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MTSA Junior year

Quarterly Clinical Objective (QCO) MTSA (Updated November 2013)

Junior students

Practicum 1: Second Quarter – first Junior year August through November.

1. Know the function of the basic parts of the anesthesia machine to include O2, N2O, flow gauges, agent specific vaporizers, flush valves, inspiratory/expiratory sides of the circle, pop off valves, and CO2 absorbant canisters. Be able to check the anesthetic machine for working order to include wall and tank supply of O2 and N2O, suction supply, scavenger mechanism, test circuit for leaks & valves/flowmeters for patency and working order.

Questions for your student –

a. Can they do a complete machine check

b. Can they name 20 safety features of an anesthesia machine

c. Can they troubleshoot machine leaks

d. Can they have a discussion about sodalyme versus baralyme versus lithilyme

e. Can they discuss converting a semi closed circuit to an open circuit and its implications in inspired versus rebreathed gases.

2. Place and use standard monitoring equipment to include BP cuff, precordial/esophageal stethoscopes, temperature probes, EKG, neuromuscular blockade monitor, pulse oximeter, inspiratory oxygen monitor  and expiratory agent monitors. Use molded earpiece in monitoring pulse and breath sounds and to check BP. Place and use more advanced monitoring modalities to include arterial lines and CVP lines with guidance and supervision. Recognize safety alarms, and trouble shoot for causes.

3. Have all equipment in working order to include but not limited to : precordial/esophageal stethoscope, stylet, laryngoscope, Miller/MAC (appropriate size) blades/bulbs, LMA, tongue blades, oral airways an assortment of IV needles and tape.

4. Know the milligrams/micrograms per cc & the method to calculate dosage of routine intravenous anesthetic and supportive drugs.

5. Prepare basic drug and equipment set up to be used for any anesthetic: sedation, regional or general (maybe institution specific).

6. Make and document preanesthetic visit, fill out preanesthetic check sheet, seek instructor assistance where appropriate in developing  anesthetic care plan.

7. Construct a complete anesthetic plan one each patient to include approximate blood volume & tolerble loss, fluid replacement to cover existing deficits, maintenance fluid choice & course of anesthetic to include induction, maintenance, emergence & possible complications. Expect instructor suggestions/revision of plan of care and harmoniously adhere to the suggestions/revisions

8. Prepare IV fluids successfully start IV’s with sterile technique ( no more than two attempts), administer caluclated amount of fluid to the patient & operate any pumps involved in drug administration with instructer advice and assistance

9. Appropriately postion a patient on an OR table with all pressure points guarded. Be able to change postions of the operating room table.

10. Know that the patient is appropriately ventilated. Answer questions relative to breath sounds, O2 saturation, ETCO2 numerical and waveform patterns. Correctly & atraumatically insert an oral/nasal airway.

11. Successfully & consistently intubate the trachea with  instructor advice and assistance. Perform fiberoptic intubations with guidance and supervision. Recognise inappropriate placement of ETT immediately.

12. Administer general, bier block & spinal nesthesia, conscious sedation and redose an epidural anesthetic with instructor advice and assistance.

13. Demonstrate by pattern of agent or drug administration that emergence from anesthesia is timely.

14. Keep an accurate, neat, legible anesthetic record with instructor advice and assistance.

15. Be aware of and practice sterile technique in the OR. Appropriately use universal precautions

16. Be cognizant of methods of patient transfer to PACU to include actual physical move, pertinent facts to relate to PACU personnel and assuring stable condition.

17. Make & document post-anesthetic visits and document & consult with instructor relative to complications & treatment of such.

18. Arrive at affiliate in time to fulfill all expectations. Leave the facility as appropriate with the situation considering both class and relief available. Maintain harmonius attitude. Request instructors evalaution of performance daily. Fulfill duties of call person as assigned.

19. Demonstrate a healthy working ethic and effectilvely communicate with all individulas influencing patient care both verbally and non-verbally.


MTSA Third Quarter

Practicum II- Third Quarter.(November-February)

1. Continue to develop skills & previous quarter objectives. In each instance the student should need less advice & assistance from the instructor than in the previous quarter, becoming more independent & polished in each skill.

