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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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Categories
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 Personal Finances Preparing for Grad School/Residency Wellness

#102 – Marriage + Anesthesia School with Brad & Madisson Marcum

Brad & Madisson Marcum join me to talk about the dynamics of being married and going to anesthesia school together. They met in nursing school, had divergent paths professionally for a bit, with Brad starting nurse practitioner school and Madisson considering anesthesia school. They ended up sharing the same goal of becoming CRNAs and we talk through their approach to applying together, getting into the University of Evansville together and working through the program alongside one another.

In episode 15, I talked with Jenny & Robert Montague about what it’s like for the significant others of anesthesia residents. Jenny has her Master of Science in Nutrition and works as a Registered Dietitian and supported Robert and their 2 kids while he attended the University of New England’s anesthesia program.

In epsisode 50, I caught up with Lein & Nate Woodin to talk specifically on parenting in anesthesia school. Nate is a family therapist and supported Lein and their 2 kids while she went through the University of New England’s anesthesia program.

In this episode, Brad & Madisson Marcum talk about what it’s like to both get into and work through anesthesia school together. We’re planning for this to be the first in a series of conversations with them as they progress through their program. They’re just finishing their first year of training and have yet to start clinicals. I plan to touch base with them down to the road to see how that phase of the program goes.

Folks are often making difficult decisions around when to do anesthesia school. For a couple in my program, the husband went through school 2 years ahead of his wife, who was in my class, and they overlapped for just one semester. A local couple here in Portland stacked their programs end to end with one of them fully completing the program and a semester after that, the other starting anesthesia school. That stretched their anesthesia training experience to a full six years as a couple.

My hope is that this conversation with Brad & Madisson helps you and your partner think through the considerations around what you want to do or how it’s going for you if you’re currently in a program.

Brad hails from Salem, Illinois and spent 5 years as a critical care Registered Nurse in the cardio thoracic & transplant ICUs at Mayo Clinic prior to starting anesthesia school in the University of Evansville’s DNAP program. His clinical interests are regional anesthesia and opioid sparring anesthetic techniques with an emphasis on pharmacology and pharmacogenetics.

Madisson is from Effingham, Illinois and also spent 5 years as a critical care Registered Nurse in the trauma surgical ICU at Mayo Clinic in Rochester prior to anesthesia training. Her clinical interests are regional anesthesia and difficult airway management.

They are focusing their doctoral project on the functionality and effectiveness of virtual reality training in anesthesia programs and plan to utilize Peter Stallo’s SIMVANA VR platform for research. You may remember my conversation with Peter in episode 96 on SIMVANA and virtual reality in anesthesia education. It’s a fascinating discussion on what will likely become a central element to anesthesia education in years to come.

Long term, Brad & Madisson intend to become involved in medial mission trips and create a pediatric charity foundation to provide basic necessities to children in need in their local area following anesthesia school.

Brad and Madisson Marcum

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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 Business/Finances

#100 – Vantage Point January 2024

Have you noticed how stoked podcasters get about their one hundredth episodes? 

It’s kind of a thing.

If you want to hear interesting shows – check out the hundredth episodes.  Or 200th.  Or 1000th.  

Podcasters usually get super stoked about hitting triple digits with their shows and often set up the number 100 episode as some sort of tribute to themselves by taking a look back over their favorite episodes.

Don’t get me wrong… I’m pumped about number 100.  But this isn’t going to be a look back at all the best shows or highlight moments.  I’d rather hit on the why behind Anesthesia Guidebook.  

Some of you all might just be joining us.  

Maybe this is the first time you’ve heard Anesthesia Guidebook and you’re taking a look around.  Maybe you’ve been listening since From the Head of the Bed… either way, I’d like to hit on where we came from and where we’re going.

