Category: Clinical Tips

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Anesthesia Education Clinical Tips Preparing for Grad School/Residency

#105 – The Impact of Precepting on Clinical Learning

What’s up yall! This is Jon Lowrance and this is episode 105 of Anesthesia Guidebook – the impact of precepting on clinical learning with Jennifer Heiden. This episode is coming out on February 21, 2024.

Jennifer Heiden is completing her Doctor of Nursing Practice in anesthesiology at the University of Arizona and this podcast is part of her doctoral work. In this episode, we’re going to walk through the behaviors, tips & techniques preceptors can do in order to positively impact the clinical learning outcomes of anesthesia residents. Jennifer wants to hear about your experiences either as an anesthesia trainee or as a clinical preceptor in the survey that is attached to this episode. The link is in the show notes. It’s a quick survey, totally anonymous and will be used to help Jennifer complete her doctoral project at the University of Arizona.

Survey Link is Here:

https://uarizona.co1.qualtrics.com/jfe/form/SV_88sSJwSor8yDoGy

Prior to anesthesia training, Jennifer worked in medical, surgical and cardiac ICUs for 8 years on the East and West coasts. Prior to nursing school, Jennifer completed a bachelor’s degree in finance from Boston University and lived in Colorado for almost twenty years hiking, running and climbing in the mountains. 

She currently lives in Temecula, California, and has been working through anesthesia school as a single mom to her 14-year-old son. She still enjoys climbing, running and spending time with her son and all their animals.

I hope you enjoy this show. The mission of Anesthesia Guidebook is to help you master your craft as a provider. The art & science of clinical precepting is foundational to raising the next generation of highly competent providers. I’m thrilled to take a fresh look at precepting with Jennifer and you can find lots of other shows on Anesthesia Guidebook that touch on clinical education with links to each of those in the show notes to this episode.

And if you’d like to get the show notes to these podcasts straight to your inbox, along with being the first to know when a new episode drops, subscribe to the show on the website. All that does is send you the episode & show notes, nothing more & no hidden agenda. It’s totally free and I will never sell or distribute your email. So if you want to be the first to know and have all the links right at your finger tips, subscribe to show at AnesthesiaGuidebook.com!

#8 – How to master precepting with Will C0hen

#21 – Best practices in precepting with Obinna Odumodo

#22 – The demo-do teaching technique

#55 – Incivility in the Workplace with Joshua Lea, DNP, MBA, CRNA & Kelly Gallant, PhD, CRNA

#74 – Thrive in Training: how to crush clinical

#75 – Thrive in Training: communicating with preceptors

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Airway Anesthesia Education Anesthesia Equipment and Technology Cardiac Case Studies Clinical Tips Enhanced Recovery After Surgery Human Physiology and Pathophysiology Leadership in Emergencies Outpatient Anesthesia Pharmacology Preparing for Grad School/Residency

#104 – At-home cardiorespiratory events following ambulatory surgery – Chuck Biddle, PhD, CRNA

Chuck Biddle PhD, CRNA is a Professor Emeritus of anesthesiology at Virginia Commonwealth University and served as the editor in chief of the AANA Journal for 35 years.  His anesthesia education & master’s degree are from Old Dominion University and he completed his PhD in Epidemiology at the University of Missouri.  

Chuck is one of my favorite people in the world of anesthesiology.  He’s one of those folks who have put the time in over decades to develop a true, deep mastery of their profession while at the same time bringing with them a level of authenticity, integrity and humility that garners true respect.  He’s a guide.  He’s helped countless physician & nurse anesthesiology trainees develop and gain a love of the work we do.  And one of the central focuses of his career has been fervently working to understand the things that put our patients at risk and develop research and insights for practice to advance patient safety.

Which brings us to this show.  

In this episode, Dr Biddle turns our attention to what happens to patients after they go home from day surgery.  We talk about a study his team did at VCU where they sent patients home with pulse oximeter monitors and tracked their course for 48 hours following day surgery. 

We talk how novel this idea is in that very few studies have actually looked at what happens to patients following ambulatory surgery and that a certain segment of these patients – those who have obstructive sleep apnea are at particular risk for devastating postoperative complications.  Chuck points to Jonathan Benumof’s, MD 2016 article in the Canadian Journal of Anesthesia titled Mismanagement of patients with obstructive sleep apnea may result in finding these patients dead in bed (full article below).  Dr Benumof is a world-renowned physician anesthesiology and expert in airway management and pulmonary physiology. He is a professor of anesthesiology at the University of California – San Diego’s School of Medicine. Over the 15 years prior to the publication of Dr Benumof’s article in which he served as an expert witness in litigation cases, he testified on 12 cases where OSA patients died within 48 hours of surgery.  In  the article, he unpacks each of those cases and provides the following prototypical dead in bed OSA patient:

“A 58-yr-old continuous positive airway pressure (CPAP)-compliant male (170 cm, 120 kg, body mass index 40 kgm-2) with polysomnography (PSG)-proven severe OSA undergoes orthopedic, upper airway, or abdominal surgery under general anesthesia. The patient has an uncomplicated stay in the postanesthesia care unit until discharged to an unmonitored bed without CPAP or oxygen. After receiving small (and within standard of care) doses of narcotics for pain for 11 hr, the patient is found DIB [dead in bed]. Advanced cardiac life support is either not attempted or fails to return the patient to their baseline state of life (Benumof, 2016).”

This episode is one of those discussions that makes you see the work you do in a whole new light and gives you a renewed sense of ownership over making sure you and your colleagues are doing the right thing for your patients.  This show is coming out on 28 January 2024 and was originally recorded at VCU’s studio with a table top microphone back in the summer of 2017.  I apologize that the audio is a little hazy but the power of Dr Biddle’s research and passion for this topic are still very much relevant to providers today.  So with that, let’s get to the show!

Benumof, J. L. (2016). Mismanagement of obstructive sleep apnea may result in finding these patients dead in bed. Canadian Journal of Anesthesia, 63(1), 3.Download

Benumof, J. L. (2015). The elephant in the room is bigger than you think: finding obstructive sleep apnea patients dead in bed postoperatively. Anesthesia & Analgesia, 120(2), 491.

Hill, M. V., Stucke, R. S., McMahon, M. L., Beeman, J. L., & Barth Jr, R. J. (2018). An educational intervention decreases opioid prescribing after general surgical operations. Annals of surgery, 267(3), 468-472.

Biddle, C., Elam, C., Lahaye, L., Kerr, G., Chubb, L., & Verhulst, B. (2021). Predictors of at-home arterial oxygen desaturation events in ambulatory surgical patients. Journal of Patient Safety, 17(3), e186-e191. 

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Categories
Anesthesia Education Clinical Tips Enhanced Recovery After Surgery Human Physiology and Pathophysiology Opioid Free Anesthesia Pharmacology

#103 – Dexmedetomidine Deep Dive with Eliana Zimmerman

What’s up folks! This is Jon Lowrance with Anesthesia Guidebook and this is episode 103… a deep dive on dexmedetomidine with Eliana Zimmerman. This episode is coming out on January 21, 2024.

Before we get to the show I want to remind folks that I’ll be speaking in person at the Encore Symposiums’ Autumn in Bar Harbor & Acadia National Park conference running October 14-17 of this year. If you have never been to Maine, this is a great excuse to make it up here. And even if you have been or if you live here in vacationland… there’s scarcely a better place to be than Bar Harbor in October. It’s absolutely stunning. Peak leaf season usually hits in October for Bar Harbor, which is a coastal village just outside the entrance to Acadia National Park. Just google those key words… Acadia National Park – October. Or peak leaf season Bar Harbor. Then sign up for the conference ASAP because this one usually sells out quick. It’s Encore Symposiums’ Autumn in Bar Harbor & Acadia National Park conference, running October 14-17. I’m looking forward to bringing fresh perspectives on what’s new in anesthesia, pharmacology, ERAS, airway management & more for this conference. You’ll also get to meet a bunch of my friends & crew from Maine Medical Center, as this is one our team’s favorite conferences to attend… it’s close to home and has absolutely breath-taking scenery. I hope to see you there!

This is the second show I’ve done specific to dexmedetomidine… you’d have to go back a full 100 episodes… way back to episode #2 for the other show, which I did with Matt Poirier who I continue to work alongside at Maine Medical Center.

In this show, Eliana Zimmerman joins me to unpack the literature on perioperative use of dexmedetomidine, specifically focusing on the clinical impacts of dexmedetomidine in colorectal surgery.

As part of her doctorate research at Northeastern University, Eliana completed a series of expert panel inquires, synthesized with current literature, to arrive at recommendations for best practice concerning the use of dexmedetomidine in colorectal surgery. Her infographic and resources are provided in the show notes.

Eliana Zimmerman graduated Wesleyan University with a degree in Neuroscience in 2017, and University of Pennsylvania with a degree in Nursing in 2018. She worked as an ICU nurse at Jefferson Methodist Hospital from 2019 – 2022. She is currently a nurse anesthesia doctoral student at Northeastern University with an anticipated graduation of May 2025. In her limited free time she likes to backpack, run, and spend time outdoors. Her fiancé, two cats, and dog have kept her sane during the long days of anesthesia training.  

References

Chen, C., Huang, P., Lai, L., Luo, C., Ge, M., Hei, Z., Zhu, Q., & Zhou, S. (2016). Dexmedetomidine improves gastrointestinal motility after laparoscopic resection of colorectal cancer: A randomized clinical trial. Medicine (Baltimore), 95(29), e4295–e4295. https://doi.org/10.1097/MD.0000000000004295

Chen, H., & Li, F. (2020). Effect of Dexmedetomidine with Different Anesthetic Dosage on Neurocognitive Function in Elderly Patients After Operation Based on Neural Network Model. World Neurosurgery, 138, 688–695. https://doi.org/10.1016/j.wneu.2020.01.012

Cheung, C. W., Qiu, Q., Ying, A. C. L., Choi, S. W., Law, W. L., & Irwin, M. G. (2014). The effects of intra‐operative dexmedetomidine on postoperative pain, side‐effects and recovery in colorectal surgery. Anaesthesia, 69(11), 1214–1221. https://doi.org/10.1111/anae.12759

Ge, D.-J., Qi, B., Tang, G., & Li, J.-Y. (2015). Intraoperative Dexmedetomidine Promotes Postoperative Analgesia in Patients After Abdominal Colectomy: A Consort-Prospective, Randomized, Controlled Clinical Trial. Medicine (Baltimore), 94(37), e1514–e1514. https://doi.org/10.1097/MD.0000000000001514  

He, G.-Z., Bu, N., Li, Y.-J., Gao, Y., Wang, G., Kong, Z.-D., Zhao, M., Zhang, S.-S., & Gao, W. (2022). Extra Loading Dose of Dexmedetomidine Enhances Intestinal Function Recovery After Colorectal Resection: A Retrospective Cohort Study. Frontiers in Pharmacology, 13, 806950–806950. https://doi.org/10.3389/fphar.2022.806950

Lu, Y., Fang, P.-P., Yu, Y.-Q., Cheng, X.-Q., Feng, X.-M., Wong, G. T. C., Maze, M., & Liu, X.-S. (2021). Effect of Intraoperative Dexmedetomidine on Recovery of Gastrointestinal Function After Abdominal Surgery in Older Adults A Randomized Clinical Trial. JAMA Network Open, 4(10), e2128886–e2128886. https://doi.org/10.1001/jamanetworkopen.2021.28886

Qi, Y.-P., Ma, W.-J., Cao, Y.-Y., Chen, Q., Xu, Q.-C., Xiao, S., Lu, W.-H., & Wang, Z. (2022). Effect of Dexmedetomidine on Intestinal Barrier in Patients Undergoing Gastrointestinal Surgery–A Single-Center Randomized Clinical Trial. The Journal of Surgical Research, 

Sun, W., Li, F., Wang, X., Liu, H., Mo, H., Pan, D., Wen, S., & Zhou, A. (2021). Effects of Dexmedetomidine on Patients Undergoing Laparoscopic Surgery for Colorectal Cancer. The Journal of Surgical Research, 267, 687–694. https://doi.org/10.1016/j.jss.2021.06.043

Tang, Y., Liu, J., Huang, X., Ding, H., Tan, S., & Zhu, Y. (2021). Effect of Dexmedetomidine-Assisted Intravenous Inhalation Combined Anesthesia on Cerebral Oxygen Metabolism and Serum Th1/Th2 Level in Elderly Colorectal Cancer Patients. Frontiers in Surgery, 8, 832646–832646. https://doi.org/10.3389/fsurg.2021.832646

Xu, B., Li, Z., Zhou, D., Li, L., Li, P., & Huang, H. (2017). The influence of age on sensitivity to dexmedetomidine sedation during spinal anesthesia in lower limb orthopedic surgery. Anesthesia & Analgesia, 125(6), 1907-1910. https://doi.org/10.1213/ANE.0000000000002531

Zhang, J., Liu, G., Zhang, F., Fang, H., Zhang, D., Liu, S., Chen, B., & Xiao, H. (2019). Analysis of postoperative cognitive dysfunction and influencing factors of dexmedetomidine anesthesia in elderly patients with colorectal cancer. Experimental and Therapeutic Medicine, 18(3), 3058–3064. https://doi.org/10.3892/ol.2019.10611


If you want to dive deeper, recommended reading:

  1. Ischemia Reperfusion Injury:
    1. “Pathophysiology of Reperfusion Injury”  https://www.ncbi.nlm.nih.gov/books/NBK534267/#:~:text=Ischaemia%2DReperfusion%20injury%20(IRI),essential%20to%20salvage%20ischaemic%20tissues
  2. Postoperative pain and the Gut Microbiome
    1. Brenner, Shorten, & Mahony 2021

DNP Reference Tools

  1. AGREE II 
    1. Overview
      1. https://www.ncbi.nlm.nih.gov/books/NBK525667/
    1. Manual
      1. https://www.agreetrust.org/resource-centre/agree-ii/
  2. United States Preventive Service Task Force Grading
    1. Methods:
      1. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes
    1. Grading System
      1. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions
  3. Modified Delphi Technique Assessment of Appropriateness
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299905/
Dexmedetomidine-InfographicDownload
Zimmerman-E-Narrative-1Download

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Anesthesia Education Anesthesia Equipment and Technology Cardiac Clinical Tips Human Physiology and Pathophysiology

#101 – EKG Lead Selection for Perioperative Monitoring – Mark Kossick, DNSc, CRNA

This is an incredibly special podcast that I’m thrilled to pull forward from our old show, From the Head of the Bed, to Anesthesia Guidebook.

I love that this episode is number 101 because EKG lead selection should be 101-level knowledge for anesthesia providers, yet so many folks have not mastered this fundamental knowledge as part of their practice. I hope you get as much from this as I have over the years.

Dr Mark Kossick was a full professor of anesthesia at Western Carolina University when my wife, Kristin, and I attended the program and he actually just retired in late 2023 from that university. Kristin arranged for Dr Kossick to contribute his expertise to this podcast while we were still in the program back in early 2015 and this episode was released as one of the original group of podcasts that launched From the Head of the Bed that year.

Dr Kossick will give a more detailed introduction of his professional background at the start of this show – and, I’m thrilled to have Kristin’s voice on the podcast with all her pre-Mainer southern drawl – as she introduces him. Dr Kossick was known as an incredibly challenging yet supportive professor. His area of expertise was intra-operative monitoring and the uptake and distribution of volatile anesthetics. He had a passion for the many beautiful curves of the science of anesthesia, whether it was the oxyhemoglobin dissociation curve, the Fa/Fi curve or one of the many other curves that define the science behind what we do every day. Kristin and I and so many other CRNAs from WCU, the University of Alabama at Birmingham and others have learned so much from Dr Kossick and consider ourselves fortunate to have sat in and survived his classes.

This is an incredibly thorough review of the very basics of EKG lead placement, selection and monitoring for anesthesia care. This is a skill and knowledge set that, unfortunately, many anesthesia providers and perioperative nursing staff overlook and blaze past. As Dr Kossick says in the show, simply having a EKG pattern on the screen from careless placement of EKG leads is not enough for safe monitoring. Dr Kossick walks us through the core data on EKG monitoring, including some modified leads, so this show is excellent for both trainees and experienced providers alike.

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Anesthesia Education Anesthesia Equipment and Technology Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency

#97 – Safety is a capacity

What up folks! This is another short podcast on the idea that safety is a capacity, not an outcome. This idea comes out of Todd Conklin & Sidney Dekker’s work on organizational safety where they discuss two ways of looking at safety:

The Safety 1 Perspective or the old way of thinking is that safety is about minimizing errors.  It’s about identifying risks, including human behaviors, and implementing steps to prevent errors from happening.  Success is often measured in low to zero error rates and errors are punishable offenses.  

The Safety 2 Perspective doesn’t overlook the need to minimize errors.  But it focuses on building the capacity for the right thing to happen versus a feverish focus on whack-a-moling potential risk and, frankly, whack-a-moling the people who make mistakes.

The idea is that safety is not an outcome but rather a capacity that’s built up over time through thoughtful design of systems and careful handling of people and systems both when things go right as well as when errors happen.  It’s about figuring out how humans are doing the work – including all of their workarounds – in order to generate successful outcomes and finding ways to support and foster positive outcomes on a consistent basis.  And when things go wrong, people aren’t punished.  While egregious error or outright negligence is always possible, Safety 2 presumes people are smart and are trying to do the right thing.  So if something goes wrong, there is likely a system input, factor or design that created a high probability that something would in fact go wrong.  So the focus is on understanding how the worker performed in a faulty system and trying to improve that system so there’s a higher likelihood that the right thing happens the next time around.

Check out the short podcast for a couple of illuminating stories to bring these principles to life. As always, drop me an email or message on social media if you’d like to connect!

