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!
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!
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!
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.
This is episode 88 and it’s part 3 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. 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 discussed the principles of damage control resuscitation.
And in this final episode of the series, we talk about the path to becoming a military CRNA, a little bit more about Dustin’s personal journey and the importance of supporting our troops. Now, I know the wars in Iraq and Afghanistan have fortunately come to an official end and that right now in August of 2022 we are in a period of time where United States troops are not in active combat roles. However, the United States still have the world’s largest military with approximately 1.3 million active service members and nearly 200,000 personnel actively deployed oversees. What Degman shares in this episode about how to engage with and support active service personnel is a powerful message for each of us. These individuals continue to make a sacrifice to serve the mission that our nation has given them. That we support them and how we support them matters. And so we’re going to talk a bit about that in this episode. And again, in terms of direct relevance to anesthesia, this episode has incredible traction for those of you who are or want to become military CRNAs or physician anesthesiologists or those of you who work with, are friends with or in families with these individuals.
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.
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.
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.
This is part 2 of my conversation with Mason McDowell, DNAP, CRNA. In 2014, he, along with his wife and 2 young daughters, sold everything they owned and moved full time to the heart of Africa… to the town of Beré in the nation of Chad, to provide anesthesia services at hospital with severe resource limitations.
Dr McDowell was a professor of mine and the assistant program director at Western Carolina University when he made the decision to move to Chad. I remember him preparing and talking about the why behind his decision and watching that process unfold was incredibly powerful.
In part one of our conversation (episode 61), Mason talks about the decision to go to Chad, what he and his family did there and why they had to evacuate the country emergently and return to the United States. In this episode, Mason shares advice for those who wish to travel and provide anesthesia for underdeveloped, impoverished and/or remote communities.
The stories Mason shares in this 2-part series are remarkable but they only scratch the surface of his time in Chad. I’ll link to his blog at whyweshouldgo.blogspot.com in the show notes where you can read about the day-to-day, night-to-night tales from providing anesthesia and general medical services in Chad. THOSE stories are heart wrenching. There we innumerable times when Mason and his team had to make decisions based on the severe resource limitation that we simply would never have to make here in the United States. I’d like to share one of Mason’s stories with you here:
4-3-2-1 8 Dec 2014, Bere, Chad by Mason McDowell, DNAP, CRNA
I was called out of our morning meeting at the hospital
around 730am with the wave of a hand. I knew what it was even before I asked for confirmation: Bébé? Oui.
A mother had just delivered twins but baby #2 wasn’t breathing. I gave oxygen, breathed for him with an ambu bag and tried to keep him warm. Danae (the OB/GYN) lifted her scrub shirt to press baby against her skin to warm him as I continued to hand ventilate. Eventually he was breathing on his own and was sent to our “NICU”– that’s the neonatal intensive care unit; except in Chad it means he is getting oxygen while he rests in a tiny cardboard box in our OR with 2 hot water bottles tucked beside him. Guess what? He’s still alive tonight!
Flash forward to around 8pm when our volunteers arrived from the US. They were only here 10 minutes before an urgent phone call: maternity…a mom turned quickly…send Mason now! I threw on scrubs and my friend Shawn (also an anesthetist) hurried along behind me.
We arrived to find a seemingly dead looking pregnant woman laying on the floor and frothing at the mouth. We moved her quickly down the sidewalk to the OR and began CPR. Chest compressions, oxygen/ventilation, IV epinephrine…Nothing. Now thats a terrible situation–lifeless and pregnant. I told Danae “she’s dead-dead …get the baby out”.
I barely finished the sentence before Danae cut down and retrieved a baby girl. Good pulse but not breathing. After an extended period of manual ventilation and stimulation the baby perked up and breathed on her own! The unmistakeable scent of Arabic perfume lingered in the air as it radiated from the cloth I used to wrap the baby in. The fabric had been part of her mothers clothing. Blood covered the OR table, floor, and the surgeon. We cleaned up the baby’s mother and brought in the family for a final viewing. Tears and prayer filled the OR. The family left to find a truck to carry the body away and I walked home alone under a brilliant night sky, still replaying the events of the day and looking for lessons to learn.
I returned home to find suitcases filled with treasures from the US. Our friends brought items purchased or donated for us and our hospital– it was like an early Christmas. After 30minutes of sorting goodies and eating junk food another call came: stat C-section. Seriously?!
A very young mother with complicated labor was already in preop when I arrived. Unfortunately the dead body from an hour ago was still in the OR (still waiting for family) and we had to find a way to move it out and bring in the new patient without making a big scene. If it wasn’t so sad it would have been comical. We pushed the dead woman into our tiny preop room after angling the new patient’s stretcher in a way that she had to twist around to see the body. And that’s exactly what she tried to do. We built a human wall with the 4 of us as we shuffled along pulling the new patient past the body (just 2 feet away).