I love when one year turns over to another.  I’m not big on new year’s resolutions and my wife and I don’t even stay up any more to see the clock tick over midnight on New Year’s Eve.  We’ve got a 2-year old who’s potty training this weekend and his 9 month old brother is crawling all over the place.  So we generally go to bed early to wake up and keep pace with these little dudes.  But I do get stoked when a year comes to a close and another begins.  It helps mark a rhythm in our lives.  Just after the winter solstice, the longest night and shortest day of the year.  Then we turn to a new year where new things will happen and the best of the old things are brought with us.  So there’s the 100th episode and there’s the new year… it’s like toast with Nutella and bananas.  Doubly amazing.  

In this show, I touch on what Anesthesia Guidebook means to me and what I hope it means for you. I’ll hit on a couple of upcoming shows headed your way in 2024 and then we’re out. Happy New Year and thanks for checking the show out and getting after it out there!

In Memory of Peter Strube, DNP, MBA, Lt Col (ret), CRNA, FAANA. Matt Zinder wrote an amazing eulogy here and copied below:

The profession of nurse anesthesiology has lost one of its greatest advocates. Peter Strube, DNP, MBA, Lt Col (ret), FAANA passed away peacefully in his home Monday, December 11, 2023 following a brief illness. Dr. Strube’s dedication to colleagues, students, residents, and to the profession of nurse anesthesiology was evident in his tireless efforts to promote and educate all those who had the good fortune to work with him.

Dr. Strube earned his BA in Nursing from Luther College in 1994 and his Master’s in Nurse Anesthesia from St. Mary’s University in 2006. He went on to earn his Doctor of Nursing Practice degree from Rosalind Franklin University in 2017 and his MBA from Edgewood College in 2019.

Dr. Strube retired from the US Army Nurse Corps after 21 years of service, having achieved the rank of Lieutenant Colonel. He deployed four times, which included service in both Iraq and Afghanistan. He earned the War on Terrorism medal, the Enduring Freedom medal, the Mobilization Armed Forces Reserve medal, the Iraqi Freedom and Global War on Terror medal, and held numerous certificates of achievement, appreciation, and training from the United States Army.

Dr. Strube was an Assistant Professor at Newman University School of Nurse Anesthesia and was a developer of the pharmacology CPC Modules for multiple CRNA education programs. His teaching background included serving as an Assistant Program Director at the University of Wisconsin Oshkosh, an Associate Professor at Saint Mary’s University of Minnesota, and an Assistant Professor at Rosalind Franklin University of Medicine and Science.

Peter was the CEO of Strube Educational Services, where he provided invaluable tutoring services to nurse anesthesiology residents, enabling them to excel in their studies and succeed in their anesthesia board exams. His tutoring program has assisted over 500 residents with their success in their medical training. Furthermore, he authored numerous professional articles and shared his expertise as both a national and international speaker. He successfully guided and contributed to over 10 doctoral projects.

Beyond his professional accomplishments, Dr. Strube was deeply committed to his community. He served as a member of the Mount Horeb Board of Education, acted as a Commissioner on the Dane County Ethics Board, and offered crucial mentorship to veterans in crisis through court appointments. Furthermore, he proved to be an active and dedicated CRNA representative and advocate, having served on the Wisconsin state association board, AANA Region 3 Director, and most recently, being honored with induction into the esteemed AANA 2023 Class of Fellows.

Dr. Peter Strube left an indelible mark on his profession and everyone with whom he collaborated. He was a great friend and family man and will be sorely missed.

He is survived by his wife, Rebecca, and children, Noah, 23, Xander, 21, and Sarah, 18, and is also survived by mother Nancy Sommerfeld, father Donald Strube, sisters Shannon and Nicky (Troy) Cross, niece Josie Cross and nephew Chance Cross.

Services will be held Tuesday, January 16, 2024 at:
Evangelical Lutheran Church
315 E Main St
Mount Horeb, WI 53572

Visitation to begin at noon and service will begin at 3 p.m.

Obituary contributed by Matt Zinder, MS, CH, CRNA.