2. Perform fiberoptic intubations (models acceptable) with guidance & supervision. Recognize inappropriate placement of ETT immediately.

3. Show appropriate independence with medical supervision in care plan construction & administration of general anesthesia, Bier block anesthesia, spinal anesthesia, & monitored anesthesia care, with advice & limited assistance

4. Administer Bier Blocks & re-dose an epidural, with instructor advice & limited assistance

5. Administer anesthesia for emergency surgical & obstetrical patients, with instructor advice & limited assistance

6. Arrive & leave affiliate as expected & as appropriate with the situation. Maintain harmonious attitude. Fulfill duties of “call” person, as assigned

Fourth and fifth Quarter ( March- August)

1. Continue to polish skills & objectives of the previous quarters. Instructor advice & assistance should be minimal in most instances.

2. With appropriate supervision, independently develop care plans for all risk patients. Seek instructor assistance if needed & administer safe anesthesia to all risk patients.

3. Show increasing ability to administer sound, smooth anesthesia with limited instructor participation in low risk patient categories having less complex surgical procedures to include, but not be limited to Cysto, D&C, hysterectomy, cholecystectomy, laparoscopy, extremity orthopedic procedures, & dental procedures.

4. Administer anesthesia to patients of all ages for a wide spectrum of surgical procedures. Instructor assistance is appropriate with extremes in ages, increased patient risk, or surgical procedures with increased complexity for anesthesia, to include thoracotomy, craniotomy, & major vascular procedures. Participate in “call” as assigned.

5. Perform all tasks with the expectation that the major role of the instructor is supervision, thus allowing the student to increase his medically supervised independence in performing the anesthetics assigned to him.

Senior year

Practica V – IX: Senior year


(Mid-August/Start of 2nd YEAR at MTSA – Graduation; Approx. 14 months in program - Graduation)

During quarters 6 – 9 & by the end of the 10th quarter, in addition to accomplishing & perfecting the objectives for quarters 2 – 5, the anesthesia student should be able to:


1. With less instructor assistance, show increasing growth & competency in skills, techniques, procedures & objectives of previous quarters.


2. Complete specific “Specialty” affiliations. Complete all cases required by MTSA & NBCRNA/ CCNA/COA. Request assignment to cases required for Clinical Record, but are less available routinely &/or more challenging, such as intra-thoracic procedures. Complete the specific objectives outlined for each facility.


3. Demonstrate appropriate medically supervised independent skills in anesthesia induction, management, & emergence in emergency procedures, intra-thoracic procedures, surgery performed in the prone/lateral positions, intracranial/neurological procedures, assessing preoperative & intra-operative fluid losses, & plan replacement of colloid, crystalloid, & blood elements that become deficient while the patient is under his care.


4. Demonstrate harmonious interpersonal relationships working with all personnel as befitting a professional nurse anesthetist.


5. Administer appropriately supervised anesthesia to all ASA class patients, utilizing a wide variety of agents, techniques & skills. Where possible, be an active participant in regional anesthesia. Where appropriate, perform fiberoptic intubations & insert arterial & invasive monitoring devices with appropriate direction.


6. Participate in the call experience, & demonstrate ability to make appropriate clinical judgments. Be a valued member of the OR team.


Reviewed: June 2008, July 2009, & July 2012; December, 2012; Revised June 2011

Union School of Anesthesia-junor year





At the conclusion of the first and second semesters, the graduate student should be able to:


  1. Synthesize an appropriate anesthesia management plan.  This should include the demonstration of physical assessment skills.  The management plan must analyze and synthesize the pre-existing patient pathology and the implication of the planned operative procedure.  The management plan should include estimation of blood volume and allowable blood loss, fluid replacement needed to replace existing deficits and anticipated intraoperative loss, selection of appropriate maintenance fluid, and selection of an appropriate anesthesia technique.  The anesthesia technique should include induction, maintenance, and emergence.


  1. Demonstrate the ability to perform an appropriate preanesthetic visit.  This is to include proper introduction and questioning of the patient as well as obtaining an informed consent for a given anesthesia technique, discussing technique and risks/benefits if allowed by the clinical site.  Proper documentation of findings is critical component of this process.