Resources:

Todd Conklin’s Pre-Accident Investigation podcast

Sidney Dekker’s professional website

Upcoming conferences I’m speaking at:

Maine Association of Nurse Anesthesiology: https://meana.org MEANA Fall Conference in Portland, Maine (virtual option available)

Encore Symposium’s New England at the Cliff House, Cape Neddick, Maine October 16-19, 2023

Encore Symposium’s Autumn in Bar Harbor & Acadia National Park, October 14-17, 2024

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Airway Anesthesia Education Anesthesia Equipment and Technology Case Studies Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency

#93 – OR Fires with April Bourgoin, DNAP, CRNA

In this episode, I speak with Dr April Bourgoin, DNAP, CRNA about operating room fires – how they can start and how we can respond to them as anesthesia providers. This show was originally released in 4 years ago in February of 2019 on the podcast From the Head of the Bed and was recorded with a table top microphone so the audio is a little suboptimal, but I’m sure you’ll still find this to be a very hot topic that will smolder in your memory for years to come after they key details become seared into your clinical practice. Hopefully, this podcast will really help you turn up the heat on your OR fire prevention practices… and now that we have almost all of the puns put out, let me tell you about Dr Bougoin.

Dr Bourgoin completed her Master of Nursing Science (MSN) and Doctorate of Nurse Anesthesia Practice at Virginia Commonwealth University. Prior to becoming a CRNA, she served for eight years as an active duty commissioned officer in the Army with experience as a critical care Registered Nurse and flight nurse with the 82nd Airborne Dustoff medevac team. She served two combat tours prior to transferring to the Army Reserves at the rank of Major and then returned to school for her master’s and doctorate degrees in anesthesia.

Dr Bourgoin had a case in which there was an OR fire and we discuss that story in detail in this podcast. She then unpacks OR and airway fires for us, including contributing factors, prevention, crisis management and the importance of critical incident debriefing.

Currently, I have the incredible privilege in working closely with April to support our CRNA group at Maine Medical Center in Portland, Maine. April is one of our 2 CRNA Supervisors and an invaluable part of our CRNA leadership team. I think you’re really going to enjoy hearing from her on this topic and in an upcoming episode on the pathophysiology of vaping associated lung injury.

In the show notes to this episode we have links to the Anesthesia Patient Safety Foundation’s infographics and video on OR fire prevention and safety, which are excellent resources to share with colleagues & classmates. We also link to a resource called Anesthesia eNonymous, which is a website hosted by faculty from Virginia Commonwealth University’s Nurse Anesthesia program where providers and anesthesia learners can anonymously share and read real stories of near misses, medical errors & other clinical experiences. As it’s been said: good judgment comes from bad judgment and it’s better to learn from others mistakes & bad judgement calls than having to make your own along the way. So be sure to check out the links in the show notes to this podcast that Dr Bourgoin has shared and with that, let’s get to the show!

Anesthesia Patient Safety Foundation Fire Safety Video

Anesthesia e-Nonymous – Virginia Commonwealth University

APSF Fire Safety Video Contributes to 44% Decrease in Intraoperative Fires Since 2011

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Anesthesia Education Anesthesia Equipment and Technology Clinical Tips Pharmacology

#90 – The Environmental Impact of Desflurane with Jacob Bonnema

Climate crisis is a growing global health problem, one which the field of anesthesia contributes to with its use of volatile anesthetic gases. This podcast is part of the doctoral project of Jacob Bonnema and it aims to increase knowledge and awareness of the environmental effects of volatile gases, particularly desflurane, to empower providers to plan environmentally-conscious anesthetics.

As of October 2022, Jacob Bonnema, BSN, RN, CCRN is a senior nurse anesthesia resident at NorthShore University HealthSystem School of Nurse Anesthesia in Chicago, IL. He has a passion for environmentalism and when it came to selecting a topic for his DNP project, wanted to choose a subject that would incorporate that interest.

Jacob is conducting a study associated with this podcast and we’re asking for your participation.  Please click the link below to take the pre-survey, then listen to show and follow the same link below to take the post survey.

Jacob has made this incredibly easy by imbedding the audio for the podcast directly between the 2 surveys at the link below. Just click the link and you’ll see the pre-survey, then the audio content and then the post-survey all at Jacob’s site… super easy!

You can also listen to the audio at Anesthesia Guidebook or wherever you listen to podcasts!

Take the Survey Here!

QR Code Survey.png
QR Link for the survey

Here’s 2 reasons you should do these super quick surveys:  the most important is that it will help you learn the content better and make this show stick in your incredibly powerful brain.  By testing your knowledge up front, then listening to the content, the retesting to see what you picked up in the show, you will increase your ability to recall this information so you sound really smart when talking about it with your colleagues & students at work. 

And the second reason is that by completing this survey you can feel good about yourself because you’re contributing to science.  The more people who complete the pre & post surveys, the better data Jacob will have.  And that makes you and Jacob happy.  And me.  We’ll both be stoked if you pause the podcast now and hit the pre & post surveys.

All right, with that, let’s get to the show… 

(References available upon request; Jacob’s contact information is available through the survey link.)

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Anesthesia Education Anesthesia Equipment and Technology Business/Finances Case Studies Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency Wellness

#89 – Distraction in the OR with Heather Turcotte, DO

What’s up y’all this is Jon Lowrance and this is episode 89 – Distraction in the OR with Heather Turcotte, DO. Y’all, I am so stoked to bring you this conversation… I caught up with Dr Turcotte earlier this summer as she was finishing her residency in anesthesia and I’m pumped to finally get this out to you in early September of 2022. This topic was the focus of her residency project and senior grand rounds presentation and it definitely created a stir in our group as CRNAs, physicians, residents & SRNAs grappled with how to appropriately use cell phones and other technology in their practices.

Since it’s late summer, early fall… I gotta give a shout out to all the residents & SRNAs out there who graduated this summer. It’s always fun to see yall wrap up clinicals & residency projects and transition into your new jobs or fellowships.

I love getting texts & photos from SRNAs of their board results with the word PASS printed in the middle of the page… It’s such an incredible moment that makes all of the hard work worth it. So thanks to all of you who have reached out by email, text & social media recently with your passing boards photos, positive reviews & ratings of the podcasts and questions. This podcast puts me in touch with so many amazing people… I’ve recently heard from experienced providers to newly minted CRNAs on the day they pass boards, to brand new CA1’s to ICU nurses who found the podcast and are on the path to becoming anesthesia providers. Wherever you are in your own journey, my hope is that Anesthesia Guidebook will be a go-to guide for you as you seek to get your learn on and master your craft.

Heather Turcotte, DO joins me in this is fascinating conversation that weaves through the considerations around using cell phones in the OR, checking email/internet, music that’s playing, conversations, door swings and other forms of distraction in the operating room.

Dr Turcotte was born and raised in the great state of Maine. She earned a doctorate in physical therapy and practiced as a physical therapist for 4 years before going back to medical school in 2014 at the University of New England. Dr Turcotte finished her residency in anesthesiology at Maine Medical Center in 2022 and entered into private practice. Outside of medicine, she enjoys spending time with her husband and 3 kids, who are 9, 6, and 1 years old at the time of this recording, going to the beach, and drinking lots of coffee!

In this conversation, Dr Turcotte brings this discussion to life with a case study where an anesthesia provider settled out of court in a dispute on negligence in a case where the patient experienced hypotension and a PEA arrest, survived the case but died a few days later. The anesthesia provider had used their cell phone and anesthesia station computer to check email and online news stories. Interestingly, an expert anesthesia witness testified that the actions of the anesthesia provider in managing the patient were flawless. But just because the provider had used their cell phone & surfed the internet on the work computer, the legal team advised they settle to avoid a jury verdict on the case.

Cell phone use, open internet access including email, music playing the OR and so many other forms of distraction are common elements in operating rooms across the United States. Some institutions create policies that limit cell phone use in the OR. Others have policies that are more vague while others have no formal policies around cell phone use in the OR. There’s legitimate considerations for each of these… On one hand, how does a hospital enforce a policy that is very strict? Does creating a policy set that institution up for compliance issues or litigation? On the other hand, how can hospitals help engineer safe and reliable environments for providers to work in? As technology continues to become more and more central t0 the work we do, the issues of attention span, distraction, user experience of technology and systems engineering to create & maintain safe environments will remain important factors for each provider, group and institution to consider.

References

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Airway Anesthesia Equipment and Technology Clinical Tips Human Physiology and Pathophysiology Leadership in Emergencies Pharmacology Trauma

#87 – Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA – Part 2

What’s up yall this is Jon Lowrance with Anesthesia Guidebook.  I am so pumped to bring you this series of 3 episodes on Combat Trauma Anesthesia!  

This is episode 87 and it’s part 2 off a three-part series with Dustin Degman, a CRNA formerly with the United States Army.

In the first episode, we discussed Dustin’s experience in Afghanistan serving at a forward operating base in Paktika Province in 2012 to 2013.  We talk about what makes up forward surgical teams and the role of CRNAs as the sole anesthesia provider on these teams.

In this part – part two, we discuss the principles of damage control resuscitation in the context of forward surgical bases and combat zones. While this discussion is focused on combat trauma anesthesia, the core underlying principles of damage control resuscitation hold true for civilian trauma centers.

And then in part three, we’re gonna come back and talk about the path to becoming a military CRNA and the importance of supporting our troops.  

This series was originally recorded in early 2015, just a year or so after Dustin had returned from Afghanistan and while the war there was still raging.  At the time, I was completing my anesthesia training at Western Carolina University and working on launching From the Head of the Bed… the podcast the preceded Anesthesia Guidebook.  Dustin was one of my professors and clinical faculty at WCU and was kind enough to volunteer his time for these interviews back then.  The reason I’m bringing them forward here is that they’re chock full of wildly fantastic details on the experience of a forward-deployed military anesthesia provider and the principles of trauma anesthesia, which are absolutely relevant today.

Dustin served with the Unites States Air Force from 1998 – 2002 as a critical care Registered Nurse.  He was honorably discharged and went on to complete his anesthesia training outside of the military.  In 2010, he re-enlisted with the Army Reserves as a CRNA and was deployed in November 2012 to Forward Operating Base Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team providing damage control resuscitation to injured soldiers.  Most recently, Dustin serves as the chief CRNA at PeaceHealth’s Peace Harbor Medical Center in Florence, Oregon.  In 2021, Dustin was awarded the PeaceHealth Mission & Values award and the organization put together an incredible video tribute to Dustin.  Degman is the real deal… he was the real deal a decade ago when he was serving in Paktika Province, Afghanistan, which he talks about in these next 3 episodes and he’s still the real deal as he serves as a CRNA with Peace Harbor Medical Center out on the coast of Oregon.

I think you’re going to really enjoy hearing from Dustin on combat trauma anesthesia and with that, let’s get to the show!

To close each of these 3 episodes out, I’d like to encourage you to make a donation to the Pat Tillman Foundation in honor of Army Ranger Pat Tillman who was killed in Afghanistan in 2004.  The Pat Tillman Foundation awards academic scholarships to military service members, veterans and their spouses.  Dustin Degman identified this as one of the several service organizations that he believes in and encourages you to give to either the Pat Tillman Foundation or an organization you connect with.  If we each give $10-20, our collective impacts will make a huge difference.

Resources:

#83 – Positive Deviance as a Catalyst for Change with Cherie Burke, DNP, CRNA

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Anesthesia Education Clinical Tips Leadership in Emergencies Trauma

#86 – Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA – Part 1

What’s up yall this is Jon Lowrance with Anesthesia Guidebook.  I am so pumped to bring you this next series of 3 episodes!  

This is episode 86 and it kicks off a three-part series with Dustin Degman, a CRNA formerly with the United States Army on combat trauma anesthesia.  

In this first episode, we discuss Dustin’s experience in Afghanistan serving at a forward operating base in Paktika Province in 2012 to 2013.  We talk about what makes up forward surgical teams and the role of CRNAs as the sole anesthesia provider on these teams.

In part two, we discuss the principles of damage control resuscitation and the context of operating in a combat zone.

In part three, we talk about the path to becoming a military CRNA and the importance of support our troops.  

This series was originally recorded in early 2015, just a year or so after Dustin had returned from Afghanistan and while the war there was still raging.  At the time, I was completing my anesthesia training at Western Carolina University and working on launching From the Head of the Bed… the podcast the preceded Anesthesia Guidebook.  Dustin was one of my professors and clinical faculty at WCU and was kind enough to volunteer his time for these interviews back then.  The reason I’m bringing them forward here is that they’re chock full of wildly fantastic details on the experience of a forward-deployed military anesthesia provider and the principles of trauma anesthesia, which are absolutely relevant today.

Dustin served with the Unites States Air Force from 1998 – 2002 as a critical care Registered Nurse.  He was honorably discharged and went on to complete his anesthesia training outside of the military.  In 2010, he re-enlisted with the Army Reserves as a CRNA and was deployed in November 2012 to Forward Operating Base Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team providing damage control resuscitation to injured soldiers.  Most recently, Dustin serves as the chief CRNA at PeaceHealth’s Peace Harbor Medical Center in Florence, Oregon.  In 2021, Dustin was awarded the PeaceHealth Mission & Values award and the organization put together an incredible video tribute to Dustin.  Degman is the real deal… he was the real deal a decade ago when he was serving in Paktika Province, Afghanistan, which he talks about in these next 3 episodes and he’s still the real deal as he serves as a CRNA with Peace Harbor Medical Center out on the coast of Oregon.

I think you’re going to really enjoy hearing from Dustin on combat trauma anesthesia and with that, let’s get to the show!

To close each of these 3 episodes out, I’d like to encourage you to make a donation to the Pat Tillman Foundation in honor of Army Ranger Pat Tillman who was killed in Afghanistan in 2004.  The Pat Tillman Foundation awards academic scholarships to military service members, veterans and their spouses.  Dustin Degman identified this as one of the several service organizations that he believes in and encourages you to give to either the Pat Tillman Foundation or an organization you connect with.  If we each give $10-20, our collective impacts will make a huge difference.

Resources:

Care behind the battlefield
Dustin Degman was featured in Asheville’s Mountain Express in 2013.

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Anesthesia Education Clinical Tips Human Physiology and Pathophysiology Opioid Free Anesthesia Pharmacology Regional Anesthesia

#85 – The McLott Mix – Part 2 with Jason McLott, MSN, CRNA

Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium.

Jason is clear that the McLott Mix helps achieve opioid-free anesthesia, not opioid-free analgesia, recognizing the role of opiates, if needed, in post-operative analgesia plans.

Jason completed his anesthesia training at Oakland University’s Beaumont Nurse Anesthesia program and works in a CRNA-only practice at Blue Ridge Hospital in rural North Carolina. He regularly mentors SRNAs from Western Carolina University, giving them exposure to a CRNA-only practice, extensive regional anesthesia experience and opioid-free anesthesia techniques. Jason also instructs regional anesthesia courses with Twin Oaks Anesthesia.

If you’ve followed Anesthesia Guidebook for any amount of time, you’ll probably remember that Western Carolina University is my alma mater. I would highly recommend WCU as a premier school for becoming a CRNA. The faculty & clinical sites are top notch and you can’t beat the location down in Asheville, North Carolina.

In Part 1 of this conversation, we talked about Jason’s background, what led him to get into opioid-free anesthesia and the details of the McLott Mix and how he suggests it be used. In Part 2 of our conversation, we come back to talk in more detail on the nuances of how Jason uses the McLott Mix in his practice and how providers can instigate change in moving their practices and groups towards opioid-free anesthesia. Part 2 is a prime example of what Randy Moore & Desirée Chappell & I talked about in episode 82 on change management in healthcare. Hopefully these 2 shows with Jason McLott get you thinking about real ways that you can build opioid-free techniques into your anesthesia practice.

Schenkel, L., Vogel Kahmann, I., & Steuer, C. (2022). Opioid-Free Anesthesia: Physico Chemical Stability Studies on Multi-Analyte Mixtures Intended for Use in Clinical Anesthesiology. Hospital pharmacy, 57(2), 246-252.

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Anesthesia Education Clinical Tips Enhanced Recovery After Surgery Human Physiology and Pathophysiology Opioid Free Anesthesia Outpatient Anesthesia Pharmacology Preparing for Grad School/Residency Regional Anesthesia

#84 – The McLott Mix – Part 1 with Jason McLott, MSN, CRNA

Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium. In this episode, Mr McLott himself unpacks the story of the mix’s development, efficacy and principles for opioid-free anesthesia. He’s clear that this mix helps achieve opioid-free anesthesia, not opioid-free analgesia, recognizing the role of opiates, if needed, in post-operative analgesia plans.

Jason completed his anesthesia training at Oakland University’s Beaumont Nurse Anesthesia program and works in a CRNA-only practice at Blue Ridge Hospital in rural North Carolina. He regularly mentors SRNAs from Western Carolina University, giving them exposure to a CRNA-only practice, extensive regional anesthesia experience and opioid-free anesthesia techniques. Jason also instructs regional anesthesia courses with Twin Oaks Anesthesia.

If you’ve followed Anesthesia Guidebook for any amount of time, you’ll probably remember that Western Carolina University is my alma mater. I would highly recommend WCU as a premier school for becoming a CRNA. The faculty & clinical sites are top notch and you can’t beat the location down in Asheville, North Carolina.

In Part 1 of this conversation, we talk about Jason’s background, what led him to get into opioid-free anesthesia and the details of the McLott Mix and how he suggests it be used. In Part 2 of our conversation, we come back to talk in more detail on the nuances of how Jason uses the McLott Mix in his practice and how providers can instigate change in moving their practices and groups towards opioid-free anesthesia. Part 2 is a prime example of what Randy Moore & Desirée Chappell & I talked about in episode 82 on change management in healthcare. Hopefully these 2 shows with Jason McLott get you thinking about real ways that you can build opioid-free techniques into your anesthesia practice.

Schenkel, L., Vogel Kahmann, I., & Steuer, C. (2022). Opioid-Free Anesthesia: Physico Chemical Stability Studies on Multi-Analyte Mixtures Intended for Use in Clinical Anesthesiology. Hospital pharmacy, 57(2), 246-252.

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Anesthesia Education Business/Finances Clinical Tips Preparing for Grad School/Residency

#83 – Positive Deviance as a Catalyst for Change with Cherie Burke, DNP, CRNA

“Positive deviance is really about… taking those things that people are doing right and sharing them with everyone so that everyone is doing things to improve our patients’ care, our patients’ outcomes.” 

Cherie Burke, DNP, CRNA

Dr Cherie Burke joins me to unpack how positive deviance can be a catalyst for change in healthcare.

Positive deviance is all about looking for what’s going right and transferring those lessons to other opportunities, processes & providers to improve performance.