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Anesthesia Education Preparing for Grad School/Residency Wellness

#99 – The Effects of Anesthesia School Didactic Formatting on Resident Wellbeing – Cassie Capps

Cassie Capps, BSN, SRNA joins me to talk about the effects of didactic formatting in anesthesia training on resident wellbeing including stress, anxiety, confidence and academic performance. Her specific focus is on the mix of online versus in-person course work for nurse anesthesia trainees.

Cassie overviews what the literature says about this topic and is looking for YOU to join her efforts by completing a very quick survey about your experience at the end of this podcast.

The survey HAS CLOSED.

Cassie is completing her Doctor of Nursing Practice in anesthesiology at the University of Arizona and this study is part of her doctoral work. Prior to anesthesia training, Cassie was a CVICU Registered Nurse for 8 years and worked in the cath lab for 5 years before that. Prior to nursing school, Cassie completed a Master’s degree in music with a focus on Piano Performance & Pedagogy. She continues to teach piano on the side while completing her doctorate in anesthesiology at the University of Arizona.

Her unique experience with anesthesia school included moving through her program as a single mom of an 11 year old daughter. She also continues to play a big role in the lives of her two former stepdaughters who are now young adults.

This podcast is coming out on December 26, 2023. I hope you’ve had an amazing year and am thrilled to bring this episode to you. Please take a moment and complete the survey and help Cassie get some solid data for her project. Stay tuned because I plan to reconnect with Cassie in a couple of months after she’s crunched the numbers and see what she’s learned.

REFERENCES

Alajmi, B., & Alasousi, H. (2019). Understanding and motivating academic library employees: theoretical implications. Library management, 40(3/4), 203-214. https://doi.org/10.1108/LM-10-2017-0111

Baqutayan, S. M. S. (2015). Stress and Coping Mechanisms: A Historical Overview. Mediterranean Journal of Social Sciences; Vol 6, No 2 S1 (2015): March 2015. https://www.mcser.org/journal/index.php/mjss/article/view/5927/5699

Berry, G. R., & Hughes, H. (2020). Integrating Work-Life Balance with 24/7 Information and Communication Technologies: The Experience of Adult Students With Online Learning. The American journal of distance education, 34(2), 91-105. https://doi.org/10.1080/08923647.2020.1701301

Botha, E., Gwin, T., & Purpora, C. (2015). The effectiveness of mindfulness based programs in reducing stress experienced by nurses in adult hospital settings: a systematic review of quantitative evidence protocol. JBI database of systematic reviews and implementation reports, 13(10), 21-29. https://doi.org/10.11124/jbisrir-2015-2380

Centers for Disease Control and Prevention. (2022). Poor nutrition. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/nutrition.htm

Columbia University. (2022). How sleep deprivation impacts mental health. https://www.columbiapsychiatry.org/news/how-sleep-deprivation-affects-your-mental-health

Conner, M. (2015). Self-Efficacy, Stress, and Social Support in Retention of Student Registered Nurse Anesthetists [Article]. AANA Journal, 83(2), 133-138. http://ezproxy.library.arizona.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=asn&AN=102321364&site=ehost-live

Council on Accreditation of Nurse Anesthesia Educational Programs (COA). (2020, 3/22/21). FAQ’s and statement regarding meeting clinical requirements. https://www.coacrna.org/coa-statement-regarding-coronavirus-disease-2019-covid-19/

Council on Accreditation of Nurse Anesthesia Educational Programs (COA). (2022). List of accredited educational programs. https://www.coacrna.org/wp-content/uploads/2022/07/List-of-Accredited-Educational-Programs-July-18-2022-1.pdf

Day, C. M. F., Lakatos, K. M., Dalley, C. B., Eshkevari, L., & O’Guin, C. (2022). The Experience of Burnout in the SRNA Population and Association With Situational and Demographic Factors. AANA Journal, 90(6), 447-453. 

