. But I still have to remind myself WHY I want to do it on a nearly daily basis. There is still a daily mental game happening that is at least partially willpower. How about exercise? For me, it takes far less willpower to exercise now than it used to. At least once a week I do have to force myself to GO to the gym, but 100% of the time, once I am there it is purely automatic to dress down, and once I do, I am in the mood to work out. And usually, there is no forcing myself involved: I feel better when I move, and I look forward to it. So this doesn't seem to siphon much from my willpower budget. But the other flaw might be more in how I read the article: it mentions that willpower is something that can be exercised and increased, and that "[f]ocusing on success is important because willpower can grow in the long term. Like a muscle, willpower seems to become stronger with use. The idea of exercising willpower is seen in military boot camp, where recruits are trained to overcome one challenge after another. " So perhaps initially, this urge to shop can be attributed to depleting the willpower budget early in the process, but after a while (like, ahem, 13 months) it should be easier to resist, for that reason at least. Of course there are other reasons for continued shopping too, like actually needing smaller clothes.

Another thought I had was about all the willpower-heavy things I am doing right now: new eating plan, exercise, sticking to a budget (self imposed, but still necessary), and studying, of course. Studying proves to be the most difficult for me. I can always find 100 things I'd rather do than study, and I find myself getting started later and later in the day. I start out the day with great expectations for myself, and a nice to-do list filled with school-related tasks, but just getting started on them is hard to do. Yet I have no problem eating sensibly and exercising, and even most of my shopping involves no purchasing. Perhaps I just need to "exercise" this particular ability a little better. One suggestion, off the top of my head? Don't try to study at home. I do much better at the library.

The link to the episode of Talk of the Nation in question can be found here.