Not many people may know, but a physician anesthesiologist is not the only one that can provide anesthesia for patients. There are different degrees and professions that can do the procedure. In this episode,, Dr. Richard Marn talks with Heather Angus, a nurse anesthetist working in NYC. Heather shares what her career is all about and illustrates a typical day in the life of a nurse anesthetist. They also dive into what it’s really like to work in her profession and discuss how she got into health care.

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Did you know a physician anesthesiologist is not the only one that can provide anesthesia for patients? There are different degrees and professions that can allow you to provide anesthesia. There’s an MD or DO degree where you can become a physician anesthesiologist. There’s someone who gets a DDS or DMD degree, which could be a dentist anesthesiologist. There’s a nurse anesthetist, otherwise known as a CRNA, which stands for Certified Registered Nurse Anesthetist. CRNAs are an integral part of the healthcare system. Some hospitals and organizations use them more than others. We’re going to learn how they work in various situations depending on the institution. You’ll see how some of the CRNAs, depending on the situation and the reach of the country, can also work independently apart from an anesthesiologist. Depending on the situation or community or state, some CRNAs have to work under the auspices of a physician and some do not. It depends on what part of the country you’re in.

Anesthesia is a vigilant career. You need to be well-rested. Click To Tweet

Our guest is a CRNA and her name is Heather Angus. She went to college at West Virginia University, where she got her Nursing degree. As a nurse, she worked at Johns Hopkins Hospital in the ER department. She also worked for American Mobile Healthcare, where she traveled for several years across the country. She also worked as a Burn ICU Nurse at Tampa General Hospital. Eventually, she went on to Columbia University where she earned her CRNA degree, which is a Master’s of Science Degree. Since graduating from CRNA school, she has been working at Mount Sinai Hospital for the last many years. Utilizing her Nursing degree, she has traveled with the Global Smile Foundation. We’re going to learn a little bit of what she does for them.

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Heather, welcome to the episode. Thanks for joining me.

Thank you for the invite.

I am happy that you’re part of this. I’m glad you even said hello and okay because we haven’t talked to each other for years.

It’s been a while. You left Mount Sinai and then I hear from you about this.

I left Mount Sinai in 2016. Thanks for joining. I want to learn about what your career is all about. Could you tell me what a CRNA is?

CRNA is a Certified Registered Nurse Anesthetist. That means you receive a Bachelor’s degree either by a 2 or 4-year program. You have at least 1 to 2 years of Critical Care experience. You apply and you’re accepted into a program that’s a Master’s degree program. Depending on the program, it could be either a Master’s or a Doctorate. It could be anywhere from 3 to 4 years of post-graduate education. You have your undergrad degree in Bachelor’s, and then you go back to school for a Master’s or a Doctorate.

What does a CRNA do?

CRNA is responsible for giving anesthetics to surgical patients. We will do evaluations of the patients. You’ll set up the anesthesia room, provide the anesthetic and follow the patient from beginning to end. Depending on which state you’re in, you could be doing that independently or you’re doing it under the supervision of an anesthesiologist.

What kind of patients do you take care of as a CRNA? Is it only certain ages, healthy or non-healthy patients?

You’re trained to treat any kind of patients as far as open-heart procedures or pediatric patients or pregnant patients. General patients for any kind of surgery. During your training in the 3 to 4 years that you receive in your graduate education, you will have different rotations to treat any kind of patient that needs surgery.

What kind of patients do you take care of at Mount Sinai in your regular day-to-day?

It could be any kind of procedure for like endoscopy, OB obstetrics patients, general surgeries. We also are in the electrophysiology lab, that’s where any heart procedures are. At Mount Sinai, we don’t do anesthesia for open-heart. We do some transplants, but not all transplant patients.

What you do as a CRNA can vary based on the institution that you’re working at. For example, even though a hospital may do certain procedures, sometimes they may not have the nurses do those procedures.

Our physician colleagues, we call them Anesthesia Residents. When we went to school for CRNA, we need to have a certain amount of cases to graduate. Depending on the institution, if you’re in a teaching facility, the anesthesia residents also need to receive those numbers. They need to obtain the experience that they need to graduate as well. We’re a good adjunct to the anesthesia department to help the residents get all of the cases that they need to graduate as we did during our training.