Desmet, P., & Fokkinga, S. (2020). Beyond maslow’s pyramid: Introducing a typology of thirteen fundamental needs for human-centered design. Multimodal technologies and interaction, 4(3), 1-22. https://doi.org/10.3390/mti4030038

Freitas, F. A., & Leonard, L. J. (2011). Maslow’s hierarchy of needs and student academic success. Teaching and learning in nursing, 6(1), 9-13. https://doi.org/10.1016/j.teln.2010.07.004

Griffin, A., Yancey, V., & Dudley, M. (2017). Wellness and thriving in a student registered nurse anesthetist population. AANA Journal, 85(5), 325-330. 

Hale, A. J., Ricotta, D. N., Freed, J., Smith, C. C., & Huang, G. C. (2019). Adapting Maslow’s Hierarchy of Needs as a Framework for Resident Wellness. Teaching and Learning in Medicine, 31(1), 109-118. https://doi.org/10.1080/10401334.2018.1456928

Harwood, K. J., McDonald, P. L., Butler, J. T., Drago, D., & Schlumpf, K. S. (2018). Comparing student outcomes in traditional vs intensive, online graduate programs in health professional education. BMC medical education, 18(1), 240-240. https://doi.org/10.1186/s12909-018-1343-7

Hoffman, H. J., & Elmi, A. F. (2020). Comparing Student Performance in a Graduate-Level Introductory Biostatistics Course Using an Online versus a Traditional in-Person Learning Environment. Journal of statistics and data science education, ahead-of-print(ahead-of-print), 1-10. https://doi.org/10.1080/10691898.2020.1841592

Imus, F. S., & Burns, S. (2015). What to Consider Before Beginning Graduate Education: A Pilot Study. AANA J, 83(5), 345-350. https://www.ncbi.nlm.nih.gov/pubmed/26638456

Imus, F. S., Burns, S., & Weglarz, D. M. (2017). Self-efficacy and graduate education in a nurse Anesthesia program: A pilot study. AANA Journal, 85(3), 205-216. 

Institute for Healthcare Improvement. (2023). How to improve. https://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx

Kondo, M. C., Jacoby, S. F., & South, E. C. (2018). Does spending time outdoors reduce stress? A review of real-time stress response to outdoor environments. Health & place, 51, 136-150. https://doi.org/10.1016/j.healthplace.2018.03.001

Lowrance, J. (2023). Anesthesia Guidebook. https://anesthesiaguidebook.com

Malek-Ismail, J. (2021). Thriving in the First Semester of Graduate School: A Process of Rebalancing and Self-Determination. The American journal of occupational therapy, 75(S2), 7512520410-7512520410p7512520411. https://doi.org/10.5014/ajot.2021.75S2-RP410

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. 

Mesisca, J., & Mainwaring, J. (2021). Stress, Anxiety, and Well-being in Nurse Anesthesia Doctoral Students. AANA J,89(5), 396-402. https://www.ncbi.nlm.nih.gov/pubmed/34586993

Montag, C., Sindermann, C., Lester, D., & Davis, K. L. (2020). Linking individual differences in satisfaction with each of Maslow’s needs to the Big Five personality traits and Panksepp’s primary emotional systems. Heliyon, 6(7), e04325-e04325. https://doi.org/10.1016/j.heliyon.2020.e04325

National Center for Education Statistics. (2021). Table 9. Unduplicated headcount enrollment at Title IV institutions, by control of institution, student level, level of institution, and distance education status of student: United States, 2020–21. In: U.S. Department of Education.