Aggressive action & investigation is the norm when something goes wrong. Think about when a sentinel event happens. There’s mandatory reporting, root cause analysis (RCAs), critical incident debriefs and a concerted effort to prevent errors & improve processes in the future. Positive deviance is a process of applying a similar degree of effort to what’s working right. Can we find the high performers, figure out what they’re doing well and transfer those techniques, processes & beliefs to other domains?

Cherie Burke, DNP, CRNA completed her Master of Science in Nursing at DeSales (duh-sales) University, her Doctorate in Nursing Practice at La Salle (la-sal) University, a post-doctoral fellowship in patient safety at the VA Medical Center in Philadelphia and is currently a PhD candidate at Duquesne (do-cane) University.

Dr Burke and I worked together at Maine Medical Center in Portland, Maine and have also taught alongside one another with Cornerstone Anesthesia Conferences. Cherie is actually who connected me with Jayme Rueter, the CRNA who founded Cornerstone and who gave me my first shot at teaching other CRNAs at continuing education conferences.

I think you’re going to enjoy this conversation… learning how to find positive deviance at play in our organizations is key for us to improve the work that we do.

This episode was originally released on From the Head of the Bed on January 26, 2016.

Resources: 

Bradley, E. H., Curry, L. A., Ramanadhan, S., Rowe, L., Nembhard, I. M., & Krumholz, H. M. (2009). Research in action: using positive deviance to improve quality of health care. Implementation science, 4(1), 1-11.

Ford, K. (2013). Survey of syringe and needle safety among student registered nurse anesthetists: are we making any progress?. AANA journal, 81(1).

Gary, J. C. (2013). Exploring the concept and use of positive deviance in nursing. AJN The American Journal of Nursing, 113(8), 26-34.

Lawton, R., Taylor, N., Clay-Williams, R., & Braithwaite, J. (2014). Positive deviance: a different approach to achieving patient safety. BMJ quality & safety, 23(11), 880-883.

Prielipp, R. C., Magro, M., Morell, R. C., & Brull, S. J. (2010). The normalization of deviance: do we (un) knowingly accept doing the wrong thing?. Anesthesia & Analgesia, 110(5), 1499-1502.

Rosenberg, T. (2013, February 27).  When deviants do good.  The New York Times, Retrieved from http://opinionator.blogs.nytimes.com/2013/02/27/when-deviants-do-good/?_r=0

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Anesthesia Education Clinical Tips Personal Finances Preparing for Grad School/Residency Wellness

#78 – Thrive in Training: how to transition to practice

This episode covers advice for the last six months of anesthesia training, transitioning out of training and into the first six months of your anesthesia practice.

The year encompassing your last six months of training through boards and your first six months of practice is epic!  

There’s a huge learning curve you encounter during your first six months of anesthesia practice following the “completion of training.” Finishing training is a bit of a misnomer given that the best providers keep training… keep practicing and developing towards true expertise and mastering their craft.

This was the first solo episode I produced on From the Head of the Bed, meaning just me and the mic. I originally published this on February 1, 2016, about 8 months after I completed anesthesia training and passed boards. At the time, I wanted to do a show on transitioning to practice before the lessons of that time faded from my immediate memory.

I think there’s three big aspects of the last six months of anesthesia training: completing your research/thesis/DNP or residency project, securing a job and passing boards. For CRNAs, we must pass boards before we begin work. For physician residents, you may start working as a board-eligible physician anesthesiologist and work towards completing boards after you make that transition to practice.

I speak a bit about wrapping up training in this episode from the experience side of things… your co-residents will likely scatter to take jobs all across the nation after training. Try to connect with them in the final months and thank your program faculty. They pour a ton of effort into developing you as a provider and launching you into the world. A little gratitude goes a long way towards helping them know their work is appreciated.

The first six months of your practice brings a massive learning curve as you’re finally charged with putting all of the pieces together on your own. This is an important time where you must answer the following questions concerning your actual practice:

  1. Why do I do what I do?
  2. Why do I not do what I don’t do?

Sounds simple enough, but you must clarify your decision making around clinical judgments and interventions finally for yourself and not because your program faculty or preceptors prefer you to do or not do something. My encouragement is that you frame your decision making on the latest evidence for best practices and not simply because you taught one way to do things. You must continue to evolve your practice after graduation.

I hope you enjoy this show. As always, drop your comments or questions on the website, social media or in an email to me. If you haven’t already, please take 3-5 minutes and drop a review on Apple podcasts. You rating, but especially your written review, helps push the podcast out to more people and helps those individuals trust the show.

I mentioned this article in the podcast:

Assante, J., Collins, S., & Hewer, I. (2015). Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review. AANA Journal, 83(4), 281-288.

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Anesthesia Education Clinical Tips Preparing for Grad School/Residency

#76 – Thrive in Training: the SEE & NCE exams

This episode covers the NBCRNA’s SEE & NCE exams for SRNAs/RRNAs. Get these on lock down. Thrive in training.

The Self-Evaluation Exam (SEE) is a 240-question computerized adaptive exam that’s designed for three reasons:

  1. help the SRNA gauge their progress in their training program
  2. help program faculty gauge how well they’re preparing students
  3. help SRNAs prepare for the NCE board exam

NBCRNA’s website for the SEE is here: SEE Resources.

The National Certification Exam (NCE) is the board exam required to become a Certified Registered Nurse Anesthetist (CRNA).

The NCE is a 100-170 question computerized adaptive exam that includes 30 random, non-graded questions. All examinees will take at least 100 questions. The exam shuts off between 100 – 170 questions once a minimum passing (or failing) standard is met. The cost of NCE is $995 and is available only to graduates of accredited nurse anesthesiology training programs.

NBCRNA’s website for the NCE is here: NCE Resources.

The NBCRNA also provides an exam tutorial for the SEE/NCE, which is an extremely valuable resources: SEE/NCE Exam Tutorial.

In this podcast, I break down the SEE & NCE in detail and share advice for how to approach both exams. I also go in-depth on preparation for the NCE in episode 14 of Anesthesia Guidebook with expert-exam coach, LTC Peter Strube, DNP, CRNA. Dr Strube has coached nurse anesthesia trainees in passing boards both ahead of their initial try at boards and, most often, after they’ve failed. His insights are invaluable for preparing for boards so I’d definitely recommend checking out that episode.

I will also hit on the NCE in an upcoming show about wrapping up training and preparing for the transition to practice.

You can watch the trailer for SOMM here.

As always, drop me an email, IG/Facebook message or comment here on the website with your questions or comments.

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Anesthesia Education Clinical Tips Preparing for Grad School/Residency

#75 – Thrive in Training: communicating with preceptors

In this episode, the founders of From the Head of the Bed… Jon Lowrance, Kristin (Andrejco) Lowrance, Brad Morgan & Cassidy Padgett, talk about how to communicate with preceptors as anesthesia trainees.

This conversation was recorded as one of the original podcasts released at the launch of From the Head of the Bed, the podcast the proceeded Anesthesia Guidebook, back on March 10, 2015. Over 7 years later, it’s getting a re-release here as part of the Thrive in Training series and the tips shared are just as relevant as ever.

All four of these folks were third-year SRNAs at the time of this recording and offer tips for anesthesia trainees hitting the clinical environment for how to communicate with preceptors. How well you get along with the folks you work with in the OR will either make or break your day – as an anesthesia trainee and as a licensed anesthesia provider. It takes a hefty dose of emotional intelligence to navigate the relationships found in the OR. This is one of the things that many anesthesia trainees find surprising: just how hard they have to work to understand the people they work with, what relationships are already at play in the OR between OR RNs, surgeons, CSTs & anesthesia providers and how to create positive working relationships with preceptors.

It’s rare that anesthesia training programs – for CRNA or physician anesthesiologists – provide education on how to become a clinical anesthesia educator or preceptor. Those skills are usually left up to anesthesia providers to figure out on the job. Given that, many anesthesia providers don’t approach their roles as preceptors and clinical educators with deliberate and highly functional skills and techniques. They just do their job as anesthesia providers and expect anesthesia trainees to figure the job out as they work together through the day. Given this context, it’s critical for anesthesia trainees to understand how to communicate with preceptors in order to create positive working relationships.

That’s not to say that the onus is just on anesthesia trainees for creating their own positive educational experiences. Certainly, clinical faculty and anesthesia training programs should bear the primary responsibility for creating effective educational environments for their trainees. But given that the quality of educational settings for anesthesia trainees can vary greatly, along with the clinical teaching skills of faculty, it can only help if you as an anesthesia trainee show up with some knowledge of how to communicate with your preceptors. So that’s what we talk about in this podcast.

We hit on the following topics:

  • Importance of communication skills in the perioperative environment
  • How to prepare for clinicals
  • Tips for making pre-clinical phone calls to preceptors
  • The use of cell phones/electronic devices in the OR
  • Common questions preceptors ask students
  • How your communication skills should evolve during training
  • Importance of being teachable, flexible, humble and thankful

In the podcast, we talk about the “smooth & in” video. Unfortunately, I can’t find it and the prior link has been removed. It was a classic. If someone can find it, let me know.

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Anesthesia Education Clinical Tips Preparing for Grad School/Residency

#74 – Thrive in Training: how to crush clinical

This episode offers a run down on how to prepare for the clinical phase of anesthesia training. We touch on practical tips like which apps are helpful, what gear to utilize & how to acclimate to the clinical environment as well as meta issues like developing emotional intelligence and the right kind of attitude to create success in your journey.

I also highlight a bunch of other shows on Anesthesia Guidebook that are not part of this series that you may find helpful.

Outside of the Thrive in Training series, we’ve got lots of content on pharmacology and much more to come.  But to prepare for clinical, don’t miss the shows on the top drawer run down (episodes 17, 18 & 19), which for years were the number 1 requested content and remain some of the most listened to episodes.  Other shows on pharmacology include run downs on dexmedetomidine, succinylcholine, buprenorphine, the pharmacokinetics & pharmacodynamics of volatile anesthetics, local anesthetics and ondansetron for preventing spinal induced hypotension.  We’ve got an episode on a multi-modal, opioid sparing approach to total knee replacement surgery, one that overviews regional anesthesia, one on opioid free anesthesia and one on the anesthesia implications for patients who use cannabis.  

Other content that you’ll find helpful are 2 shows for anesthesia trainees who are going through the process with your families:  episode 15 is specifically about your significant others and anesthesia school with Jenny & Robert Montague.  Rob is now one of my CRNA colleagues here in Portland, Maine and his wife, Jenny, is a Registered Dietician.  They have 2 young kids and talk about the experience of doing anesthesia school as a family.  The other episode is number 50 – parenting during anesthesia training with Lein & Nate Woodin.  Lein was actually in Robert’s class at the University of New England and her husband, Nate, is a licensed child therapist.  They’re an amazing couple, also with 2 young kids, and we focus in specifically on the changing dynamics of parenting during anesthesia training.  Nate brings a wealth of experience to the conversation as a child therapist and husband of an SRNA.  

A couple other episodes you’ll want to go back to check out that would fit perfectly in the Thrive in Training series:  

Episode 10 is 10-quick tips on mastering airway management, episode 24 is with Jason Bolt and we talk about avoiding landmines as an anesthesia trainee in how you represent yourself on social media.  Episodes 31-37 all deal with learning anesthesia & the path to expertise; so we hit on deliberate practice, understanding cognitive state of flow in balancing challenge with skill and the power of the invisible can-of-calm.  We also hit on asynchronous learning, emotional intelligence of SRNAs and the transition, this year, of entry-to-practice training for CRNAs becoming a doctorate degree, when, for the last 30 years or so, it’s been a master’s degree.  

Then there’s a 10-episode run on provider wellness from episodes 51 through 60 that touch on everything from how to pay your debt off, to dealing with the pandemic to how to weather the storms and setbacks you’ll have in anesthesia training.  The top show in that run for anesthesia trainees, if you want to go back and just pick out one, is episode 54: hardship in anesthesia school.  This continues to be one of the most-listened to episodes from all of Anesthesia Guidebook and zeroes in on the best advice and stories I have for you if you find yourself up against a wall or being beat down by god-knows what on your path to becoming an anesthesia provider.  

Here’s the NRS Video Dream where Ben Marr imagines what life would be like if he was good at paddling. It’s amazing! (This is what it’s like to be a novice in the OR, watching the expert providers all around you… you just WANNA BE GOOD!)

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Anesthesia Education Clinical Tips Personal Finances Preparing for Grad School/Residency Wellness

#67 – How to Thrive in Training

This is the first episode in a series that will focus on helping anesthesia residents thrive in training. This is designed for physician and nurse anesthesia trainees and will unpack crucial beta for helping you dial your game in during anesthesia training.

In this first episode I discuss finding your why behind going to anesthesia school. Your why is what will propel you through the tough times in training and help you find the motivation to excel.

Angela Duckworth is a psychologist and researcher who, in her bestselling book titled Grit – the power of passion and perseverance, says that grit is what separates those who succeed from those who fail when facing extreme challenge.

Your why will help you develop the level of grit that you need to get through the challenges of anesthesia training.  

Grit is what you have when your passion fuels a perseverance that propels you through obstacles to achieve your goals.

Duckworth says there’s four components of developing grit: interested, practice, purpose and hope.

Do you have an authentic interest in the work anesthesia providers do? Are you stoked about the field of anesthesia and have an accurate mental representation of what it’s actually about?

You will need to develop deliberate practice in order to master the craft of anesthesia and become competent in the core skills/knowledge base. If you’re unwilling to do this, anesthesia training will quickly seem overwhelming and you probably won’t make it. But deliberate practice is the key to unlocking true skill development and expertise and will make the road ahead achievable.

You must know your purpose – or your why – behind going to anesthesia school. This episode is all about finding that. It will be the reason you come back to when the road gets tough and you have to find the motivation to push through the challenges, set backs and hurdles that will inevitably come your way.

And lastly, hope is what you will have in your back pocket when you believe that the journey is worth all the hard work you put in. Hope comes when you believe that the juice is worth the squeeze, that the payoff is worth the effort.

Interest. Practice. Purpose. Hope. When you understand and foster each of these in your journey, you will develop a grittiness that will see you through the steepest of climbs and most difficult days.

Stay tuned for the upcoming series where you’ll hear from CRNAs, professors and SRNAs alike on the following topics:

  • developing a growth mindset
  • dialing in didactics
  • crushing clinicals
  • developing time management
  • avoiding landmines and overcoming set backs
  • dealing with hardship in anesthesia training
  • financial management
  • preparing for and acing exams and boards
  • tips for the job hunt
  • transitioning to practice and through the first six months after training

This series is an active work in progress so if there’s something you want to hear about, be sure to reach out and let me know!

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Anesthesia Education Clinical Tips Preparing for Grad School/Residency Wellness

#57 – Incivility in the Workplace – Joshua Lea, DNP, MBA, CRNA & Kelly Gallant, PhD, CRNA

Josh Lea, DNP, MBA, CRNA and Kelly Gallant, PhD, MSN, CRNA join me to discuss workplace incivility in anesthesia training. We discuss the role of precepting SRNAs and anesthesia residents, root causes and implications of incivility and processes for improving healthy work environments. 

Josh Lea, DNP, MBA, CRNA is a professor of anesthesia at Northeastern University’s Nurse Anesthesia Program and staff CRNA at Massachusetts General Hospital in Boston.  He serves on the board of the Anesthesia Patient Safety Foundation and focuses on burnout & creating healthy work environments as his area of research and publication. He has spoken extensively on the topics both nationally and internationally through his work with the Anesthesia Patient Safety Foundation and as a member of the American Association of Nurse Anesthetists (AANA) Health and Wellness Committee. 

Kelly Gallant, PhD, SRNA completed her anesthesia training at Northeastern University in Boston. She received her Bachelor’s degree from Northeastern in 2010 and spent 8 years working in the surgical intensive care unit as a Registered Nurse while researching pediatric pulmonary hypertension and caregiver reactions as part of her PhD, which she completed at Northeastern in 2017. Kelly then returned to school to study anesthesia completing her Master of Science at Northeastern in May 2020. Kelly was the fiscal year 2019 SRNA Representative to the AANA Health & Wellness Committee. and also contributed to episode #52 – SRNA Wellness in COVID-19 of Anesthesia Guidebook.

References:

Elmblad, R., Kodjebacheva, G., & Lebeck, L. (2014). Workplace Incivility Affecting CRNAs: A Study of Prevalence, Severity, and Consequences With Proposed Interventions. AANA Journal, 82(6), 437–445.

Katz, D., Blasius, K., Isaak, R., Lipps, J., Kushelev, M., Goldberg, A., Fastman, J., Marsh, B., & DeMaria, S. (2019). Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety, 28(9), 750–757.

Neft, M., Hartgkidek, A., & Lea, J. (2017). Wellness milestone: The road to wellness: Paving the way toward a healthy work environment. AANA NewsBulletin.

Mahoney, C. B., Lea, J., Schumann, P., & Jillson, I. (2020). Turnover, burnout, and job satisfaction of certified registered nurse anesthetists in the United States: Role of job characteristics and personality. AANA Journal, 88(1), 39-48.

Mahoney, C. B., Lea, J., Jillson, I., & Meeusen, V. (2014). Turnover of nurse anesthetists: The similarities and differences between countries. BioMed Central Ltd. 14(2).

Other Resources:

Do you want to learn from APSF about patient safety? Easy. Just subscribe to the APSF Newsletter for FREE and connect with APSF on Twitter, Facebook, and LinkedIn.

AANA Promoting a Culture of Safety and Healthy Work Environment: Practice Considerations PDF

AANA Webpage on Bullying, Disruptive Behavior and Workplace Incivility

AANA SRNA Wellness

Need Help? Not sure? Check out AANA Ask For Help website.


AANA Nurse Anesthesia Leadership Survival Guide PDF

Do you have more questions about workplace incivility? Feel free and contact Joshua Lea, DNP, MBA, CRNA at lea.joshua@gmail.com, Kelly Gallant, PhD, MSN, CRNA at gallant.k@husky.neu.edu or wellness@aana.com.  For concerns related to alcohol or other drugs, call the AANA Helpline at 1-800-654-5167 for 24/7 live confidential help.