Now in the OR: IV fluid, monitors, spinal anesthetic administered easily–cut down and baby retrieved in textbook fashion. Except…Silent baby. Floppy baby. Apneic baby. After stimulating, warming, and ventilating with oxygen…nothing. Pulse rate 160:perfect. But he’s not breathing.
Ventilate. Stimulate. Spank…again and again. The sound of surgery continued behind me. NDilbe attended to the mother as I worked on the baby boy. After maybe 40 minutes that baby boy had a perfect heart rate, perfect color, perfect body temperature… but he wouldn’t breath. Not even a sputter. I told Danae I was stopping. We have no ventilator here and no other option. Chad is harsh. Only the strongest survive. I kept my hand draped over his chest and I stroked his hair as I felt the warmth of his body slip away while I whispered words of prayer. It think it took about 10 minutes to see his heart rate slow and then finally stop. I stayed with him and I finally glanced over my shoulder at his young momma: She knew. She saw my eyes and heard the silence. It took 10 minutes to watch a baby die once I quit breathing for him. How long will it take to forget this day?
4 resuscitations
3 babies in peril
2 babies beat the odds
1 husband/father/friend who is beyond thankful for faith and daily blessings. Life is good even when it’s hard.
-Mason
A young patient assess Mason McDowell, DNAP, CRNA.
You can find that and so many other stories in Mason’s writing.
Mason and his family moved to Chad with the intention of living there for years. Unfortunately, a couple of years into their new journey, the political and security situation deteriorated rapidly in Chad and the US State Department issued a warning that all US Citizens should evacuate immediately. Mason talks about the decision to leave with a day’s notice and the culture shock he and his family experienced upon their return to the US. Not long after that, in May of 2017, I caught up with him to record these interviews.
This podcast and the one to follow are pure gems. You’re gonna hear from Dr. Mason McDowell who in 2014, sold everything he, his wife and 2 young daughters owned and moved full time to the heart of Africa… to the town of Beré in the nation of Chad to provide anesthesia services at hospital with severe resource limitations.
Dr McDowell was a professor of mine and the assistant program director at Western Carolina University when he made the decision to move to Chad. I remember him preparing and talking about the why behind his decision and watching that process unfold was incredibly powerful. He’ll talk a little about that in this show.
I just want to frame how massive of a change this was for Dr McDowell and his family. They lived in a planned community of beautiful residential homes and businesses nestled in the mountains of Asheville, North Carolina. The community housed a satellite campus for WCU and our anesthesia program. Mason could walk to work from his home, step across the street to a number of stellar restaurants or high end shops or even stroll to the end of the block to the grand movie theater to watch a show with some fresh popcorn. He was well-respected in the local community and maintained an anesthesia practice at the local 800-bed trauma center with all the technology and resources you could imagine. And they decided to leave all of that and move full time to Bere, Chad. The hospital where Mason went to work didn’t have a functional anesthesia machine. Mason flew to Europe to buy a draw-over vaporizer so that he could bring inhalational anesthesia to the Bere. Before Mason and that machine showed up, the options were either ketamine or spinals. That’s it.
The stories Mason shares here are remarkable but they only scratch the surface of his time in Chad. I’ll link to his blog at whyweshouldgo.blogspot.com in the show notes where you can read about the day-to-day, night-to-night tales from providing anesthesia and general medical services in Chad. THOSE stories are heart wrenching. There we innumerable times when Mason and his team had to make decisions based on the severe resource limitation that we simply would never have to make here in the United States. I’d like to share one of Mason’s stories with you here:
4-3-2-1 8 Dec 2014, Bere, Chad by Mason McDowell, DNAP, CRNA
I was called out of our morning meeting at the hospital
around 730am with the wave of a hand. I knew what it was even before I asked for confirmation: Bébé? Oui.
A mother had just delivered twins but baby #2 wasn’t breathing. I gave oxygen, breathed for him with an ambu bag and tried to keep him warm. Danae (the OB/GYN) lifted her scrub shirt to press baby against her skin to warm him as I continued to hand ventilate. Eventually he was breathing on his own and was sent to our “NICU”– that’s the neonatal intensive care unit; except in Chad it means he is getting oxygen while he rests in a tiny cardboard box in our OR with 2 hot water bottles tucked beside him. Guess what? He’s still alive tonight!
Flash forward to around 8pm when our volunteers arrived from the US. They were only here 10 minutes before an urgent phone call: maternity…a mom turned quickly…send Mason now! I threw on scrubs and my friend Shawn (also an anesthetist) hurried along behind me.
We arrived to find a seemingly dead looking pregnant woman laying on the floor and frothing at the mouth. We moved her quickly down the sidewalk to the OR and began CPR. Chest compressions, oxygen/ventilation, IV epinephrine…Nothing. Now thats a terrible situation–lifeless and pregnant. I told Danae “she’s dead-dead …get the baby out”.