What’s your typical day like as a CRNA? What time do you wake up? What’s your day like? Do you get lunch? How does that day play out usually?

My day has to start with coffee. Anesthesia is a vigilant career. You need to be well-rested and caffeinated, at least for me.

One or five cups?

I’m up to three a day. I’ll know what my patients are the night before. When I get to Mount Sinai, I will go to the pharmacy, collect the drugs I know I need for the procedures I’m doing. I’ll set up the operating room with the anesthesia supplies, then go and talk to my patients. Talking to my patient is my favorite part of the job. I’m a big talker. I feel like you have to establish a rapport and trust in your patient quickly in anesthesia, which is very different from past nursing careers that I’ve been in. Within 10 to 15 minutes, getting a good idea about your patient, their history, all the medications they’re on. Also, knowing how to apply that to give a safe, effective anesthetic for their procedure.

Talking to the patient, bring the patients into the room, and place an IV, which is putting an intravenous in to be able to give your drugs. In that timeframe, I try to make them feel less anxious as much as I can. I will do a vacation technique where I talk about their last vacation or where they would like to go to. I do find sometimes patients wake up and they feel like they went on the vacation that they go on. One patient was talking about surfing before he went to sleep. When I woke him up, he was like, “I went surfing and it was the most relaxing dream of my life.” Sometimes you’ll hear people say, “People wake up the same way they fell asleep.”

I tried to distract, talk their ear off about something nice, and putting them to sleep with the medications as you’re giving them some oxygen when you would insert a breathing device once they’re asleep. During the surgery, you are maintaining anesthesia depth for the procedure. In the end, you wake them up, starting to turn off all the anesthesia as the surgery is finishing and having a smooth awakening. Most people don’t even remember waking up. They remember being in the recovery room and asking when the procedure is going to start.

I never tried the vacation technique. I often found most patients don’t remember much at all under anesthesia.

Most patients don’t remember, but I’ve had patients seriously wake up and say, “That was a relaxing dream.” We have the patients that say, “Am I counting back from 100?” I say, “No, unless you like Math.”

Is there any moment that you remember like a harrowing experience as a CRNA?

As a nurse anesthetist or a CRNA, we are giving anesthesia for surgery. As everyone knows, elective surgeries were put on hold because we needed all of the beds available in the hospital, which was a thing at Mount Sinai. We made all of the different floors for COVID patients because there were many. The nurse anesthetist needed to be rerouted to where we were needed, which a lot of us went to different ICUs that they had formed for other Coronavirus patients. About 5 or 6 of us went to the rapid response team. The rapid response team is a team for the hospital that responds to anybody that is not doing well, they’re decompensating, the nurses or doctors feel like they need a second look to see, “Does this patient need a breathing device or another modality that may try to help get them along with the virus as far as treating it?”

I was on that team. Unfortunately, there were lots of patients that we had to intubate, which is putting the breathing device. Their respiratory process was compromised that they needed a breathing device. The harrowing experience for me was going into a patient’s room, seeing them decompensated that they needed a breathing device, and then realizing that the statistics on surviving intubation was low that I may be the last person that this person sees because the families were not in the room. When I realized this was going to be my role, I tried to think of something to say to the patient that maybe would last in their mind. When I would go into the room, I would tell them, “You’re not breathing well now. We’re going to do our best to help you. We’re going to put you to sleep in a breathing device, but while you’re asleep, know that we’re going to work very hard to try to get you off of the breathing machine. Fight for it.”

That was the only thing I could think of to say to these patients, to help me feel better about what I was doing, to be an advocate for the patient, and to know that their family couldn’t be there before I put them to sleep. I felt like I wanted a minute to tell them that we were going to work hard for them. Being a nurse anesthetist, we have a lot of skills that were necessary around the hospital. You have to have a critical care background, which means we’ve all worked in an Intensive Care Unit where patients are critical. You run a lot of infusions. Infusions are medications that need to run throughout your shift. How to titrate them, which means, “Does a patient need more? Does the patient need last to go up and down on an infusion?”