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Anesthesia Education Clinical Tips Preparing for Grad School/Residency Wellness

#54 – Hardship in Anesthesia School

This episode speaks to why anesthesia school/residency is hard and what we as SRNAs, residents, program faculty, preceptors, CRNAs and physician anesthesiologists can do about it.

Anesthesia training is hard because life is hard and doesn’t stop just because you enroll in an incredibly difficult program.

Anesthesia school is also hard because anesthesia school is just really hard.

Whether you’re a physician resident or SRNA, you have to learn to take an incredible degree of ownership for your actions and couple a voluminous depth of information with rapid, correct and highly skilled actions under time pressure in the clinical setting.

 That’s anesthesia training!

Do you need help working through the challenges of anesthesia school? Not sure if you need help? Check out the AANA’s website Ask For Help to find links to resources and context that clearly shows that SRNAs and providers alike are not alone when they face stress, burnout, frustration and challenges where professional help can be, well, helpful. You can also check out the AANA SRNA Wellness website for more content on finding a path towards peace of mind and wellness.

Below are crucial numbers to know in order to get help or support those who are in crisis. Also, the full transcript to this podcast is in PDF format so you read on the go. And the link to Jocko Willink’s video “Jocko Motivation ‘GOOD’.” Be sure to watch that every morning you wake up during anesthesia training!!

The Crisis Text Line is 741741… you can text anything to that number and a trained crisis volunteer will be on the other line: 24/7/365 for free! You can text if you’re a friend, preceptor or program faculty. You can text if you’re the one in crisis and need to talk (text) with someone to find the motivation to stay stay safe and get help.

Hardship in Anesthesia School transcript PDFDownload

BOOKS FOR YOU:

Trevor Noah’s Born a Crime

David Goggins’ Can’t Hurt Me

Laura Hillenbrand’s Unbroken

Jocko Willink’s Extreme Ownership

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Clinical Tips Human Physiology and Pathophysiology Opioid Free Anesthesia Pharmacology Preparing for Grad School/Residency Regional Anesthesia

#49 – Local Anesthetics with Skyler Rouhselang, BSN, SRNA

This episode was originally published in April 2019 on From the Head of the Bed… a podcast for the anesthesia community. In this podcast, Skyler provides a thorough overview of local anesthetics including relevant anatomy and physiology (i.e. nerve fibers, sodium channels, pKa, etc), types of local anesthetics and factors that effect onset, potency, duration of action and absorption. We touch on methemoglobinemia, Local Anesthetic Systemic Toxicity (LAST) and common dosing and max dosing for local anesthetics. This is a great run down for anyone wanting to brush up on local anesthetics!

At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a level 1 trauma center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. Skyler has married and changed her name to Skyler Williams, DNP, CRNA. As of September 2021, Dr Williams practices anesthesia as a CRNA at IU Health Arnett Hospital in Lafayette, IN.

Resources

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.

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Clinical Tips Pharmacology Preparing for Grad School/Residency

#48 – IV Induction Agents with Ashley Scheil, BSN, SRNA

This episode was originally published in April 2019 on From the Head of the Bed… a podcast for the anesthesia community. In this podcast, Ashley walks us through an overview of the most common IV anesthesia induction agents. We cover propofol, ketamine, etomidate, barbiturates (e.g. methohexital), dexmedetomidine and benzodiazepines (e.g. midazolam). A run down of the mechanism of action, dosing, onset, metabolism and physiologic effects are provided. This is an excellent introduction to these common medications and how to utilize them as part of a routine IV induction of anesthesia.

Ashley Scheil earned her BSN from Purdue University in 2012. She worked as a critical care Registered Nurse in the surgical ICU at the Roudebush VA Medical Center in Indianapolis for 6 years before going back to anesthesia school to earn her DNP at Marian University in May of 2020. Dr Scheil, DNP, CRNA practices anesthesia at IU Health Arnett Hospital as of September 2021.

Resources

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Cohen, L., Athaide, V., Wickham, M. E., Doyle-Waters, M. M., Rose, N. G., & Hohl, C. M. (2015). The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Annals of emergency medicine, 65(1), 43-51.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Morris, C., Perris, A., Klein, J., & Mahoney, P. (2009). Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?. Anaesthesia, 64(5), 532-539.

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.Audio Player

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Categories
Clinical Tips Human Physiology and Pathophysiology Pharmacology Preparing for Grad School/Residency

#47 – Pharmacodynamics of Volatile Anesthetics with Skyler Rouhselang, BSN, SRNA

This episode was originally released in April 2019 on From the Head of the Bed… a podcast for the anesthesia community.  In this podcast, Skyler walks us through the pharmacodynamics of volatile anesthetics. We talk extensively about the concepts related to minimum alveolar concentration (MAC), the mechanism of action of volatile anesthetics and the physiologic response to volatiles. You don’t want to miss this excellent overview of core anesthesia concepts!

At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a level 1 trauma center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. Skyler has married and changed her name to Skyler Williams, DNP, CRNA. As of September 2021, Dr Williams practices anesthesia as a CRNA at IU Health Arnett Hospital in Lafayette, IN.

References

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.

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Categories
Clinical Tips Human Physiology and Pathophysiology Pharmacology Preparing for Grad School/Residency

#46 – Pharmacokinetics of Volatile Anesthetics with Skyler Rouhselang, BSN, SRNA

This episode was originally released in April 2019 on From the Head of the Bed… a podcast for the anesthesia community. In this podcast, Skyler gives a succinct run down on the pharmacokinetics of volatile anesthetics. We talk about uptake, distribution, elimination and metabolism and unpack concepts such as blood gas solubility, oil gas solubility, Fa/Fi curves and more. You don’t want to miss this excellent overview of core anesthesia concepts!

At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a level 1 trauma center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. Skyler has married and changed her name to Skyler Williams, DNP, CRNA. As of September 2021, Dr Williams practices anesthesia as a CRNA at IU Health Arnett Hospital in Lafayette, IN.

References

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences

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Categories
Anesthesia Equipment and Technology Clinical Tips Pharmacology Preparing for Grad School/Residency

#45 – The Anesthesia Machine with Ashley Scheil, BSN, SRNA

In this episode, which was originally released in April of 2019 on From the Head of the Bed… a podcast for the anesthesia community, Ashley provides an incredibly detailed run down of the anesthesia machine: the flow of gas through the machine, high, intermediate and low pressure system components in the machine, variable bypass vaporizer structure & function, relevant gas laws, safety systems & features and more! If you’re an anesthesia learner just hitting the ORs, this show will give you a detailed run down on what you need to know to use the anesthesia machine. If you’re a seasoned provider and clinical educator/preceptor, this show provides a wonderful reminder of core information on the machine so you can best support your learners.

Ashley Scheil earned her BSN from Purdue University in 2012. She worked as a critical care Registered Nurse in the surgical ICU at the Roudebush VA Medical Center in Indianapolis for 6 years before going back to anesthesia school to earn her DNP at Marian University in May of 2020. Dr Scheil, DNP, CRNA practices at IU Health Arnett Hospital as of September 2021.

Resources

E – Cylinder Calculation

Amount of oxygen in cylinder in liters divided by liters of flow:

At full pressure (1900 PSI): 660 liters / 3 lpm = 220 minutes of O2.

At half pressure (950 PSI): 330 liters / 10 lpm = 33 minutes of O2.

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.

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Categories
Airway Case Studies Clinical Tips Preparing for Grad School/Residency

#44 – Clinical Flow: from OR set up through intubation with Ashley Scheil, BSN, SRNA

In this episode, Ashley and I talk through how to set up an operating room anesthesia workstation, perform a preoperative patient assessment and progress through an IV induction and intubation.

You’ll hear Ashley walk you through everything from how to do a quick machine set up, where to put your tape, how to introduce yourself to patients & work through a preop assessment and how to proceed from getting in the door of the OR through getting the tube where you want it to go after induction. This is a great podcast to help SRNAs and other anesthesia learners to get their clinical flow down!

Ashley Scheil earned her BSN from Purdue University in 2012. She worked as a critical care Registered Nurse in the surgical ICU at the Roudebush VA Medical Center in Indianapolis for 6 years before going back to anesthesia school to earn her DNP at Marian University in May of 2020. Dr Scheil, DNP, CRNA practices at IU Health Arnett Hospital as of September 2021.

Resources

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.

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Categories
Cardiac Clinical Tips

#43 – LVADs in non-cardiac surgery with Ben Levin, MD

Ben Levin, MD

This podcast was the last episode I published on From the Head of the Bed and originally came out on July 4, 2020.  In August of that year, I launched Anesthesia Guidebook and this episode is being re-released on September 16, 2021.   

In this episode, I have the privilege of speaking with Ben Levin, MD on the perioperative management of patients with left ventricular assist devices (LVADs) for non-cardiac surgery. This is your podcast if you’re looking for a refresher or quick overview of managing patients with LVADs as an anesthesia provider!

We discuss how LVADs work, why people have them, the differences between LVADs as bridge to transplant or destination therapy and crucially, how to manage these patients perioperatively during non-cardiac surgery with special emphasis on monitoring and hemodynamic management.

Dr Levin received his Master’s of Science in biomedicine and his medical degree from Tufts University Medical School. He completed his anesthesia residency at Maine Medical Center in Portland, Maine in 2020 and recently returned to MMC after completing a fellowship in critical care at Massachusetts General Hospital. His clinical areas of interest include cardiovascular surgery and critical care, echocardiography and mechanical circulatory support devices. 

Dr Levin provided a PDF of a presentation on LVADs he gave as his senior project during his residency and you can find that below.  It’s got all the references, studies, graphs, management algorithms, chest xrays and device pictures you could want to make this info sink in.

LVADs-with-Ben-Levin-PDFDownload

References

Rogers, J. G., Butler, J., Lansman, S. L., Gass, A., Portner, P. M., Pasque, M. K., … & INTrEPID Investigators. (2007). Chronic mechanical circulatory support for inotrope-dependent heart failure patients who are not transplant candidates: results of the INTrEPID Trial. Journal of the American College of Cardiology, 50(8), 741-747.

Rose, E. A., Gelijns, A. C., Moskowitz, A. J., Heitjan, D. F., Stevenson, L. W., Dembitsky, W., … & Watson, J. T. (2001). Long-term use of a left ventricular assist device for end-stage heart failure. New England Journal of Medicine, 345(20), 1435-1443.

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Categories
Clinical Tips Enhanced Recovery After Surgery Opioid Free Anesthesia Pharmacology Regional Anesthesia

#42 – Opioid Free Anesthesia with Tom Baribeault, DNP, CRNA & Jayme Reuter, MS, CRNA

This episode was originally released on From the Head of the Bed on March 3, 2019 and recorded in Scottsdale, Arizona. Tom Baribeault, DNP, CRNA and Jayme Reuter, MS, CRNA talk with me about opioid free anesthesia.

We discuss the progression to opioid free anesthesia (OFA), where OFA fits into enhanced recovery programs and the specific techniques of how to provide a comfortable, opioid-free perioperative experience for our patients.

Find out more about the Society for Opioid Free Anesthesia, including a resource-filled members-only section of their website which includes overviews of pharmacological alternatives to opioids and specific opioid-free anesthetic plans.

At the time of this recording, Tom Baribeault was the Chief CRNA at Lexington Surgery Center in Lexington, Kentucky. He completed his anesthesia training at Case Western Reserve University. Tom has a passion for teaching anesthesia providers and others on opioid-free anesthesia, enhanced recovery after surgery, ultrasound guided regional anesthesia and point of care ultrasound. He is the president and founder of the Society for Opioid Free Anesthesia and is a member of the American Association of Nurse Anesthetists and the Kentucky Association of Nurse Anesthetists. Since this recording, Tom completed his Doctor of Nursing Practice

Jayme Reuter, MS, CRNA is the Program Director and founder of Cornerstone Anesthesia Conferences. She completed her anesthesia training at Baylor College of Medicine and practices at Houston Methodist Hospital, which is part of Texas Medical Center. She created Cornerstone Anesthesia Conferences in 2017 with a mission to be the foundation for excellence in continuing anesthesia education.

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Categories
Clinical Tips Opioid Free Anesthesia Outpatient Anesthesia Pharmacology Preparing for Grad School/Residency Regional Anesthesia

#41 – Regional Anesthesia with Shane Garner, MS, CRNA, NSPM-C

This episode was originally released in April of 2020 on From the Head of the Bed… a podcast for the anesthesia community and is being re-released on 5 September 2021 on Anesthesia Guidebook.

In this episode, I speak with Shane Garner, MS, CRNA, NSPM-C about an introduction & overview of regional anesthesia. We discuss:

  • opioid-free anesthesia
  • how to gain experience in regional anesthesia as a SRNA or CRNA
  • fellowships in pain management available to CRNAs
  • the Non-Surgical Pain Management (NSPM) board examination
  • how to start a block program and gain surgeon buy-in
  • Exparel (bupivacaine liposome injectable suspension)
  • when to use regional anesthesia catheters and more!
Shane Garner, MS, CRNA, NSPM-C

Shane Garner is a CRNA who works in Ripon, Wisconsin and is passionate about teaching anesthesia providers on personal finance as well as regional anesthesia.  He has a Bachelor of Science in Nursing from the University of Minnesota and graduated from Rosalind Franklin University with his Master of Science in Nurse Anesthesia in 2012.  He went on to complete a fellowship in Advanced Pain Management at the University of South Florida before becoming board certified in Nonsurgical Pain Management through the NBCRNA. Shane is an adjunct faculty member at the University of Alabama at Birmingham’s nurse anesthesia program and regularly instructs with Twin Oaks Anesthesia & Cornerstone Anesthesia Conferences.

Resources:

University of South Florida Advanced Pain Management Fellowship

NBCRNA Non-Surgical Pain Management Board Exam

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Categories
Anesthesia Education Clinical Tips Pharmacology Preparing for Grad School/Residency

#40 – Gas and Grass: Anesthetic Considerations for Care of the Cannabis User

Study Link: http://depaul.qualtrics.com/jfe/form/SV_9Y32tyhtj6i8GZU

Nicole Kellogg, BSN, SRNA and Elizabeth Fullford, BSN, SRNA join me to discuss the anesthetic considerations for cannabis users.

This podcast is part of a study they’re conducting on the efficacy of an educational podcast for SRNAs and CRNAs. PLEASE COMPLETE THE PRE-SURVEY AND POST-SURVEY HERE. The study will be live through the end of October 2021.

At the time of this episode’s publication (1 September 2021) Elizabeth Fulford & Nicole Kellogg were third-year anesthesia trainees at the NorthShore University HealthSystem School of Nurse Anesthesia. 

Elizabeth Fulford, BSN, SRNA received her undergraduate degree from Michigan State University in 2011. Prior to anesthesia school, Liz primarily practiced in pediatric ICUs and also adult post-anesthesia care units in several states throughout the country.  She is an avid skier and enjoys camping with her husband Sean and fur child, Mandy.

Nicole Kellogg’s, BSN, SRNA nursing background was in rapid response and in a medical-cardiac intensive care unit.  She lives in Geneva, Illinois with her husband and two young kids and says fulfilling her dream of becoming a CRNA would not be possible without her family.  

Nicole Kellogg, BSN, SRNA
Elizabeth Fullford, BSN, SRNA

Below are the outline with citations of the podcast discussion plus the full bibliography.

FULFORD-KELLOGG-Podcast-Show-NotesDownload

References

Alexander, J. C., & Joshi, G. P. (2019). A review of the anesthetic implications of marijuana use. Proceedings – Baylor University Medical Center, 32(3), 364-371. doi:10.1080/08998280.2019.1603034.

Drug Enforcement Agency. (n.d.). Controlled Substance Schedules.https://www.deadiversion.usdoj.gov/schedules/#:~:text=Some%20examples%20of%20substances%20listed,methylenedioxymethamphetamine%20(%22Ecstasy%22).

Echeverria-Villalobos, M., Todeschini, A. B., Stoicea, N., Fiorda-Diaz, J., Weaver, T., & Bergese, S. D. (2019). Perioperative care of cannabis users: A comprehensive review of pharmacological and anesthetic considerations. Journal of clinical anesthesia, 57, 41-49. doi:10.1016/j.jclinane.2019.03.011

Flanagan, B. (2021). Harnessing the Endocannabinoid System: What It Means for the Anesthesia Provider. AANA Journal 89(3), 261-268. 

Holmen, I. C., Beach, J. P., Kaizer, A. M., & Gumidyala, R. (2020). The association between preoperative cannabis use and intraoperative inhaled anesthetic consumption: A retrospective study. Journal of clinical anesthesia, 67, 109980-109980. doi:10.1016/j.jclinane.2020.109980

Horvath, C., Dalley, C. B., Grass, N., & Tola, D. H. (2019). Marijuana Use in the Anesthetized Patient: History, Pharmacology, and Anesthetic Considerations. AANA Journal, 87(6), 451-458.

Huson, H. B., Granados, T. M., & Rasko, Y. (2018). Surgical considerations of marijuana use in elective procedures. Heliyon, 4(9), e00779-e00779. doi:10.1016/j.heliyon.2018.e00779.

Salottolo, K., Peck, L., Tanner Ii, A., Carrick, M. M., Madayag, R., McGuire, E., & Bar-Or, D. (2018). The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury. Patient safety in surgery, 12(1), 16-16. doi:10.1186/s13037-018-0163-3.

Twardowski, M. A., Link, M. M., & Twardowski, N. M. (2019). Effects of Cannabis Use on Sedation Requirements for Endoscopic Procedures. The Journal of the American Osteopathic Association, 119(5), 307. doi:10.7556/jaoa.2019.052

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Categories
Anesthesia Education Business/Finances Clinical Tips Preparing for Grad School/Residency

#38 – The Master Anesthesia app with Matthew Willis, DNP, CRNA

Dr Matthew Willis is the CRNA who created and produces the educational app Master Anesthesia, which is available from the App Store and Google Play Store.  

I’ve been using this app for the last several months and I’m super impressed at a few things:

  1. it’s packed with real-world information that’s evidence based from case tips to pharmacology
  2. the calculator is amazing… it’s so easy to use and gives you all the information you really need super fast.. more on that in just a sec
  3. Matthew has made crowd-sourcing the continued build of the app super easy… he’s looking for people to contribute so the quality and scope of the app will continue to improve as more people make contributions.  It’s like a curated wikipedia app focused specifically on anesthesia content.  And you get recognition in the app for your contributions. 