  1. Perform a comprehensive anesthesia machine and monitor assessment.  This is to include monitor and anesthesia machine checks.

          Questions for your student –

          a. Can they do a complete machine check

          b. Can they name 20 safety features of an anesthesia machine

          c. Can they troubleshoot machine leaks

          d. Can they have a discussion about sodalyme versus baralyme versus lithilyme

          e. Can they discuss converting a semi closed circuit to an open circuit and its implications in inspired versus rebreathed gases.

  1. Demonstrate a thorough knowledge of the structure, function and use of the anesthesia machine.  This should include the principles involved with the function and use of flow meters, vaporizers, flush valve, circle system and unidirectional valves, APL valve, soda lime canister, and scavenging system, mechanical ventilation, and I:E ratios.  The student must be able to “trouble-shoot” malfunctions that occur during the course of anesthesia.


  1. Apply routine monitors used during the administration of anesthesia.  This is to include the EKG, blood pressure cuff, pulse oximeter, precordial and esophageal stethoscope, peripheral nerve stimulator, temperature, BIS (if available), end-tidal CO2 and agent gas analysis monitors.


  1. Recognize and respond to safety alarms that may be activated during anesthesia (e.g., threshold levels for HR, BP, SaO2, end-tidal gas values).  This should include the ability to silence the alarm once the problem has been recognized and appropriate intervention has been taken.


  1. Prepare airway equipment based upon the preanesthetic assessment.  The student should be able to verify a proper functioning laryngoscope, select the proper size blade and endotracheal tube, LMA, oral airway, endotracheal tube introducer, or nasal trumpet.


  1. Demonstrate the ability to prepare intravenous fluids and perform intravenous cannulation on patients with easily accessible veins.  This procedure should be performed with appropriate sterile technique.  The student should also be familiar with use of an intravenous infusion pump (e.g., BARD INFUS O.R.), and know how to calculate the concentration of drugs mixed in an intravenous infusion.


  1. Demonstrate the ability to properly position patients for the prescribed operative procedure. This is to include techniques used for prevention of nerve injury and limb ischemia. The student should be able to articulate physiological changes associated with trendelenburg, reverse trendelenburg, prone, lateral, and lithotomy positions.


  1. Assess for adequate ventilation of the lungs during a general, regional or MAC anesthetic.  This is to include the assessment of breath sounds, oxygen saturation, end-tidal CO2 values, positive inspiratory pressures, and CO2 waveform morphologies.


  1. Prepare anesthetic drugs, neuromuscular blockers, and commonly prepared vasoactive drugs (e.g., ephedrine, atropine) required for the scheduled surgical procedure and based upon the preanesthetic assessment.


  1. Recall the concentration (mg/ml or volume %) and dose (mg/kg or mcg/kg) of the intravenous drugs and/or inhalational agents used to administer anesthesia.  This includes intravenous induction agents, opioids, sedatives, muscle relaxants, reversal drugs, antiemetics, vasoactive drugs (e.g., esmolol).  The student should be familiar with the concepts of uptake and distribution of inhalational agents and the pharmacodynamics and pharmacokinetics of anesthestic drugs and adjuncts.


  1. Recall the minimum alveolar concentration of the inhalational anesthetics (MAC).  The student should also be able to describe the concepts of blood:gas and oil:gas solubility, second gas effect, and diffusion hypoxia.


  1. Demonstrate a knowledge of sterile technique and be able to use universal precautions.


  1. Demonstrate the technical skills of inserting an oral or nasal airway, LMA, endotracheal tube.  The student should be able to intubate approximately 75% of patients with Mallampati score of 1 to 2.  The ability to recognize and properly respond to esophageal or endobronchial intubation must be developed during this first semester.


  1. Demonstrate beginning technical skills and knowledge related to regional anesthesia techniques (i.e. spinal and epidural anesthetic techniques).


  1. Create an accurate, neat, and legible anesthetic record in a timely fashion.  The student should also be able to demonstrate the skills necessary for maintaining an automated anesthetic record in clinical sites that have incorporated this software.