We are experienced with ventilators. We’re experienced with sedation. Once you put in a breathing device, the patient needs to be sedated to be able to help their respiratory system and interpret different lab values. We were helpful during the crisis because we had a lot of ICU nurses, but not enough. We had floor nurses taking care of patients that they hadn’t taken care of before. We were placed in units to help with the floor nurses to be able to manage these patients. During Coronavirus, nurse anesthetists were very helpful and some people managed patients in the ICU unit. We had a couple of nurse anesthetists that manage the operating rooms for the Coronavirus patients because once someone was diagnosed with Coronavirus, they still needed surgeries as well. Emergency surgeries were still being performed during that time. We had a nurse anesthetist still managing those procedures as well.

Can you tell me an instance where pre-COVID, you were helping a patient that you felt you had a strong impact on that patient’s care?

A few patients I’ve had similar to this experience where they had anesthesia in the past and had a very terrible experience, either they woke up nausea, vomiting or they were anxious about going in. In our job, we’re not meeting people on the best day of their life. It’s usually they have something going on, anxious and everybody’s blood pressure is about 20% higher than normal whenever they come into the operating room. I remember one patient was nervous in the pre-operative area. That’s where we talked to them before they come in for the procedure. She was shaking, nervous and had a bad experience in the past. During that 10 to 15 minutes, you try to instill some trust in your patient. She came back to the room, anxious, crying.

Once I placed her IV, I gave her some medication to help her relax. I have Pandora Unlimited on my phone. I asked her, “What is your favorite music station? Who is your favorite artist?” She loved country music, which I love country music. We started listening to country music as everybody was getting ready for the surgery and getting prepared. I was a little delayed. They were looking for one more thing before we could put the patient to sleep. The surgeon walked into the room and said, “What is going on here?” She was nervous before and now she’s singing country music. Music and a little medication help people along and make everybody else feel good about a patient before they go off to sleep.

Were you singing along with her?

No, that might cause a nightmare.

You put her at ease and sometimes it’s not just about medications, it’s everything else, the conversation, ambiance and music.

Anesthesia is a science. There are lots of gray areas in science. When you’re a student as a nurse anesthetist, you’ll work with different people all the time and everybody has, “This is how I do it. This is the reason why I do it. I want you to do it like this.” It can be anywhere from the drugs you’re infusing during surgery or how they taped the eyeshot for those surgeries. There are lots of gray areas in anesthesia. You have to roll with it, but there is an art to it as well, where you don’t want to think of the patient as a surgery, you want to think of the patient as who they are, what they’re there for and what they’re going through. I still have my empathy for my patients, which has never changed.

What is your favorite part of your job?

My favorite part is when the patient wakes up, they’re not in pain, comfortable and say, “When are we starting the procedure?” A very smooth awakening and to be comfortable in the recovery room is my favorite part.

What misconceptions do people have about your career?

Not very often, but sometimes I hear, “I don’t want a nurse giving my anesthesia. I want a doctor. If you’re a nurse, how can you be giving anesthesia?” I’ve been a nurse anesthetist for many years. I’ve heard that a handful of times. Most of the public are aware that nurses and doctors can give anesthesia. Whenever I hear that, I try to explain, “I have seven years of education. I have ten years of experience as a nurse and seven years of nurse anesthesia experience.” I wouldn’t make a patient have a nurse anesthetist that they’re not comfortable with. I’ll go tell the anesthesiologist that I’m working with what’s happening and what we can do about it. A lot of times, at least at Mount Sinai, one anesthesiologist could be covering 1 to 3 of us. It’s impossible for the patient to have their own anesthesiologist for the procedure.

Music and a little medication helps people along and make everybody else feel good about a patient before they go off to sleep. Click To Tweet

I try to explain it as best as possible. That could be a misconception. Also, some people think that the anesthesiologist starts the case, gives all the medications, puts the breathing tube in, and we sit there during the procedure. What happens is we work together and bring the patient into the room. They’re there for the important part of the procedure, putting in the breathing tube, taking out the breathing tube, and in any emergency parts of the case. We actually put in the breathing device. We are there to maintain anesthesia and take out the breathing device as well.