And lastly, the app is 100% free!  My other go-to anesthesia app cost me $100 and it only gives me half the information Master Anesthesia does.  I’d have to pay another $100 for access to the coexisting disease information.   

I can’t say enough about how significant it is that Matthew has kept this app completely free for the anesthesia community and he continues to dump an incredible amount of personal time building it despite having a full time job and a family.  The Master Anesthesia app is quintessential free open access medical education or FOAM… a concept I recently talked about on the podcast in episode #34.  FOAM removes pay walls and financial barriers so healthcare providers – and importantly students and residents – can access leading content for free. 

For the first 30 minutes of the discussion, we unpack the app and its features and in the back half of the interview, Matthew discusses how he started the app as his DNP project and what fuels his motivation now.

So the app features a run down on common surgeries, pathologic conditions, anesthesia-related drugs and a super high-powered calculator.  This calculator is unlike anything I’ve seen; it really is unique.  It tells you everything from common vital signs, airway device sizing, tidal volumes, drug & fluid calculations and local anesthetic dosing all based on the weight and/or height of your patient.  The local anesthetics dosing also does combined medication dosing so you can rapidly see the remaining maximum dose amounts and volumes based on what’s already been given for any concentration of local you plan to give.  It’s amazing… if you only get the app to use the calculator, it would be worth your time & effort.

Matthew Willis, DNP, CRNA has a background in finance, web and mobile design.  He received his undergraduate degree in nursing from Boise State University in 2014 and completed his doctor of nursing practice and anesthesia training at the Louisiana State University Health Sciences Center in 2019.  He currently works as an independent anesthesia provider in Iowa and has a wife and 4 children.  

I reached out to Matthew after I made suggestion on content within the app and he graciously agreed to come on Anesthesia Guidebook to share his story.  Again, Matthew currently is not making any revenue off Master Anesthesia and I have no financial connection with Matthew or this app… this episode is just good ole’ storytelling with no conflicts of interest. 

App Store Link: 

https://apps.apple.com/app/id1550793078#?platform=iphone

Google Play Link:

https://play.google.com/store/apps/details?id=com.masteranesthesia

Website Link:

Landing Page

Facebook Group Link: 

https://www.facebook.com/groups/masteranesthesia

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Categories
Anesthesia Education Business/Finances Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency Wellness

#37 – Emotional Intelligence of SRNAs with Shawn Collins, DNP, PhD, CRNA

This episode is coming out on August 21, 2021 but it FIRST came out way back on September 19, 2015.  

The show is on emotional intelligence of SRNAs with Dr Shawn Collins, DNP, PhD, CRNA.

At the time of the interview, Dr Shawn Collins was the nurse anesthesia program director and the interim dean of the College of Health & Human Sciences at Western Carolina University (WCU).  I was super early in developing the podcast From the Head of the Bed and was actually still a SRNA at WCU even though the show was published after I graduated.  In the show, Dr Collins will walk us through what emotional intelligence is and how, if harnessed, can impact your work as an anesthesia trainee and provider.  

I think emotional intelligence is central to human behavior, relationships and success in whatever you’re doing… it’s about how we relate to one another.  I love how Dr Collins talks about getting a bird’s eye view of any situation you’re in and reading the emotional state of the other people around you.  Exercising emotional intelligence is often about learning how to walk through your life with this third-person view point of the situations you’re in.  It’s about understanding where other people are at, where they’re coming from, what their biases & goals might be and adapting your interaction with them to get you both – or a whole team of people – moving in the direction you want.  It’s thinking about: who is this person, where are they coming from, what might their hopes, dreams, fears or concerns be right now, how do they perceive me, who do they think I am – who am I FOR REAL – where am I headed, what are my goals and how can I tailor my interaction with this individual, in the context of all this, to get us both moving where we need to go.  This is every day stuff for anesthesia providers.  Emotional intelligence, when harnessed, will make your interactions with patients so much better and more meaningful.  It’ll help you deal with surgeons, OR nurses, CSTs, hospital administrators, preceptors, your boss, your trainees & students with greater skill & efficacy.  Emotional intelligence is like a key that unlocks an incredibly powerful, supercharged tool in relationships and it will help create success for you in whatever stage of your career or, for that matter you marriage or dating relationships or business partnerships, that you’re in.  

Dr Collins completed his master’s in anesthesia at Erlanger Medical Center at the University of Tennessee Chattanooga, his doctor of nursing practice degree at Rush and his PhD in leadership at Andrew’s University.  

Dr Collins is currently the associate dean for academic affairs and graduate studies for Loma Linda University’s School of Nursing, where he supports 2 master’s programs, a PhD program and 8 clinical doctorates. 

He was the program director when I attended WCU and was instrumental in helping my classmates and I launch the podcast From the Head of the Bed, serving as our project chair and one of the co-authors of the paper we published on social media in nurse anesthesia education in the AANA Journal.  Without him giving us a huge GREEN LIGHT and a lot of support & guidance along the way, From the Head of the Bed, and therefore this podcast would not exist… 

And with that, let’s get to the show…. 

Resources

Collins S. Emotional Intelligence as a Noncognitive Factor in Student Registered Nurse Anesthetists. AANA Journal [serial online]. December 2013;81(6):465-472. Available from: Academic Search Complete, Ipswich, MA. Accessed September 19, 2015.

Collins S, Andrejco K. A longitudinal study of emotional intelligence in graduate nurse anesthesia students. Asia Pac J Oncol Nurs [serial online] 2015 [cited 2015 Sep 19];2:56-62. Available from: http://www.apjon.org/text.asp?2015/2/2/56/157566

Kristin Andrejco was a co-author, along with Dr Collins, of the above study published in the Asia Pacific Journal of Oncology Nursing. She helped create From the Head of the Bed and still exerts a bit of influence on Anesthesia Guidebook under her new name.

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Categories
Anesthesia Education Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency Wellness

#32 – Harnessing the power of deliberate practice

This podcast discusses deliberate practice, a concept developed by renowned cognitive psychologist Anders Ericsson, PhD. Deliberate practice is the kind of practice that top performers employ in order to reach the very highest levels of excellence across domains. Ericsson studied countless musicians, athletes, dancers, chess players, medical professionals and others to uncover the secrets and power of deliberate practice.

Malcolm Gladwell popularized some of Ericsson’s work in his 2008 book, Outliers, as the 10,000-hour rule to expertise, stating that on average, it takes about 10,000 hours to develop as an expert. But it’s not as easy as that. It’s not that simple. It’s not just about being on the job for 10,000 hours. And you know what I’m talking about. You’ve worked with people who are very experienced yet not the best – not even great – perhaps even mediocre, at their jobs. What Ericsson saw is that it takes top performers around 10,000 hours of deliberate practice – a concentrated, effortful, focused kind of practice, with feedback from a coach, to achieve the top level in any field.

Check out the podcast and links in the show notes for a quick break down and some examples of how to harness deliberate practice to improve your anesthesia career.

Resources:

Ericsson, K. A. (2008). Deliberate practice and acquisition of expert performance: a general overview. Academic emergency medicine, 15(11), 988-994.

Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81.

Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939

Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.

Weinger, M. B., Banerjee, A., Burden, A. R., McIvor, W. R., Boulet, J., Cooper, J. B., … & Torsher, L. (2017). Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology: The Journal of the American Society of Anesthesiologists, 127(3), 475-489.  

Young, J. 5 May 2020. Researcher Behind ‘10,000-Hour Rule’ Says Good Teaching Matters, Not Just Practice. (podcast). EdSurg Podcast.  Retrieved from https://www.edsurge.com/news/2020-05-05-researcher-behind-10-000-hour-rule-says-good-teaching-matters-not-just-practice. 

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Categories
Anesthesia Education Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency

#31 – Expertise in Anesthesia with Denham Ward, MD, PhD

This episode originally released on From the Head of the Bed in February of 2017.

Denham Ward, MD, PhD joined me to talk about expertise in anesthesia. At the time of this recording, Dr Ward was the director of the Academy at Maine Medical Center Institute for Teaching Excellence and professor of anesthesiology at Tufts University School of Medicine. He is Emeritus Professor and Chair of Anesthesiology and Emeritus Professor of Biomedical Engineering at the University of Rochester.

This podcast focuses on developing and maintaining expertise over a career in anesthesia.  Highlights range from defining expertise, specialization in anesthesia, types of problem solving and clinical decision making, deliberate practice, grit and how to teach and coach the development of expertise in trainees as well as experienced clinicians. We touch on Ericsson’s ideas on deliberate practice and the 10,000 hour rule for expertise, Dreyfus’ conceptions of skill acquisition from novice-advanced beginner-competent-proficient-expert, Kahneman’s System 1 and System 2 ways of thinking, Moulton’s “when to slow down,” Gawande’s ideas on the benefit of getting coached to improve our performance even well into our careers and more.

“The difference between medicine and music is… musicians practice, practice, practice and then they go to Carnegie Hall for one evening…  We’re essentially at Carnegie Hall every day.”  Denham Ward, MD, PhD

“Most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers.” Anders Ericsson

References:

Benner, P. (1982). From novice to expert.  The American Journal of Nursing, Vol. 82.  Retrieved from http://www.healthsystem.virginia.edu/pub/therapy-services/3%20-%20Benner%20-%20Novice%20to%20Expert-1.pdf.

Dreyfus HL, Dreyfus SE. (2005).  Expertise in Real World Contexts. Organization Studies, (26)5: 779-792. Retrieved from https://www.pdx.edu/sites/www.pdx.edu.unst/files/UNSTArticleDreyfus.pdf

Duckworth, A. (2016). Grit: The power of passion and perseverance (Vol. 124). New York, NY: Scribner.  Retrieved from http://www.simonandschuster.com/books/Grit/Angela-Duckworth/9781501111105. Screen shot by author.

Dweck, C. S. (2008). Mindset: The new psychology of success. Random House Digital, Inc..  Retreived from https://www.penguinrandomhouse.com/books/44330/mindset-by-carol-s-dweck-phd/9780345472328/. Screen shot by author.

Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939

Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81.

Gawande, A. (2011). Personal best. The New Yorker, (30). 44.  Retrieved from http://www.newyorker.com/magazine/2011/10/03/personal-best.

Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.

Kaminski, J. (Fall, 2010). Theory applied to informatics – Novice to Expert. CJNI: Canadian Journal of Nursing Informatics, 5 (4), Editorial. Retrieved from http://cjni.net/journal/?p=967.

Moulton, C. E., Regehr, G., Mylopoulos, M., & MacRae, H. M. (2007). Slowing down when you should: a new model of expert judgment. Academic Medicine: Journal Of The Association Of American Medical Colleges, 82(10 Suppl), S109-S116.

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Business/Finances Clinical Tips Personal Finances Preparing for Grad School/Residency Wellness

#29 – On Retirement with Eric Carlson, CRNA

I caught back up with Eric Carlson, CRNA to discuss his recent retirement and advice he has for anesthesia providers still in the thick of it. Eric was interviewed by Kristin Lowrance, MSN, CRNA way back in 2015 for our podcast “From the Head of the Bed.” We just re-released that podcast as #28 – Can’t Intubate, Can’t Oxygenate (CICO) during stat C-section: a case study with Eric Carlson, CRNA on Anesthesia Guidebook. If you haven’t listened to it, it’s a harrowing story of how he managed this incredibly difficult airway and situation.  

I wanted to catch back up with Eric following his retirement and today you’ll hear us reflect back on that podcast he & Kristin did several years ago.  I was surprised by what he had to say about it.  

We also take a look back on Eric’s career… what influenced his decision to go into anesthesia, how to look for your first job in anesthesia and what influences where you work throughout your career.  Eric spent most of his career in a tertiary care facility with over 800 inpatient beds and 50 operating rooms.  We touch on how challenging it can be to keep pace with a very demanding practice setting and walk through an article by Judy Thompson published in the AANA Journal in late 2020 titled “the certified registered nurse anesthetist as a late career practitioner” that looks at whether anesthesia providers should have mandatory retirement ages or cognitive testing as part of recredentialing. The link to that article is here:

Thompson, Judy. (2020).  The certified registered nurse anesthetist as a late career practitioner.  AANA Journal. Retrieved from: https://www.aana.com/docs/default-source/aana-journal-web-documents-1/thompson-r.pdf?sfvrsn=ea716ae2_4 

We also talk about how Eric planned financially for retirement and tips for practicing anesthesia providers on how to get there.  You’ll hear him discuss the last case he ever did and what it’s been like to step over to the other side… beyond the OR and into retirement.

Eric served as a preceptor for Kristin and me during our anesthesia training at Western Carolina University and we were always impressed with the depth of his knowledge, the sense of being anchored & unflappable that comes from deep competence, his willingness to teach and kindness as a preceptor.  Eric is a remarkable human being and I think you’ll really enjoy hearing from him as we look back over his career and the advice he’d give to folks who are still in the thick of it.

This podcast is absolutely relevant for SRNAs or anesthesia residents.  It can be profoundly helpful to hear from someone who is way down the road when you’re just getting started.  It’s like seeking out the village elder when you’re preparing to begin your own journey & adventure.  Listen to his stories.  Hear this wisdom in his voice.  

The following interview was posted by the North Carolina Association of Nurse Anesthetists in an email on 15 May 2015 to members titled “Spotlight on CRNAs” where a North Carolina CRNA is introduced at greater depth to the membership.  Of note, Eric was interviewed by Dustin Degman, CRNA, who has also contributed to our podcast in the Combat Trauma Anesthesia series.  In the interview, Dustin talks with Eric about his experience with the difficult airway case that he speaks to in the show featured on this page.  This interview is posted with the permission of the NCANA.

Eric Carlson, CRNA

Interviewed by Dustin Degman, CRNA

You were recently on the podcast “From the Head of the Bed” where you explained a case that, I guess you could say, changed the way you practice today. You got to give your history, the beginning of the scenario, and there was a moment that you said “I had a difficult airway case”. I must tell you that I was completely locked-in at that moment. Nothing was going to distract me from listening to the next 25 minutes. What I want to ask is, what about that event changed you most, either as a person or in practice?

This is a challenging question to answer. I am sure the event changed me both as a person and a CRNA practitioner. At the time of the event, I was very early in my career and riding high in self confidence. The event changed my level of confidence and reinforced the significance of the risks we take as CRNAs performing our job every day. I had to actively work on rebuilding my confidence over the ensuing months, slowly, I was able to regain some of the loss, but for better or for worse, I probably did not get back to the level I had been. In the long run, I think it made me a better CRNA because I realized that bad things can occur in our line of work at any time and you always need to have a back-up plan in mind. Be prepared for the unexpected. As a person, the event may have made me a more humble individual and helped me realize that we are all susceptible to very challenging occurrences in our profession.

People, who know you, know that you are a wonderful provider. Your patients, colleagues, and the students really look up to you. Is there something you would like to share about being a great mentor?

I appreciate the feedback and compliment. I consider myself very fortunate to have made the decision to become a CRNA more than 30 years ago. We all have many forks in the road when we have to make a choice that could affect the rest of our lives. When I had been a nurse for five years, I began to consider what specialty I may want to pursue to fulfill my desire to have a career pathway I may enjoy for the long term versus bouncing from one subspecialty to another. As an ED nurse at a teaching hospital, I was exposed to CRNAs both directly helping out in difficult cases, and assisting/teaching new Anesthesiologist residents with different tasks in the ED. These episodes spurred my interest so I talked to the Chief CRNA and learned more about the profession. That conversation led to my decision to pursue becoming a CRNA versus my other consideration of becoming a flight nurse. To this day, it was one of the best decisions I ever made. I am very proud of my profession and can honestly say I still love my job after three decades. I still tell my students they have chosen one of the coolest careers they could ask for. I guess my enthusiasm spills over.

I find the NCANA to have some of the most motivated members I have ever met. I feel like they bring out the best in me and am so thankful for the work that they do for our profession. You have been involved with the board and different committees for the past 15 years. Why did you choose the government relations committee for this term?

I was involved with the NCANA in the early 2000s. I decided to take leave from the active involvement in order to devote time to my family and help my wife raise our two children. Now that my children are grown, I have the opportunity to participate in the NCANA once again. Overall, the NCANA is under appreciated by the majority of its members, the active members serving on the Board and Committees are doing a lot of work that most members are never aware of. These dedicated members are volunteering their time and efforts to help preserve our profession and our livelihoods. Major changes can take place in the laws and regulations that govern our profession. These changes could directly effect our day to day job description, if the NCANA is not keeping watch over the potential changes in the laws and regulations then who is? We could go to work one day and find that our scope of practice has been completely redefined and we would be at a loss to change it at that point. One role of the NCANA, and the primary role of the Government Relations Committee is to monitor and respond to activity of the North Carolina General Assembly, the Board of Nursing, and the Board of Medicine that may effect our profession. Being part of this committee has allowed me to learn more about the importance of its function.

Any sound advise you would like to pass on to students who are about to graduate and become members of the NCANA?

Yes, be proud of your accomplishments and your career choice! Be active in the NCANA, so you and others can continue to enjoy the many rewards of being a CRNA. Someone has to take the helm, if not you….then who?

In the past 30 years, you have witnessed significant changes. We now typically use the ultrasound for central line placement, new adjuncts in airway management, and a significant increase in monitoring, e.g. pulse oximetry. What was the biggest adjustment for you as a provider? And, was there anything that occurred during your practice where you said “This is really going to change the way we do anesthesia”?

When I first started anesthesia school, we had to fight for the one automated non-invasive blood pressure machine in the department. The practice of anesthesia was full of many risks at that time, and still is today. The primary change has been technology allowing us to identify a problem before it becomes a crisis. The first time I used a pulse oximeter, I was annoyed by the beeping. At the time, I had no idea how much technology would change the practice of anesthesia.

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Airway Case Studies Clinical Tips Leadership in Emergencies Obstetrics

#28 Can’t Intubate, Can’t Oxygenate (CICO) during stat C-section: a case study with Eric Carlson, CRNA

This podcast was originally published on March 1, 2015.