I barely finished the sentence before Danae cut down and retrieved a baby girl. Good pulse but not breathing. After an extended period of manual ventilation and stimulation the baby perked up and breathed on her own! The unmistakeable scent of Arabic perfume lingered in the air as it radiated from the cloth I used to wrap the baby in. The fabric had been part of her mothers clothing. Blood covered the OR table, floor, and the surgeon. We cleaned up the baby’s mother and brought in the family for a final viewing. Tears and prayer filled the OR. The family left to find a truck to carry the body away and I walked home alone under a brilliant night sky, still replaying the events of the day and looking for lessons to learn.
I returned home to find suitcases filled with treasures from the US. Our friends brought items purchased or donated for us and our hospital– it was like an early Christmas. After 30minutes of sorting goodies and eating junk food another call came: stat C-section. Seriously?!
A very young mother with complicated labor was already in preop when I arrived. Unfortunately the dead body from an hour ago was still in the OR (still waiting for family) and we had to find a way to move it out and bring in the new patient without making a big scene. If it wasn’t so sad it would have been comical. We pushed the dead woman into our tiny preop room after angling the new patient’s stretcher in a way that she had to twist around to see the body. And that’s exactly what she tried to do. We built a human wall with the 4 of us as we shuffled along pulling the new patient past the body (just 2 feet away).
Now in the OR: IV fluid, monitors, spinal anesthetic administered easily–cut down and baby retrieved in textbook fashion. Except…Silent baby. Floppy baby. Apneic baby. After stimulating, warming, and ventilating with oxygen…nothing. Pulse rate 160:perfect. But he’s not breathing.
Ventilate. Stimulate. Spank…again and again. The sound of surgery continued behind me. NDilbe attended to the mother as I worked on the baby boy. After maybe 40 minutes that baby boy had a perfect heart rate, perfect color, perfect body temperature… but he wouldn’t breath. Not even a sputter. I told Danae I was stopping. We have no ventilator here and no other option. Chad is harsh. Only the strongest survive. I kept my hand draped over his chest and I stroked his hair as I felt the warmth of his body slip away while I whispered words of prayer. It think it took about 10 minutes to see his heart rate slow and then finally stop. I stayed with him and I finally glanced over my shoulder at his young momma: She knew. She saw my eyes and heard the silence. It took 10 minutes to watch a baby die once I quit breathing for him. How long will it take to forget this day?
4 resuscitations
3 babies in peril
2 babies beat the odds
1 husband/father/friend who is beyond thankful for faith and daily blessings. Life is good even when it’s hard.
-Mason
A young patient assess Mason McDowell, DNAP, CRNA.
You can find that and so many other stories in Mason’s writing.
Mason and his family moved to Chad with the intention of living there for years. Unfortunately, a couple of years into their new journey, the political and security situation deteriorated rapidly in Chad and the US State Department issued a warning that all US Citizens should evacuate immediately. Mason talks about the decision to leave with a day’s notice and the culture shock he and his family experienced upon their return to the US. Not long after that, in May of 2017, I caught up with him to record these interviews. I apologize up front about the audio. At the time I was using a desk top microphone that captured everything in the room and the acoustics were not ideal. But I guess these shows are about doing anesthesia in non-ideal environments so if you’ve made it this far, I bet you’ll cope with the audio just fine.
In this first episode you’ll hear about Mason and his family’s decision to go, what it was like, what they did there and why they had to leave. In the next episode, Mason shares advice for other anesthesia providers who are interested in short or long term mission work.
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.
In this episode, I tell you a story about whitewater paddling and unpack the concept of flow described by psychologist and author Mihaly Csikszentmihalyi, PhD. I also present the Can-O-Calm for the first time on the podcast. This secret, magical, weightless and even sterile (when you need it to be) tool will help get you through the most dire of circumstances with your head right, your vision clear and yes, your voice calm. The concepts of flow help us understand how to prepare for emergencies, train for challenging cases and design specialty teams, fellowship programs, board examinations, continuing education as well as primary residency programs.
Below are images of Dr Csikszentmihalyi’s flow concept as well as the quote by Elaine Scarry presented in the podcast.
“What occurs in an emergency is either immobilization, incoherent action or coherent action… If we act, we act out of the habitual… If no serviceable habit is available, we will use an unserviceable one and become either immobilized or incoherent.”
– Elaine Scarry, Thinking in an Emergency
Sources
Csikszentmihalyi, M. (1997). Flow and the psychology of discovery and invention. HarperPerennial, New York, 39.
Scarry, E. (2012). Thinking in an Emergency (Norton Global Ethics Series). WW Norton & Company.
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.
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.
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
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.
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.
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
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
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.
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.