I’m sure that must be frustrating sometimes when patients see that though.

I’m not frustrated. I feel the same way when I go to take my car to the mechanic. I have no idea what they’re saying or doing. For patients to have a question or be concerned or ask the question, it doesn’t frustrate me. I feel the same way when I’m doing something I don’t normally do as well, something that I’m not knowledgeable about. I have no idea who’s doing what, what this means when the car makes the sound. If someone asks me, I’m empathetic to what their question is and try to resolve it in whatever way we can. Someone explains to them, “We don’t have an extra anesthesiologist to give you your anesthetic. Are you okay with proceeding? There is no way we can rearrange the schedule for this.”

What’s your work-life balance like?

Anyone that knows me knows that I travel a lot. I work 39 hours a week. It’s a three 13-hour shifts. That leaves four days a week off. I balance out my life. I’m active. I do triathlons, marathons and travel a lot. I work hard and play hard. I feel like I’m very balanced in that way.

In your typical day, what time do you start? When do you arrive at the hospital? When do you usually leave?

Most cases started at 8:00 AM. I arrive at the hospital at 7:00 AM. That’s the time to go set up the room, get all the drugs that I need for the day. It ends at 7:45 PM. We do get three breaks throughout the shift.

Is that standard you find for a lot of other CRNAs in your profession?

I’m not sure. Some of my friends at other hospitals have a little bit longer lunch break and afternoon break. That varies from the institution. Some people work a 7:00 AM to 7:00 PM shift. There’s a variety of different shifts available.

Do you recommend this career to other students?

I feel like this career is a great career if you’re dedicated and motivated. You’re getting into a career that you’ve researched. I have people shadowing me at Mount Sinai. I met with someone who shadowed me many years ago. We ran into each other when I was going to all the floors for the rapid response team during Coronavirus. She remembered me and told me that she’s applying to Columbia. She sent me her essays so I could review them. We had dinner and she’s going for it. She’s also been a nurse. I’m honest when people are shadowing me, just like I was working in the Burn ICU for a couple of years. One of the nurse anesthetists asked me, “Why didn’t you go into nurse anesthesia?” I was saying, “I have no idea what you do because I was an ER nurse for eight years and then an ICU nurse for two years. I was not exposed to what nurse anesthetists do.” He had me shadow him in the OR for a patient that was 80% burned. It was a very long case. I watched how he managed the case. Working in the Burn ICU, I felt almost like I was giving anesthesia all day because it’s a very painful problem for these patients.

I felt like it was a natural progression because I had been a nurse for ten years. I like critical care. I felt like I had got to the point where if I’m going to do something, my route is either nurse practitioner or nurse anesthetist, and I like fast-paced adrenaline. That’s why I decided, “It’s been years since I’ve been out of school. I’m going to take Advanced Pharmacology and Advanced Physiology class,” before I applied to make sure I can learn again back in school. I had to buy a computer because before that, I was writing notes. Now, I was taking all my notes on the computer. I got A’s in both courses. I was like, “I’m ready.” I applied to Columbia and I got in. I researched the career and made sure it was a good choice for me. I tell people when they shadow me, “You learn an in-depth knowledge of a lot of things and you become more autonomous in your career.”

You don’t have to page your anesthesiologist to be able to give pain medication. You are giving medication. I went to Columbia, that was my choice. That was very expensive to be in New York City in graduate school. You are not supposed to work. There are people that pick up shifts here and there to support themselves. You’re living in an expensive city, going to an expensive school. I was excited to get out of school, and then I was not excited when I saw my student loan. You have to minimize. Try to save up as much money as possible.

Are you still paying your student loans off?

Yes. I decided to get into the Public Loan Forgiveness Program, which is a great program. You pay for ten years. After ten years, whatever is left over is forgiven. I got into that. You have to work full-time at a nonprofit hospital for many years. There’s some paperwork you have to do yearly to show proof that you’re at a nonprofit hospital.

It seems like you had this one interaction with this nurse that nudged you towards being a CRNA. What was the reason you even became a nurse? Was that something you want to do when you were younger?