In this episode Kristin Lowrance, MSN, CRNA talks with Eric Carlson, CRNA about a case where he was called for a stat Cesarean section and after a rapid sequence induction, he could not intubate or oxygenate the patient. The case was at 2AM and Eric was the only anesthesia provider in house. The other on-call anesthesia provider was at least 20-minutes away. Eric walks us through what happened next and how they proceeded with the decision to simultaneously rescue the baby and perform an emergency percutaneous cricothyrotomy, followed by surgical cricothyrotomy.

Kristin and Eric talk about the decision making and challenges involved in this case and advice for other anesthesia providers when it comes to emergency airway management. It’s a harrowing story that had lasting impacts on everyone involved in the case. It’s a story of leadership in emergencies, profoundly difficult decision making and an example of why we should train for failed airways in our day-to-day, week-to-week work lives: we have to be ready when disaster strikes.

I recently caught back up with Eric following his retirement from anesthesia. In episode 29 of Anesthesia Guidebook, the podcast that follows this one, Eric reflects back on both this case and the impact that telling this story had on his own life and career. We will also talk about retirement, take a look back over his career and hit on advice he would give to anesthesia providers who are still in the thick of it. Be sure to check the next episode out to hear more from Eric!

Below are links to key resources for difficult airway management.

The Vortex Approach – real-time airway crisis cognitive aids.

Chrimes, N., Bradley, W. P. L., Gatward, J. J., & Weatherall, A. D. (2019). Human factors and the ‘next generation’airway trolley. https://doi.org/10.1111/anae.14543

Difficult Airway Society

American Society of Anesthesiologist’s Difficult Airway Guidelines

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Clinical Tips Outpatient Anesthesia Regional Anesthesia

#27 – Total knee arthroplasty in the COVID-19 era with Adam Rana, MD & Ryan Mountjoy, MD

This episode outlines the overnight transition to same-day surgery & discharge for total knee patients at Maine Medical Center. Surgeon Adam Rana, MD was informed on a Tuesday afternoon in December 2020 that elective cases requiring overnight hospital stays were being canceled effective immediately. He reached out to physician anesthesiologist Ryan Mountjoy, MD, along with others, and the very next day they implemented a new anesthesia plan that got patients discharged safely the same-day of surgery. These patients experienced equivalent pain scores post-operatively while remarkably requiring less opioid refills. The length of stay was slashed from 42 hours to 12 hours.

These physicians, along with physician anesthesiology resident and lead author Derek Bunch, DO and others, have submitted this story as a proof of concept for the American Society of Regional Anesthesia and Pain Medicine (ASRA) and will present this story at other national anesthesia and surgical meetings. Dr Bunch was unfortunately unable to join us on the podcast due to working overnight call during the wee-hours of the morning when we recorded this episode but hopefully he’ll agree to come on the show in the future to talk about this or other regional anesthesia topics as he prepares to head off for his regional fellowship later this summer.

Dr Bunch’s write up is provided below courtesy of the authors with select table data following:

The introduction of a multimodal clinical pathway for outpatient total knee arthroplasty in the COVID-19 era.Download

Table 1: Pre and Post Surgical Medications

Night PriorMorning ofDischarge
Celecoxib 200 mgCelecoxib 200 mgCelecoxib 200 mg BID x 3d, then daily until complete (disp #14)
Pregabalin 50 mg  Acetaminophen 1000 mgPregabalin 50 mg BID x 3d, then nightly until complete (disp #14)
Acetaminophen 1000 mg Acetaminophen 1000 mg TID
  Oxycodone 5mg 1-2 tab q 4h PRN (disp #42)
Patients received oral analgesics before and after total knee arthroplasty as part of a multi-modal pain management plan.

Table 2: Anesthesia Protocols

Previous anesthesia protocolNew anesthesia protocol 
0.5 or 0.75% bupivicaine spinalSpinal 60mg 2% mepivicaine
Postoperative adductor canal 20cc 0.5% ropivacainePreop adductor canal with 10cc 0.5% bupivicaine, 10cc 13.3% liposomal bupivicaine
 Preop iPACK block 20cc 0.2% ropivacaine
Posterior injection by surgeon (bupivacaine 120mg, epinephrine 300mcg, morphine 8mg)Posterior injection by surgeon (bupivacaine 50mg, epinephrine 100mcg)
Propofol sedationPropofol sedation
Table 2 highlights the differences between the standard practice and the new anesthesia protocol for same-day discharge for total knee arthroplasty at Maine Medical Center.

Table 3: Demographics and Outcomes

 Next day kneeSame day Knee
Number of patients4849
Average LOS (hrs)4212
Number of patients needing IV hydromorphone post op1511
Number of patients needing oral opioids post op4132
Average pain score in hospital3.93.8
Average pain score at 2 weeks3.33
Number of patients filling narcotics following surgery2520
Total number of narcotics refills following surgery4927
Table 3 highlights preliminary data comparing a cohort of patients from one year prior to the study period when patients were shifted to same-day discharge from total knee surgery. “Average age was 63 for both groups and average ASA scores were comparable (2.3 for next day knee patients and 2.2 for same day knee patients).” D. Bunch.

Dr Adam Rana’s bio as quoted from his website: “Dr. Adam Rana is a Board Certified, Fellowship-Trained Orthopedic Surgeon who specializes in minimally invasive hip and knee replacement surgery with specific training in the anterolateral muscle sparring approach to the hip, custom partial and total knee replacement surgery as well as revision hip and knee replacement surgery… Dr. Rana earned his Bachelor’s degree with Honors in Economics and Biology from Colby College where he graduated Cum Laude. While at Colby, Dr. Rana spent two summers in Minneapolis, MN at the Hennepin County Orthopedic Biomechanics Laboratory… [and] was actively involved in research projects relating to biomechanics in hip and knee replacement systems.” He attended SUNY Downstate Medical Center for medical school and “subsequently completed his Orthopedic Surgical Residency at the Boston Medical Center… After residency, he completed a fellowship in Adult Reconstruction, Arthritis, and Joint Replacement Surgery at the Hospital for Special Surgery (HSS) in New York City.” Dr Rana is widely published in peer-reviewed journals as well as medical text chapters and frequently presents on orthopedic surgery at state and national meetings. He is actively involved in the American Academy of Orthopedic Surgeons, the American Association of Hip and Knee Surgeons and the New England and Maine Orthopedic Associations. He currently serves as the director of the Joint Replacement Center at Maine Medical Center.

You may remember Dr Ryan Mountjoy, MD, who joined us for episode 11 of Anesthesia Guidebook to talk about the use of cognitive aids in emergencies. He is a board-certified physician anesthesiologist with Spectrum Healthcare Partners in Portland, Maine.  He is the Co-Director of Orthopedic Trauma and Total Joint Anesthesia and the Co-Director of Regional Anesthesia and Acute Pain Medicine at Maine Medical Center and the Site Chief of Anesthesia at MaineHealth’s Scarborough Surgery Center.  He completed his anesthesia residency at Stanford University and then pursued a Regional and Ambulatory Anesthesia fellowship at Duke University, where he worked prior to moving to Maine. 

References

Hussain, N., Brull, R., Sheehy, B., Essandoh, M. K., Stahl, D. L., Weaver, T. E., & Abdallah, F. W. (2021). Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block AnalgesiaA Systematic Review and Meta-analysis. Anesthesiology, 134(2), 147-164.

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Business/Finances Clinical Tips Outpatient Anesthesia Pediatrics

#26 – Mobile, pediatric dental anesthesia with Paul Samuels, MD

Paul Samuels, MD is a pediatric physician anesthesiologist who works with SmileMD to provide mobile anesthesia for dental offices. We talk about the unique characteristics of working in a mobile anesthesia setting for pediatric dental cases. Topics include:

  • skills required to excel as an anesthesia provider in a mobile, pediatric setting
  • preoperative screening of patients
  • patient safety during anesthesia in dental offices
  • prevention and management of emergencies in mobile anesthesia
  • who makes up the anesthesia care team
  • how medications are handled, including controlled substances
  • typical anesthesia plans including mask induction, IV placement & airway management
  • conflict management and other challenges unique to work in unfamiliar settings
  • how documentation & billing is managed
  • the benefit of mobile anesthesia services for pediatric patients and outpatient dentists

You can hear the overwhelming enthusiasm Dr Samuels has for caring for healthy pediatric patients in an outpatient dental setting. His years of experience as a pediatric physician anesthesiologist in a large tertiary care center not only gives him a wealth of experience to bring to an outpatient setting, but also sets him up for a really enjoyable day taking care of healthy kids for dental procedures.

SmileMD is a mobile anesthesia service currently operating at dental offices in Ohio, Illinois and Kentucky. You can learn more about SmileMD through their website here, or through this podcast with founder Dr Navin Goyal.

Conflict of Interest Statement:

SmileMD reached out to me with the invitation to connect with Dr Samuels to conduct this interview on mobile anesthesia. No financial exchange was made between SmileMD and Anesthesia Guidebook or Jon Lowrance as part of the development of this podcast.

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Clinical Tips Enhanced Recovery After Surgery

#25 – Preventing Hypothermia in Arthroplasty Surgery with Brian McGrory, MD

My guest today is Dr Brian McGrory.  His is an orthopedic joint replacement surgeon at Maine Medical Center in Portland, Maine.   

He earned his bachelor’s degree in chemistry biology at Cornell, attended medical school at Columbia, followed by residency in orthopedic surgery at the Mayo Clinic Graduate School where he also earned a Master’s degree in orthopedic research.  Dr McGrory then completed a fellowship through Harvard University at Massachusetts General Hospital in adult hip & knee reconstruction.  He has served as the research director for orthopedics at Maine Medical Center and the founding editor-in-chief of Arthroplasty Today, which is a publication of the American Association of Hip and Knee Surgeons.

Today we’re going to talk about preventing hypothermia during total joint replacement surgery.  Dr McGrory recently conducted a pilot study at Maine Medical Center evaluating perioperative body temperature in patients undergoing total joint surgery.  All patients in the study received pre-operative warming at 41-degrees Celcius with 3M’s Bair Hugger forced air warmer and intraoperatively they received warm cotton blankets out of common blanket warmers and in-line IV fluid warming with 3M’s Ranger fluid warming device.  The patients in the study group were also draped in a reflective space blanket as the independent variable.  Dr McGrory will discuss the results of this pilot study in the podcast, some of which were published as a letter to the editor in The Journal of Arthroplasty, which I’ve linked to in the show notes. 

And just to review:  perioperative hypothermia has been linked to numerous bad outcomes for patients including increased infection, delayed recovery, increased blood loss, disruptions in coagulation and cardiac events, not to mention, being cold is uncomfortable for the patient.  Perioperative temperature regulation is also linked to Medicare reimbursement with the goal of one temperature reading of at least 35.5C within 30 minutes immediately before or 15 minutes after the anesthesia stop time.  If hospitals meet this mark, they may see a slight increase in reimbursement and if they miss this mark, they may miss out on a substantial percentage of reimbursement.  So there is significant precedence for maintain perioperative normothermia. 

During the podcast, we’re going to hint at the controversy with forced hot air warmers that’s been widely discussed in peer reviewed, as well as popular news, publications.  I want to roll through the conversation with Brian uninterrupted so you can hear how one surgeon has approached that controversy and still achieved normothermia for his patients intraoperatively, but at the end of the show, I’ll unpack & clarify the backstory on Bair Huggers so you know where that stands.  It’s a crazy story that twists through legal battles, medical literature, FDA statements and popular news media… so stay tuned to the end.

References

Carlson, J. (2018 December 8). Legal war engulfs 3M device.  StarTribune.  Retrieved from https://www.startribune.com/legal-war-engulfs-mmm-operating-room-device/502063131/?refresh=true. 

Carlson, J. (2018 December 9). A closer look at the scientific evidence for and against 3M’s Bair Hugger.  StarTribune.  Retrieved from  https://www.startribune.com/a-closer-look-at-the-scientific-evidence-for-and-against-the-bair-hugger/502204321/ 

Carlson, J. (2019 August 1). Judge tosses lawsuits from 5,000-plus plaintiffs against 3M warming blanket. StarTribune.   Retrieved from https://www.startribune.com/judge-tosses-lawsuits-from-5-000-plus-plaintiffs-against-3m-warming-blanket/513491312/. 

Kellam, M. D., Dieckmann, L. S., & Austin, P. N. (2013). Forced‐air warming devices and the risk of surgical site infections. AORN journal, 98(4), 353-369. Retrieved from https://aornjournal.onlinelibrary.wiley.com/doi/epdf/10.1016/j.aorn.2013.08.001 

Madrid, E., Urrutia, G., i Figuls, M. R., Pardo‐Hernandez, H., Campos, J. M., Paniagua, P., … & Alonso‐Coello, P. (2016). Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults. Cochrane Database of Systematic Reviews, (4). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009016.pub2/epdf/full 

Maisel, W., (2017 August 30).  Information about the Use of Forced Air Thermal Regulating Systems – Letter to Health Care Providers. U.S. Food & Drug Administration. https://www.fda.gov/medical-devices/letters-health-care-providers/information-about-use-forced-air-thermal-regulating-systems-letter-health-care-providers

McGrory, B. (2018). Letter to the Editor on “Hypothermia in Total Joint Arthroplasty: A Wake-Up Call.” The Journal of Arthroplasty 33(4) 3056-3059.  Retrieved from: https://www.arthroplastyjournal.org/action/showPdf?pii=S0883-5403%2818%2930506-0 

Meier, B. (2010 December 24).  Doctor Says a Device He Invented Poses Risks. The New York Times. Retrieved from https://www.nytimes.com/2010/12/25/business/25invent.html 

Ralte, P., Mateu-Torres, F., Winton, J., Bardsley, J., Smith, M., Kent, M., … & Guisasola, I. (2020). Prevention of perioperative hypothermia: a prospective, randomized, controlled trial of Bair Hugger versus Inditherm in patients undergoing elective arthroscopic shoulder surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 36(2), 347-352. Retrieved from https://doi.org/10.1016/j.arthro.2019.08.015 

Simpson, J. B., Thomas, V. S., Ismaily, S. K., Muradov, P. I., Noble, P. C., & Incavo, S. J. (2018). Hypothermia in total joint arthroplasty: a wake-up call. The Journal of arthroplasty, 33(4), 1012-1018. Retrieved from https://www.arthroplastyjournal.org/article/S0883-5403(17)30969-5/fulltext 

Turner, T. (2021 March 11). Bair Hugger Warming Blankets. Drugwatch. 

Uggen, C. (2020).  Editorial Commentary: Just Getting Warmed Up: Risks, Benefits, and Economics of Active Warming Devices. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 36(2) Retrieved from https://www.arthroscopyjournal.org/action/showPdf?pii=S0749-8063%2819%2930843-6  

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Clinical Tips Leadership in Emergencies Pharmacology

#23 – Serotonin Syndrome with Trent & Katie Bishop, CRNAs

Today my guests are Trent and Katie Bishop, a CRNA couple who practice independently and live in Durango, Colorado.  We’re going to talk about serotonin syndrome and cases that both Trent and Katie have recently experienced as providers in their practice.

Trent & Katie Bishop are CRNAs practicing independently in Durango, Colorado.

Trent has a background in biology and EMS prior to pursuing a career as a critical care Registered Nurse and now as a CRNA.  He has prior work experience at level 1 & level 2 trauma centers working in open heart and vascular surgery.  He currently enjoys working as a independent CRNA in a small surgical hospital in Durango, Colorado.  One of the things he has truly come to love about anesthesia in a rural environment is seeing his patients out in the community and knowing he did a small thing to make their lives better.

Katie has been a Registered Nurse since 2004 when she started out working on a high acuity inpatient floor before transitioning to the medical ICU in 2006.  She considers it the best experience anyone could have asked for prior to anesthesia as she ran the code team for meany years and floated & worked in other ICUs, as well.  She has worked as a CRNA at level 1 & 2 trauma centers for several years.  She absolutely loves independent  practice and regional anesthesia and is actively engaged in expanding her regional anesthesia practice.  She writes, “Aside from loving medicine and anesthesia, I absolutely adore my family and my time with our toddler, Jackson, Trent, and our furbabies (2 dogs and 1 cat).  Durango is the best place for us to be with all of the snowboarding, camping, hiking, rafting, and travel. It’s even better when friends and family come to visit.”

References

Altman, C. S., & Jahangiri, M. F. (2010). Serotonin syndrome in the perioperative period. Anesthesia & Analgesia, 110(2), 526-528.  doi: 10.1213/ANE.0b013e3181c76be9

Berger, M., Gray, J. A., & Roth, B. L. (2009). The expanded biology of serotonin. Annual review of medicine, 60, 355-366. https://doi.org/10.1146/annurev.med.60.042307.110802

Frazer A, Hensler JG. Serotonin Involvement in Physiological Function and Behavior. In: Siegel GJ, Agranoff BW, Albers RW, et al., editors. Basic Neurochemistry: Molecular, Cellular and Medical Aspects. 6th edition. Philadelphia: Lippincott-Raven; 1999. Available from: https://www.ncbi.nlm.nih.gov/books/NBK27940/

Harper Juanillo, E., Chambliss, LR. (2018). Amniotic Fluid Embolism: Clinical Challenges and Diagnostic Dilemmas. J Pediatric Women’s Healthcare. 1(2): 1012.

Wang, R. Z., Vashistha, V., Kaur, S., & Houchens, N. W. (2016). Serotonin syndrome: preventing, recognizing, and treating it. Cleve Clin J Med, 83(11), 810-7. doi:10.3949/ccjm.83a.15129

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Anesthesia Education Clinical Tips

#22 – The Demo-Do Teaching Technique

“Tell me and I will forget. Show me and I will remember. Let me do and I will understand.” – Confucius

Demo-do teaching is all about “show me and I will remember.”

Demo-do is a simple process where educators outline what will be demonstrated, then demonstrate the process as it should be performed, then coach the learner through immediately practicing the technique.

Demonstration may seem like a silly thing for clinical preceptors to do with anesthesia learners. Too often, CRNAs & physician anesthesiologists expect learners to just know what to do – having completed the reading & studying ahead of time – and get to work practicing whatever skill is to be taught without getting the chance to see a demonstration. The demo-do process changes all that. By demonstrating skills, learners get to see what they’ve studied performed by an expert just prior to them being expected to perform the skill.