  1. Safely transfer a patient from the operating room table to the stretcher, then transport to the Post Anesthesia Care Unit (PACU).  This should include constant assessment of the patient’s airway, ventilation, and as indicated hemodynamics.


  1. Provide a comprehensive anesthetic and surgical report to PACU personnel along.


  1. Perform and document the post-anesthesia visit on any inpatient within a 24 hour post-operative time period.  The student should promptly report any postoperative anesthetic complications to the clinical faculty, clinical coordinator, and Chair.


  1. Demonstrate professionalism, a positive attitude, integrity, and a respect towards faculty, staff, and patients encountered during their clinical training.


  1. Participate in continuing education activities to acquire new knowledge and improve his or her practice.


  1. Protect patients from iatrogenic complications.


  1. Apply theory to practice in decision-making and problem solving.


  1. Demonstrates a Christian attitude towards hospital officials and patients.


  1. Adheres to patient privacy issues (HIPPA).


  1. Wears name badge at all times.


  1. Serve as a role model for the profession of anesthesia and Christian community.

Union junior year II



At the conclusion of the third semester, the student should be able to:


  1. Develop, on a progressive continuum, the objectives that were set-forth for the prior semesters.


  1. Demonstrate appropriate independence when formulating anesthesia management plans.  The student should be able to develop management plans for routine procedures e.g., hysterectomy on a physical status 1or 2 patient.  Students will still require greater assistance in planning the management of patients who are having more advanced procedures and/or who have significant co-morbidity (e.g., a patient with a fractured hip and uncontrolled hypertension and reduced cardiac reserve scheduled for a open reduction and internal fixation).


  1. Provide anesthesia for emergency procedures - such as emergency intubations in an intensive care unit.


  1. Demonstrate knowledge of interpretation of invasive hemodynamic data (pressures and waveform analysis) including blood gas analysis.  The student should be able to insert arterial and central lines with assistance.


  1. During this semester the students will begin to be assigned to a specialty rotation in obstetrics, pediatrics, cardiovascular procedures, and neurosurgery.


  1. Effectively communicate with all individuals influencing patient care.


  1. Recognize and appropriately respond to anesthetic complications that occur during the perianesthetic period.


Union-Senior Year



At the conclusion of the fourth semester, the student should be able to:


  1. Refine the skills related to the objectives for the prior semesters.


  1. Demonstrate greater proficiency in technical skills and knowledge related to regional anesthesia techniques (e.g., upper and lower extremity blocks in addition to spinal and epidural blocks).


  1. Exhibit greater autonomy during the delivery of anesthesia care (preop, intraop, postop) particularly with physical status I or II patients and less complex surgical procedures.


  1. Administer anesthesia to patients of all ages for a wide spectrum of surgical procedures.  During this quarter, students will begin to do pediatric rotations.  Students should, with instructor assistance, consistently administer anesthesia for more complex procedures such as thoracotomy, craniotomy, and major vascular procedures.


  1. Demonstrate the ability to insert and manage a LMA or “mask” anesthetic with minimal assistance.


  1. Demonstrate the skills to initiate and manage a mask general anesthetic with minimal assistance.


  1. Participate in the management of acute postoperative pain management when available at their assigned clinical facilities.


  1. Provide nurse anesthesia care based on sound principles and research evidence.



FIFTH  (JAN – MAY) AND SIXTH (JUN – AUG) (August is Graduation)


At the conclusion of the fifth and sixth semester, the student should be able to:


1.         Demonstrate increasing growth and competency related to the objectives stated in all of the preceding semesters.


2.            Demonstrate appropriate independent skills in the management of anesthesia induction, maintenance, and emergence in a broad spectrum of surgical procedures.  These procedures should include emergency, intra-thoracic, intracranial, and vascular.  The student should be competent in estimating blood and fluid loss and administer the appropriated volume replacement.


  1. Administer anesthesia to patients of all ages and physical conditions (including trauma and emergency cases) for a variety of surgical and medically related procedures.


  1. Function as a resource person for airway and ventilatory management of patients.

Question of the day

Need to stump your student. Here is a link to the question of the day.