That started when I was very little. When I was born, my grandmother was diagnosed with breast cancer that year. As I was growing up, she would always tell me that, “You’re going to be my little nurse.” She was very poor. She wanted to be a nurse but didn’t have the money to do so. Throughout school, I thought, “I’ll be a nurse one day.” I did very well in all my Biology courses in high school. My Biology teacher told me, “You can do whatever you want to do. You’re very intelligent. If you want to be a doctor, you can be a doctor.” I said, “No. My grandmother told me I’m going to be a nurse.” I applied to a nursing school at West Virginia University. I started taking other pre-nursing courses.

Halfway through my first year, I was like, “Am I wanting to be a nurse because someone told me to be a nurse?” I decided to try Physical Therapy. “Maybe, I’ll be a physical therapist.” I shadowed a physical therapist in a few days. I said, “I can’t do this. This is not for me.” I thought, “I like to exercise, maybe Exercise Physiology.” I took an Exercise Physiology course. I realized how hard it would be to find a career and support myself. My roommate that year was in nursing school already. She was like, “Heather, go to nursing school. You can live wherever you want. You never have to worry about supporting yourself. You would be an excellent nurse.” I was like, “You’re right. This is what I need to do.” That’s what I did. I only had one year where I was foundering what I wanted to do. I didn’t lose that much time, but I’m glad I went through the different motions of making sure this is what I want to do.

Did your grandmother get to see you graduate from nursing school?

She got to see me graduate from nursing school. They helped me move into Baltimore where I got my first job at Johns Hopkins. She’s very proud.

How competitive is it to get into CRNA school?

It’s very competitive. The requirements when I was going to Columbia, it was only based on your letters of recommendation, experience and GRE score. There was no interview involved. Now, I believe there are three essays, a video and an interview. There are a lot of things to get at. My class was very small. There were 25 people and there were hundreds of applicants.

What do you think the future outlook is like for your profession?

I believe our career has a bright future. I feel like there are many anesthetics that need to be given around the country at all times. Even the smaller communities that may not have as many anesthesia providers, there are a lot of nurse anesthetists to provide those anesthetics. I don’t feel like they’ll ever be a time where we’re not needed or necessary. With the addition of the Doctorate programs, I feel like a lot of people are going into that for their Doctorates to do other things as a nurse anesthetist, which I think is a positive.

In reflecting back, what would you have done differently?

I look back at what I’ve done. Some of my friends became nurse anesthetists in their twenties. I believe what I did was the right course for me that I was a nurse for many years. I’ve obtained a lot of experience on the job training with emergency room patients. I traveled for four years as an ER nurse. I saw many different institutions, how they do things, different kinds of patients. I built on any kind of experience that I use now in my job.

You’re talking about your volunteerism and love to travel. Are you using those skills as a volunteer when you travel to other countries?

Yes. When I was a Burn ICU nurse, a physician that I used to work with at Mass General in the ER, contacted me one day and said, “Would you want to do a mission trip one day?” I said, “Yes, I would love to.” He was like, “It’s a pediatric mission trip for lip and cleft palates. I can let the guy know about you. He can call an interview tonight.” I was like, “I don’t do pediatrics,” which is the younger population, “I don’t do surgeries. I’ve only been an ER nurse. I have no idea what I’d be doing.” He’s like, “Don’t worry about it.” He told me I have 24 hours to find someone who is a great team player, easy to get along with, educated, can go with the flow and they’re leaving for Peru on Friday.

He goes, “You need someone to run the research project.” I was like, “I don’t even do research.” I had done one research project with the ER physician and cardiologist at Hopkins. I thought, “This is totally out of my realm of what I do, but I can learn anything if someone shows me and gives me the information. I can figure it out.” That night, the head of the Global Smile Foundation called me, asked me a bunch of questions, and everything was set up. A list of ten documents he needed that night. I said, “All of this is going to be fine, but I have to ask my nurse manager tomorrow. I have no idea what she’s going to say. The schedule is already out for months.” He was like, “Let me know tomorrow.”