Check out the podcast to get the full run down on this technique that will enhance your clinical teaching and accelerate the time it takes for learners to master what you’re teaching them.

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Anesthesia Education Clinical Tips Preparing for Grad School/Residency

#21 – Best Practices in Precepting with Obinna Odumodu, BSN, SRNA

Please follow the link below to complete the survey associated with this podcast for Obi’s research with the University of Saint Francis:

Effectiveness of a Nurse Anesthetist Preceptor Training Survey

https://www.surveymonkey.com/r/9M7VG92

Obinna Odumodu, BSN, SRNA is currently completing his doctorate in anesthesia at the University of Saint Francis in Fort Wayne, Indiana as of February 2021, when this podcast was published.  This podcast will review best practices in precepting and is being utilized as a teaching tool as part of Obi’s doctoral research.   Obi was motivated to create this podcast as a tool for helping SRNAs and CRNAs hone their skills as clinical educators.  To that end, we review the benefits of preceptor training, the qualities of effective preceptors and how to tailor approaches to teaching novices verses experienced anesthesia trainees.  We also touch on adult learning theory, how to create positive learning environments and give effective feedback.  Our hope is that this podcast will overcome the barriers of time consuming and costly preceptor training programs and give SRNAs & CRNAs some practical tools to improve their skills as clinical educators.  Like any clinical skill – whether it’s placing central lines & arterial lines or mastering an array of airway techniques, clinical education is not something you show up knowing how to do.  Being an effective preceptor is something you can get better at and if you’re working with any kind of learner, you owe it to those learners to think about and actually train on how to become a better educator.  Being an expert clinical provider does not mean you are an expert clinical educator.  It’s two skill sets.  Hopefully this podcast will help you develop as a clinical educator.  

Obinna Odumodu was born in Texas but at the age of 3, his parents moved back to Nigeria after completing their degrees at Texas A&M University College Station.  Obi grew up in Nigeria and when he was 19 years old, he returned to the United States where he completed a Bachelor’s degree in nursing at West Texas A&M University.  He worked as a critical care Registered Nurse for over a decade before returning to complete his DNP degree at the University of Saint Francis.  Obi is married to Josephine Odumodu and they have four boys.  Interestingly, Obi started training in Jujitsu with his boys when they were young and just prior to entering anesthesia school, Obi won a world jujitsu championship in 2017.  He plans to continue to train alongside his sons after completing anesthesia school later this year. 

References

Anthony, D., Anthony, D., Jerpbak, C., Margo, K., Power, D., Slatt, L., & Tarn, D. (2014). Do we pay our community preceptors? results from a cera clerkship directors’ survey. Family Medicine. https://pubmed.ncbi.nlm.nih.gov/24652633/

Ashurst, A. (2008). Career development: The preceptorship process. Nursing and Residential Care, 10(6), 307-309. https://doi.org/10.12968/nrec.2008.10.6.29440

Bain, L. (1996). Preceptorship: A review of the literature. Journal of Advanced Nursing, 24(1), 104-107. https://doi.org/10.1046/j.1365-2648.1996.15714.x

Bengtsson, M. &. (2015). Knowledge and skills needed to improve as preceptor: Development of a continuous professional development course – a qualitative study part I. BMC Nursing, 14, 51. https://doi.org/10.1186/s12912-015-0103-9.

Bonner, J. M., Greenbaum, R. L., & Mayer, D. M. (2016). My boss is morally disengaged: The role of ethical leadership in explaining the interactive effect of supervisor and employee moral disengagement on employee behaviors. Journal of Business Ethics, 137(4), 731-742. https://doi.org/10.1007/s10551-014-2366-6

Bowers, A. J. (2016). Quantitative research methods training in education leadership and administration preparation programs as disciplined inquiry for building school improvement capacity. Journal of Research on Leadership Education, 12(1), 72-96. https://doi.org/10.1177/1942775116659462

Cashin, A. J., & Newman, C. (2010). The evaluation of a 12-Month health service manager mentoring program in a corrections environment. Journal for Nurses in Staff Development (JNSD), 26(2), 56-63. https://doi.org/10.1097/nnd.0b013e3181d4789e

Easton, A. O. (2017). Development of an online, evidence-based CRNA Preceptor Training Tutorial (CPiTT): A quality improvement project. AANA Journal, 85(5). https://pubmed.ncbi.nlm.nih.gov/31566532/

Elisha, S., & Rutledge, D. (2011). Clinical education experiences: Perceptions of student registered nurse anesthetists. AANA Journal, 79(4 Supplement), S35. https://pubmed.ncbi.nlm.nih.gov/22403965/

Goldsmith, J. (2008). The code: standards of conduct, performance and ethics for nurses and midwives. https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-old-code-2008.pdf.

Hautala, K. T., Saylor, C. R., & O’Leary-Kelley, C. (2007). Nurses’ perceptions of stress and support in the preceptor role. Journal for Nurses in Professional Development, 23(2), 64-70. https://doi: 10.1097/01.NND.0000266611.78315.08.

Inayat-ur-Rehman, Hussain Shah, S. M., Bashir, Z., & Hussain, S. (2016). Relationship between dominance skills of school managers and teachers’ organizational citizenship behavior. Journal of Research & Reflections in Education (JRRE), 10(1), 28. http://prr.hec.gov.pk/jspui/bitstream/123456789/13004/1/Inayat_ur_Rehman_Education_2016_HSR_AIOU_01.02.2017.pdf

Jones, T., Goss, S., Weeks, B., Miura, H., Bassandeh, D., & Cheek, D. (2011). The effects of high-fidelity simulation on salivary cortisol levels in SRNA students: A pilot study. The Scientific World JOURNAL, 11, 86-92. https://doi.org/10.1100/tsw.2011.8

Jordan, J., Watcha, D., Cassella, C., Kaji, A. H., & Trivedi, S. (2019). Impact of a mentorship program on medical student burnout. AEM Education and Training, 3(3), 218-225. https://doi.org/10.1002/aet2.10354

Lalonde, M., & McGillis Hall, L. (2017). Preceptor characteristics and the socialization outcomes of new graduate nurses during a preceptorship programme. Nursing open, 4(1), 24-31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221437/

La, I. S., & Yun, E. K. (2019). Effects of trait anger and anger expression on job satisfaction and burnout in preceptor nurses and newly graduated nurses: A dyadic analysis. Asian nursing research, 13(4), 242-248 http:// doi: 10.1016/j.anr.2019.09.002.

Latessa, R., Beaty, N., Landis, S., Colvin, G., & Janes, C. (2007). The satisfaction, motivation, and future of community preceptors: The North Carolina experience. Academic Medicine, 82(7), 698-703. https://doi.org/10.1097/acm.0b013e318067483c

Lien, K., Chin, A., Helman, A., & Chan, T. M. (2018). A randomized comparative trial of the knowledge retention and usage conditions in undergraduate medical students using podcasts and blog posts. Cureus. https://doi.org/10.7759/cureus.2065

Man, M. (2016). Managers and organizational citizenship behavior. Scientific Bulletin, 21(1), 14-20. https://doi.org/10.1515/bsaft-2016-0031

Miesner, A. R., Lyons, W., & McLoughlin, A. (2017). Educating medical residents through podcasts developed by PharmD students. Currents in Pharmacy Teaching and Learning, 9(4), 683-688. https://doi.org/10.1016/j.cptl.2017.03.003

Mills, J., Francis, K., & Bonner, A. (2008). Getting to know a stranger—rural nurses’ experiences of mentoring: A grounded theory. International Journal of Nursing Studies, 45(4), 599-607. https://doi.org/10.1016/j.ijnurstu.2006.12.003.

Paul, C. R., Vercio, C., Tenney-Soeiro, R., Peltier, C., Ryan, M. S., Van Opstal, E. R., Alerte, A., Christy, C., Kantor, J. L., Mills, W. A., Patterson, P. B., Petershack, J., Wai, A., & Beck Dallaghan, G. L. (2020). The decline in community preceptor teaching activity. Academic Medicine, 95(2), 301-309. https://doi.org/10.1097/acm.0000000000002947

Peters, A. S., Schnaidt, K. N., Zivin, K., Rifas-Shiman, S. L., & Katz, H. P. (2009). How important is money as a reward for teaching? Academic Medicine, 84(1), 42-46. https://doi.org/10.1097/acm.0b013e318190109c

Phillips, J. M. (2006). Preparing preceptors through online education. Journal for Nurses in Staff Development (JNSD), 22(3), 150-156. https://doi.org/10.1097/00124645-200605000-00010

Price, A., Janssens, A., Woodley, A. L., Allwood, M., & Ford, T. (2019). Experiences of healthcare transitions for young people with attention deficit hyperactivity disorder: a systematic review of qualitative research. Child and Adolescent Mental Health, 24(2), 113-122. https://doi.org/10.1111/camh.12297

Ray W, &. D. (2016). The history of the nurse anesthesia profession. Journal of Clinical Anesthesia, 30, 51-58. doi:10.1016/j.jclinane.2015.11.005.

Ryan, M. L. (2018). Recruitment and retention of community preceptors. Pediatrics, 142(3). doi:10.1542/peds.2018-0673.

Sanford, P. G., & Tipton, P. H. (2016). Is nursing preceptor behavior changed by attending a preceptor class? Baylor University Medical Center Proceedings, 29(3), 277-279. https://doi.org/10.1080/08998280.2016.11929434

Scott-Herring, M., & Singh, C. S. (2017). A CRNA Preceptor Workshop to Increase Preceptor Satisfaction, Confidence, and Comfort: A Quality Improvement Project. AANA Journal 85(4):24–31. https://pubmed.ncbi.nlm.nih.gov/31566541/

Belding Schmitt, M., G Titler, M., A Herr, K., & Ardery, G. (2004). Challenges of web-based education in educating nurses about evidence-based acute pain management practices for older adults. The Journal of Continuing Education in Nursing, 35(3), 121-127. https://doi.org/10.3928/0022-0124-20040501-08

Scott-Herring, M., & Singh, S. (2017) A CRNA preceptor workshop to increase preceptor satisfaction, confidence, and comfort: a quality improvement project. AANA Journal, 85(4):24–31. https://pubmed.ncbi.nlm.nih.gov/31566541/

Sorensen, H. A., & Yankech, L. R. (2008). Precepting in the fast lane: Improving critical thinking in new graduate nurses. The Journal of Continuing Education in Nursing, 39(5), 208-216. https://doi.org/10.3928/00220124-20080501-07

Tan, K. F. (2011). A literature review of preceptorship: A model for the medical radiation sciences? Journal of Medical Imaging and Radiation Sciences, 42(1), 15-20. http://doi:10.1016/j.jmir.2010.08.004.

Schutt, M., & Stachowski, A. (2019). Development of an Online Preceptor Workshop for the DNP Nurse Anesthesia Program Recruitment and Retention. Retrieved from https://ubir.buffalo.edu/xmlui/handle/10477/81348

Merriam, S. B. (2001). The new update on adult learning theory (Ser. New directions for adult and continuing education, no. 89). Jossey-Bass.

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Anesthesia Education Business/Finances Clinical Tips Preparing for Grad School/Residency

#20 – Rural Independent CRNA Practice with Chuck Frisch, DNP, CRNA, FAAPM, CH

Today my guest is Chuck Frisch, DNP, CRNA, FAAPM, CH, a CRNA with over 35 years of experience in anesthesia who serves as the director of anesthesia at Box Butte General Hospital in Alliance, Nebraska.  He’s here to talk about rural, independent CRNA practice.

Chuck initially studied molecular, cellular & developmental biology in college before switching gears to nursing school in effort to get out of the solitude of research labs.  He completed his associates degree in biology in 1978 and a second associates degree in nursing in 1979 at Mesa College, which is now Colorado Mesa University, in Grand Junction, Colorado.  In 1985, Chuck completed his bachelor’s in anesthesia at Mount Marty College, which is now Mount Marty University, in order to becoming a CRNA.  He then completed a Master’s degree in Health Administration in 1989 with the goal of one day being a chief CRNA.  After 15 years of working in an anesthesia care team alongside physician anesthesiologists, chuck moved to Alliance, Nebraska to work in an independent anesthesia practice in 2000.  While first a co-director of anesthesia, following the retirement of his partner, he became the director of anesthesia at Box Butte General Hospital in 2002.  Chuck returned to school to complete his doctorate of nursing practice degree in 2014 at Rocky Mountain University of Health Professions in Provo, Utah.  He has served on numerous state association committees in Nebraska and served as the director of the state association for 1 term.  Chuck is a Fellow of the American Academy of Pain Medicine and served on the AANA’s practice committee and help write and verify the first NBCRNA pain management certification exam.

He’s been married for 43 years, has 4 children, two of whom were adopted internationally and his first grandchild is due to be born in June of 2021.

We talk about the unique challenges in working in a small, rural setting including patient screening for elective cases, how CRNAs are utilized throughout the hospital as airway and critical care experts, who your resources are and what kind of mindset you need to succeed in a rural independent practice. 

Dr Frisch’s bio at Box Butte General Hospital is here.

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Anesthesia Education Clinical Tips Pharmacology Preparing for Grad School/Residency

#19 – Anesthesia Top Drawer Run Down – Part 3

The Top Drawer Run Down is a 3-part series covering the 39 most commonly administered intravenous medications in anesthesia. These medications are often found in the top drawer of anesthesia carts in the United States. The Top Drawer Run Down was originally posted on From the Head of the Bed… a podcast for the anesthesia community in September of 2019.

Michael Mielniczek, MSN, CRNA joins me to deliver the run down on these medications. Michael has a deep interest in pharmacology and completed his anesthesia training with a Master’s in Nursing from the University of Scranton in 2018. He joined me on Episode 3 of Anesthesia Guidebook for a deep dive into succinylcholine, a medication that was the focus of his graduate degree research. He has spoken at state CRNA conferences on succinylcholine, as well as at the national AANA Annual Congress.

We cover the following medications in this series:

Part 1:

  • Propofol
  • Etomidate
  • Ketamine
  • Lidocaine
  • Fentanyl
  • Morphine
  • Hydromorphone
  • Remifentanil
  • Sufentanil
  • Alfentanil
  • Succinylcholine
  • Rocuronium
  • Vecuronium
  • Cisatracurium

Part 2:

  • Atropine
  • Glycopyrrolate
  • Neostigmine
  • Sugammadex
  • Metoprolol
  • Labetalol
  • Esmolol
  • Hydralazine
  • Phenylephrine
  • Ephedrine
  • Epinephrine
  • Calcium Chloride

Part 3:

  • Heparin
  • Naloxone
  • Albuterol
  • Dexamethasone
  • Famotidine
  • Ondansetron
  • Haloperidol
  • Furosemide
  • Metoclopramide
  • Ketorolac
  • Oxytocin
  • Methylergonovine
  • Carboprost

Here is the Anesthesia Guidebook Top Drawer Run Down Study Guide:

Anesthesia-Guidebooks-Top-Drawer-Run-Down-Study-GuideDownload

The information provided in this series is as accurate as possible but mistakes can happen. It is your responsibility to consult experienced healthcare providers, up-to-date published text books and peer reviewed literature before making decisions to implement information you hear in podcasts, blogs and social media posts, including Anesthesia Guidebook. Dig deep, do your homework and own your practice. Your practice is your responsibility.

Resources:

Assante, J., Collins, S., & Hewer, I. (2015). Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review. AANA journal, 83(4).

Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.

Miller, R. D., et. al. (2014). Miller’s Anesthesia. Elsevier Health Sciences.

Nagelhout, J. J., Elisha, S., & Plaus, K. (2013). Nurse anesthesia. Elsevier Health Sciences.

Ouellette, R., & Joyce, J. (Eds.). (2010). Pharmacology for nurse anesthesiology. Jones & Bartlett Publishers.

Rezai, S., Hughes, A. C., Larsen, T. B., Fuller, P. N., & Henderson, C. E. (2017). Atypical amniotic fluid embolism managed with a novel therapeutic regimen. Case reports in obstetrics and gynecology, 2017.

Tubog, T. D., Kane, T. D., & Pugh, M. A. (2017). Effects of ondansetron on attenuating spinal anesthesia-induced hypotension and bradycardia in obstetric and nonobstetric subjects: a systematic review and meta-analysis. AANA Journal, 85(2), 113-122.

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Anesthesia Education Clinical Tips Pharmacology Preparing for Grad School/Residency

#18 – Anesthesia Top Drawer Run Down – Part 2

The Top Drawer Run Down is a 3-part series covering the 39 most commonly administered intravenous medications in anesthesia. These medications are often found in the top drawer of anesthesia carts in the United States. The Top Drawer Run Down was originally posted on From the Head of the Bed… a podcast for the anesthesia community in September of 2019.

Michael Mielniczek, MSN, CRNA joins me to deliver the run down on these medications. Michael has a deep interest in pharmacology and completed his anesthesia training with a Master’s in Nursing from the University of Scranton in 2018. He joined me on Episode 3 of Anesthesia Guidebook for a deep dive into succinylcholine, a medication that was the focus of his graduate degree research. He has spoken at state CRNA conferences on succinylcholine, as well as at the national AANA Annual Congress.

We cover the following medications in this series:

Part 1:

  • Propofol
  • Etomidate
  • Ketamine
  • Lidocaine
  • Fentanyl
  • Morphine
  • Hydromorphone
  • Remifentanil
  • Sufentanil
  • Alfentanil
  • Succinylcholine
  • Rocuronium
  • Vecuronium
  • Cisatracurium

Part 2:

  • Atropine
  • Glycopyrrolate
  • Neostigmine
  • Sugammadex
  • Metoprolol
  • Labetalol
  • Esmolol
  • Hydralazine
  • Phenylephrine
  • Ephedrine
  • Epinephrine
  • Calcium Chloride

Part 3:

  • Heparin
  • Naloxone
  • Albuterol
  • Dexamethasone
  • Famotidine
  • Ondansetron
  • Haloperidol
  • Furosemide
  • Metoclopramide
  • Ketorolac
  • Oxytocin
  • Methylergonovine
  • Carboprost

Here is the Anesthesia Guidebook Top Drawer Run Down Study Guide:

Anesthesia-Guidebook’s-Top-Drawer-Run-Down-Study-GuideDownload

The information provided in this series is as accurate as possible but mistakes can happen. It is your responsibility to consult experienced healthcare providers, up-to-date published text books and peer reviewed literature before making decisions to implement information you hear in podcasts, blogs and social media posts, including Anesthesia Guidebook. Dig deep, do your homework and own your practice. Your practice is your responsibility.

Resources:

Brull, S. J., & Kopman, A. F. (2017). Current Status of Neuromuscular Reversal and Monitoring Challenges and Opportunities. Anesthesiology: The Journal of the American Society of Anesthesiologists, 126(1), 173-190.

Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.

Lauria, M.  (2018)  Emergency reflex action drills.  EmCrit RACC. Retrieved from https://emcrit.org/emcrit/emergency-reflex-action-drills/

Miller, R. D., et. al. (2014). Miller’s Anesthesia. Elsevier Health Sciences.

Nagelhout, J. J., Elisha, S., & Plaus, K. (2013). Nurse anesthesia. Elsevier Health Sciences.

Ouellette, R., & Joyce, J. (Eds.). (2010). Pharmacology for nurse anesthesiology. Jones & Bartlett Publishers.

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Categories
Anesthesia Education Clinical Tips Pharmacology Preparing for Grad School/Residency

#17 – Anesthesia Top Drawer Run Down – Part 1

The Top Drawer Run Down is a 3-part series covering the 39 most commonly administered intravenous medications in anesthesia. These medications are often found in the top drawer of anesthesia carts in the United States. The Top Drawer Run Down was originally posted on From the Head of the Bed… a podcast for the anesthesia community in September of 2019.

Michael Mielniczek, MSN, CRNA joins me to deliver the run down on these medications. Michael has a deep interest in pharmacology and completed his anesthesia training with a Master’s in Nursing from the University of Scranton in 2018. He joined me on Episode 3 of Anesthesia Guidebook for a deep dive into succinylcholine, a medication that was the focus of his graduate degree research. He has spoken at state CRNA conferences on succinylcholine, as well as at the national AANA Annual Congress.

We cover the following medications in this series:

Part 1:

  • Propofol
  • Etomidate
  • Ketamine
  • Lidocaine
  • Fentanyl
  • Morphine
  • Hydromorphone
  • Remifentanil
  • Sufentanil
  • Alfentanil
  • Succinylcholine
  • Rocuronium
  • Vecuronium
  • Cisatracurium

Part 2

  • Atropine
  • Glycopyrrolate
  • Neostigmine
  • Sugammadex
  • Metoprolol
  • Labetalol
  • Esmolol
  • Hydralazine
  • Phenylephrine
  • Ephedrine
  • Epinephrine
  • Calcium Chloride

Part 3

  • Heparin
  • Naloxone
  • Albuterol
  • Dexamethasone
  • Famotidine
  • Ondansetron
  • Haloperidol
  • Furosemide
  • Metoclopramide
  • Ketorolac
  • Oxytocin
  • Methylergonovine
  • Carboprost

Here is the Anesthesia Guidebook Top Drawer Run Down Study Guide:

Anesthesia-Guidebook’s-Top-Drawer-Run-Down-Study-GuideDownload

The information provided in this series is as accurate as possible but mistakes can happen. It is your responsibility to consult experienced healthcare providers, up-to-date published text books and peer reviewed literature before making decisions to implement information you hear in podcasts, blogs and social media posts, including Anesthesia Guidebook. Dig deep, do your homework and own your practice. Your practice is your responsibility.

Resources:

Çoruh, B., Tonelli, M. R., & Park, D. R. (2013). Fentanyl-induced chest wall rigidity. Chest, 143(4), 1145-1146.

Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.

Miller, R. D., et. al. (2014). Miller’s Anesthesia. Elsevier Health Sciences.

Nagelhout, J. J., Elisha, S., & Plaus, K. (2013). Nurse anesthesia. Elsevier Health Sciences.

Ouellette, R., & Joyce, J. (Eds.). (2010). Pharmacology for nurse anesthesiology. Jones & Bartlett Publishers.

Panchal, A. R., et. al. (2018).  2018 American Heart Association focused update on advanced cardiovascular life support use of antiarrhythmic drugs during and immediately after cardiac arrest.  Circulation, 138(23), e740-e749.    Retrieved from https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000613. 

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Clinical Tips Enhanced Recovery After Surgery Obstetrics Pharmacology

#16 – Ondansetron for preventing spinal-induced hypotension with Jenny Li, BSN, SRNA

In this episode, I talk with Jenny Li, BSN, SRNA about using pre-procedural ondansetron to prevent spinal-induced hypotension in elective cesarean-sections. Ms Li is completing her Doctorate of Nursing Practice (DNP) at the University at Buffalo and structured her doctoral work around this topic. She received a Bachelor of Science in Psychology from University of California, Davis in 2013 and went back to school for a second Bachelor’s in Nursing at the University of Rochester. She worked in the Cardiovascular ICU at Strong Memorial Hospital in Rochester, NY for 2 years before returning to school to complete her Doctor of Nursing Practice degree. She is expected to graduate in May 2021.

Resources:

Gao, L., Zheng, G., Han, J., Wang, Y., & Zheng, J. (2015). Effects of prophylactic ondansetron on spinal anesthesia-induced hypotension: a meta-analysis. International journal of obstetric anesthesia, 24(4), 335-343. . https://doi.org/10.1016/j.ijoa.2015.08.012

Heesen, M., Klimek, M., Hoeks, S. E., & Rossaint, R. (2016). Prevention of spinal anesthesia-induced hypotension during cesarean delivery by 5-hydroxytryptamine-3 receptor antagonists: a systematic review and meta-analysis and meta-regression. Anesthesia & Analgesia, 123(4), 977-988.

Karacaer, F., Biricik, E., Ünal, İ., Büyükkurt, S., & Ünlügenç, H. (2018). Does prophylactic ondansetron reduce norepinephrine consumption in patients undergoing cesarean section with spinal anesthesia?. Journal of anesthesia, 32(1), 90-97.

Kinsella, S. M., Carvalho, B., Dyer, R. A., Fernando, R., McDonnell, N., Mercier, F. J., … & Consensus Statement Collaborators. (2018). International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Obstetric Anesthesia Digest, 38(4), 171-172.

Ortiz-Gómez, J. R., Palacio-Abizanda, F. J., Morillas-Ramirez, F., Fornet-Ruiz, I., Lorenzo-Jiménez, A., & Bermejo-Albares, M. L. (2017). Reducing by 50% the incidence of maternal hypotension during elective caesarean delivery under spinal anesthesia: Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine-a double-blind, randomized, placebo controlled trial. Saudi journal of anaesthesia, 11(4), 408.

Šklebar, I., Bujas, T., & Habek, D. (2019). Spinal Anaesthesia-induced Hypotension in Obstetrics: Prevention and Therapy. Acta Clinica Croatica, 58(Suppl 1), 90.

Tatikonda, C. M., Rajappa, G. C., Rath, P., Abbas, M., Madhapura, V. S., & Gopal, N. V. (2019). Effect of intravenous ondansetron on spinal anesthesia-induced hypotension and bradycardia: A randomized controlled double-blinded study. Anesthesia, Essays and Researches, 13(2), 340.

Trabelsi, W., Romdhani, C., Elaskri, H., Sammoud, W., Bensalah, M., Labbene, I., & Ferjani, M. (2015). Effect of ondansetron on the occurrence of hypotension and on neonatal parameters during spinal anesthesia for elective caesarean section: a prospective, randomized, controlled, double-blind study. Anesthesiology research and practice, 2015.

Tubog, T. D., Kane, T. D., & Pugh, M. A. (2017). Effects of ondansetron on attenuating spinal anesthesia-induced hypotension and bradycardia in obstetric and nonobstetric subjects: a systematic review and meta-analysis. AANA J, 85(2), 113-122.

Zhou, C., Zhu, Y., Bao, Z., Wang, X., & Liu, Q. (2018). Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials. Journal of International Medical Research, 46(2), 654-662.

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Categories
Clinical Tips Enhanced Recovery After Surgery Opioid Free Anesthesia Pharmacology Regional Anesthesia

#13 – Perioperative Buprenorphine Management with Aurora Quaye, MD

Aurora Quaye, MD is an anesthesiologist who specializes in regional anesthesia and pain medicine at Maine Medical Center in Portland, Maine. She completed her residency at Massachusetts General Hospital and a fellowship in Regional Anesthesia at Brigham and Women’s Hospital.  Dr. Quaye’s clinical interests include decreasing the use of opioids for pain management, in improving provider education on non-opioid analgesic strategies, and in identifying analgesic techniques that decrease the potential for opioid misuse, dependence and addiction.  Dr Quaye has led committees to establish institutional guidelines for perioperative continuation of buprenorphine at analgesic dosing for patients with history of Opioid Use Disorder. These guidelines have been incorporated in acute pain management protocols at Massachusetts General Hospital and Maine Medical Center.  This change from the prior practice of discontinuing buprenorphine has shown early promise in facilitating postoperative pain relief while limiting opioid prescribing. 

Resources:

Quaye, A. N. A., et. al. (2020) Perioperative Continuation of Buprenorphine at Low–Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation, Pain Medicine, Volume 21, Issue 9, Pages 1955–1960, https://doi.org/10.1093/pm/pnaa020

Quaye, A. N. A., & Zhang, Y. (2019). Perioperative management of buprenorphine: solving the conundrum. Pain Medicine, 20(7), 1395-1408.

Ward, E. N., Quaye, A. N. A., & Wilens, T. E. (2018). Opioid use disorders: perioperative management of a special population. Anesthesia and analgesia, 127(2), 539.

Anderson, T. A., Quaye, A. N., Ward, E. N., Wilens, T. E., Hilliard, P. E., & Brummett, C. M. (2017). To Stop or Not, That Is the QuestionAcute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology: The Journal of the American Society of Anesthesiologists, 126(6), 1180-1186.

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Categories
Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency

#11 – Cognitive Aids Make You More Effective in Emergencies with Ryan Mountjoy, MD

This episode is a continuation of the series on Leadership in Emergencies… the art & science of resuscitation.   Be sure to go check out episode 7 of the podcast where I give a quick run down of leadership in emergencies and how we can work towards improving our individual & team performance in anesthesia crises.   

Ryan Mountjoy, MD is a board-certified physician anesthesiologist with Spectrum Healthcare Partners in Portland, Maine.  He is the Co-Director of Orthopedic Trauma and Total Joint Anesthesia and the Co-Director of Regional Anesthesia and Acute Pain Medicine at Maine Medical Center and the Site Chief of Anesthesia at MaineHealth’s Scarborough Surgery Center.  He completed his anesthesia residency at Stanford University and then pursued a Regional and Ambulatory Anesthesia fellowship at Duke University, where he worked prior to moving to Maine.  He has been practicing in the Portland area for 4 years and enjoys time with his family, anything outdoors and sampling Maine’s prolific food and beverage scene.  

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Airway Clinical Tips Preparing for Grad School/Residency

#10 – 10 Quick Tips for Learning Airway Management

This is a distillation of 10 key tips to help folks who are learning airway management improve their skills. This show gets straight to the point: 10 tips for airway management in 10 minutes.

10 Tips for Airway Management

1. Develop a growth mindset and practice deliberately

2. Do a good airway assessment

3. Develop and follow a plan

4. Control your environment

5. Position the patient and yourself for success

6. Preoxygenate adequately

7. Communicate effectively

8. Choose meds appropriately and let them work

9. Take your time with laryngoscopy

10. Recognize when you need to change your plan and do so deliberately

Chong, J. (2016).  Airway management in obese patients.  EMNote.  Retrieved from http://www.emnote.org/emnotes/airway-management-in-obese-patients 
This is my personal ramp preference – a stack of blankets wrapped with one blanket (which helps when removing the ramp after intubation) and either a pillow or foam shay on top.

Resources:

Achar, S. K., Pai, A. J., & Shenoy, U. K. (2014). Apneic oxygenation during simulated prolonged difficult laryngoscopy: comparison of nasal prongs versus nasopharyngeal catheter: a prospective randomized controlled study. Anesthesia, essays and researches, 8(1), 63.

Booth, A. W. G., Vidhani, K., Lee, P. K., & Thomsett, C. M. (2017). SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study. BJA: British Journal of Anaesthesia, 118(3), 444-451

Caputo, N., Azan, B., Domingues, R., Donner, L., Fenig, M., Fields, D., … & McCarty, M. (2017). Emergency Department use of Apneic Oxygenation versus usual care during rapid sequence intubation: A randomized controlled trial (The ENDAO Trial). Academic Emergency Medicine, 24(11), 1387-1394.

Chong, J. (2016).  Airway management in obese patients.  EMNote.  Retrieved from http://www.emnote.org/emnotes/airway-management-in-obese-patients 

Dearani, J. A., Gold, M., Leibovich, B. C., Ericsson, K. A., Khabbaz, K. R., Foley, T. A., … & Daly, R. C. (2017). The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection. The Journal of thoracic and cardiovascular surgery, 154(4), 1329-1336.

Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939

Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.

Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81.

e Silva, L. O. J., Cabrera, D., Barrionuevo, P., Johnson, R. L., Erwin, P. J., Murad, M. H., & Bellolio, M. F. (2017). Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis. Annals of emergency medicine, 70(4), 483-494. 

Heard, A., Toner, A. J., Evans, J. R., Palacios, A. M. A., & Lauer, S. (2017). Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of buccal RAE tube oxygen administration. Anesthesia & Analgesia, 124(4), 1162-1167.

Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.

Lee, P. K., Booth, A. W. G., Vidhani, K., & Bath, J. M. (2017). Spontaneous Breathing For the Difficult Airway: STRIVE Hi Demonstrates Its Versatility. Anesthesiology News.

Moulton, C. E., Regehr, G., Mylopoulos, M., & MacRae, H. M. (2007). Slowing down when you should: a new model of expert judgment. Academic Medicine: Journal Of The Association Of American Medical Colleges, 82(10 Suppl), S109-S116.

Myatra, S. N., Kalkundre, R. S., & Divatia, J. V. (2017). Optimizing education in difficult airway management: meeting the challenge. Current Opinion in Anesthesiology, 30(6), 748-754.

Nørskov, A. K., Rosenstock, C. V., Wetterslev, J., Astrup, G., Afshari, A., & Lundstrøm, L. H. (2015). Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia, 70(3), 272-281. [THIS IS THE STUDY SHOWING 93% OF DIFFICULT INTUBATIONS AND 94% OF DIFFICULT MASK VENTILATION CASES WERE NOT ANTICIPATED.] 

Patel, A., & Nouraei, S. A. R. (2015). Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia, 70(3), 323-329.

Patel, A., & Nouraei, S. A. R. (2016) Nasal ventilation: oxygenation, no desat, and thrive.  Anesthesiology News.  Retrieved from http://www.anesthesiologynews.com/Review-Articles/Article/08-16/Nasal-Ventilation-Oxygenation-NO-DESAT-and-THRIVE/37294/ses=ogst

Pratt, M. (2017). A Practical Approach to Apneic Oxygenation during Endotracheal Intubation. J Anesth Clin Res, 8(696), 2.

Pratt, M., & Miller, A. B. (2016). Apneic Oxygenation: A Method to Prolong the Period of Safe Apnea. AANA Journal, 84(5), 322-328.

Ramachandran, S. K., Cosnowski, A., Shanks, A., & Turner, C. R. (2010). Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. Journal of clinical anesthesia, 22(3), 164-168.

Weingart, S. D., & Levitan, R. M. (2012). Preoxygenation and prevention of desaturation during emergency airway management. Annals of emergency medicine, 59(3), 165-175.

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Categories
Anesthesia Education Clinical Tips Preparing for Grad School/Residency Wellness

#8 – How to master precepting with Will Cohen, MSN, CRNA

Today I’m joined by Will Cohen to talk about clinical precepting.  We discuss ways to create effective learning environments, how to expect excellence while being supportive and other tips for mastering the art of precepting.

Will created the Facebook page CRNA Preceptors and has become well known in the CRNA world for creating masterfully crafted deep dives on physiology & pharmacology to help CRNA preceptors train their resident SRNAs  

William Cohen is a CRNA who currently practices at two hospitals in the Kansas City metro area.  The first is the University of Kansas Health System which serves as the regional level 1 trauma & burn center.  The other is the Minimally Invasive Surgical Hospital, which focuses on bariatric and orthopedic surgeries and is staffed by a CRNA-only team proficient in multimodal, opioid sparing and ultrasound guided regional anesthesia techniques. 

Mr. Cohen graduated from the Our Lady of Lourdes Nurse Anesthesia Program with a Master’s degree, and had been in various clinical roles prior to entering the anesthesia environment.  He has provided patient care in the pre-hospital setting as an EMT and Paramedic in Ohio and New Jersey, as well as working as a trauma critical care nurse in Atlantic City. Throughout each phase of his career, William has always taken on preceptor roles and enjoys having learners in the clinical environment. 

William has a wide array of interests in healthcare, including precepting learners, human behavior during crisis and emergencies, airway management, opioid sparing anesthesia, and process improvement. Saving the best for last, William thrives on being a husband and father. His family loves to travel, as well as go mountain biking, skiing and experiencing whatever local foods and beers happen to be found along the way.

Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012). Stress: perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. AANA Journal, 80(4).

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Anesthesia Education Clinical Tips Leadership in Emergencies

#7 – Leadership in Emergencies – how to master the art & science of resuscitation

Leadership in emergencies is about leadership outside of emergencies. The art and science of resuscitation involves understanding and mastering both the systems design and human factors at play in emergencies. In this episode, I unpack research by Weinger, et. al. (2017) to help us see the potential for improvement in our response to emergencies as anesthesia providers. This is the tip of the iceberg and in future shows, we’ll explore concepts related to cognitive biases, leadership & followership, communication, flow, stress inoculation training and more.

Resources:

Weinger, M. B., Banerjee, A., Burden, A. R., McIvor, W. R., Boulet, J., Cooper, J. B., … & Torsher, L. (2017). Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology: The Journal of the American Society of Anesthesiologists, 127(3), 475-489.

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