I went to work and went to my manager’s office and I was super nervous because I was worried that she would say no. I walked in and said, “Laurie, I was asked to go on this pediatric mission. I think it would look good at our hospital if you let me go. I know that it’s really soon, but it’s on Friday. Will you let me know now?” She looked at me like I had three heads and was like, “Let me think about it.” I was sitting in the ICU and one of the techs that works with me, she prays a lot. I said, “Edna, you have to say a prayer now. We have to pray that Laurie lets me go on this trip because I want to volunteer. It would be a great experience. I want to go and help people.”

In the middle of the ICU, Edna started praying with me. About an hour later, my nurse manager called and said, “I’ll let you go.” It started like that. I did the research on the first mission. He asked me to go back on another mission. I went as a pre-operative nurse. That’s when I decided to go to anesthesia school. He let me go as an anesthesia tech and then another time as a sedation nurse. He’s asked me to go to Ecuador as part of my anesthesia. I would be anesthesia personnel. I did go on a mission trip with another company, ISMS. I gave anesthesia in Guatemala and they invited a Columbia student along. I was her chaperone, but she was independent, intelligent and smart. I felt like I was there as a backup, but it’s such an amazing experience to go to these different countries and provide care for people that live in poverty or the government’s not giving them an operating day appointment. We go in, do an excellent job and provide follow-up. It feeds your soul. It reminds you of why you got into your career of helping others.

You also want to do these missions. You are helping people who could use these advanced services and skills, and you’re able to bring that. It’s good that as you progress in your skillset, you provided even a higher skillset to these areas that you’re going to.

That’s another positive to our careers. The more you learn, the more you’re able to help out in different roles. I could be a pre-operative nurse or a PACU nurse. The only thing I can’t do is scrub in and be a surgical nurse. I’m not sure what instruments they’re using. It’s good to have different roles that you can help out with on a mission trip because everything is necessary.

Where can readers go to reach you and learn more about you if they want to reach you?

They could reach me at my work email. It’s HeatherAngus@MountSinai.org.

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I like to end with a fun segment called Dr. Marn’s Lightning Round. Big dogs or small dogs?

Big dog.

Would you rather cuddle with the baby panda or baby penguin?

Penguin.

If there was a hair in your soup at a restaurant, would you return it?

It depends on where I was. If I was in a place where that would be frowned upon, I would be okay. If I was like in Guatemala, I would not return it. Maybe if I’m in New York City, I would.

Anesthesia is a science, but there is an art to it as well. Click To Tweet

Do you own any stuffed animals?

No.

Who inspires you?

There are a lot of people that inspire me. I’m inspired by the people that make it. They’re not giving as many opportunities as they’re younger and they’re able to be successful. I don’t know if I can pick one single person, but I do pick Barack Obama.

When people stand up for a standing ovation, are you one of the earlier people to stand up or one of the later?

If it was amazing, yes, I would stand up early.

What’s your favorite clothing brand?

Anything campy, any kind of REI stuff like Columbia or Patagonia, anything like that. That’s my favorite.

Can you say something about yourself that most people at your workplace would not know about you?

People probably don’t know how active I am. I ran the New York City marathon in 2019. I did ask some people for some contributions because I did it for a charity team. I would say most people don’t realize that.

Do you do a triathlon?

I did a triathlon in 2019 too.

What’s something you could eat for a week straight?

Pizza.

Any type of pizza?

Lots of vegetables with basil and garlic.

Heather, thank you for joining me on this session. I appreciate it.

Thanks for the invite. I’m happy to do it.

Everybody, that’s our show. Thanks for tuning in. To learn more about our guests, check out my website, HealthCareersWithDrMarn.com or HCWithDrMarn.com. If you like what you read in the show, then please go to my website, add your name and email to my email list. That way you can get the latest announcements and news as they arise. You can also find me on Instagram, @DrRichardMarn. Thank you for reading. I’ll catch you in the next episode.

 Important Links:

• Heather Angus
• Mount Sinai Hospital
• Global Smile Foundation
• HeatherAngus@MountSinai.org
• @DrRichardMarn on Instagram

About Heather Angus, CRNA

Nurse at Mount Sinai Health System