Osaili, T. M., Ismail, L. C., ElMehdi, H. M., Al-Nabulsi, A. A., Taybeh, A. O., Saleh, S. T., Kassem, H., Alkhalidy, H., Ali, H. I., Al Dhaheri, A. S., & Stojanovska, L. (2023). Comparison of students’ perceptions of online and hybrid learning modalities during the covid-19 pandemic: The case of the University of Sharjah. PLoS One, 18(3), e0283513. https://doi.org/10.1371/journal.pone.0283513

Palmer, L., amp, J. M., Ren, D., & Henker, R. (2014). Comparison of Nurse Anesthesia Student 12 Lead EKG Knowledge, Interpretation Skill, Satisfaction and Attitude: Traditional Instruction vs. Asynchronous Online Video Lecture. Journal of Online Learning and Teaching, 10(3), 420-n/a. https://ezproxy.library.arizona.edu/login?url=https://www.proquest.com/scholarly-journals/comparison-nurse-anesthesia-student-12-lead-ekg/docview/1650489030/se-2?accountid=8360

Papaleontiou–Louca, E., Esmailnia, S., & Thoma, N. (2022). A Critical Review of Maslow’s Theory of Spirituality. Journal of Spirituality in Mental Health, 24(4), 327-343. https://doi.org/10.1080/19349637.2021.1932694

Pecka, S. L., Kotcherlakota, S., & Berger, A. M. (2014). Community of inquiry model: Advancing distance learning in nurse anesthesia education. AANA Journal, 82(3), 212-218. 

Polit, D., & Beck, C. (2020). Nursing Research. Philadelphia, UNITED STATES Wolters Kluwer Health. 

Pressman, S. D., Gallagher, M. W., & Lopez, S. J. (2013). Is the Emotion-Health Connection a “First-World Problem”? Psychological science, 24(4), 544-549. https://doi.org/10.1177/0956797612457382

Wilson, J. T., Gibbons, S. W., & Wofford, K. (2015). Process Improvement: Addressing Attrition from the Uniformed Services University of the Health Sciences Nurse Anesthesia Program. AANA J, 83(5), 351-356. https://www.ncbi.nlm.nih.gov/pubmed/26638457

Worthen, M., & Cash, E. (2022). Stress Management. StatPearls [Internet], Jan. 2022. https://www.ncbi.nlm.nih.gov/books/NBK513300/

Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. Excli j, 16, 1057-1072. https://doi.org/10.17179/excli2017-480

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Human Physiology and Pathophysiology Pharmacology Preparing for Grad School/Residency

#98 – A Deep Dive on Ketorolac with Elisabeth Stewart, MSN, MSNA, CRNA

Elisabeth Stewart, MSN, MSNA, CRNA focused her Master of Science in Nurse Anesthesia project on the pharmacology of Toradol (ketorolac) and she’s here today to tell us all about it.

Elisabeth hails from Wisconsin, holds a BS in Mathematics with a pre-med concentration and engaged in HeLa cell cancer research prior to going to nursing school.  She received a Master of Science in Nursing degree at the University of Wisconsin – Milwaukee, where she worked in a transplant ICU while completing her Clinical Nurse Leader degree and certification.  Elisabeth followed that with her Master of Nurse Anesthesia degree at the University of New England and received the UNE Outstanding Student Award for her class. Her primary clinical site in training was Maine Medical Center in Portland, Maine. When Elisabeth showed up for day one of clinical, I was serving as the SRNA Clinical Coordinator and by the time she was completing her training, I was a year into my new role as Chief CRNA at Maine Medical Center. Elisabeth was one of the best SRNAs we’ve had roll through Maine Med in years and brought a degree of professionalism, conscientiousness and excellence in clinical care that inspired confidence in her practice and reallllly made me try to recruit her as a clinical staff. As it is, she’s chosen to start her career closer to family in Massachusetts and I wish her the absolute best moving forward.

I think you’re really going to enjoy hearing Elisabeth walk through the pharmacokinetics and pharmacodynamics of ketorolac with specific focus on the risk (or lack thereof) of bleeding with the use of ketorolac. Elisabeth focused primarily on the risk of bleeding in adult breast surgery patients. She reviewed 27 research articles to boil down what the literature says about the role of ketorolac in perioperative bleeding risk in breast surgery patients. Her full write up is attached in the show notes to this episode. And with that, let’s get to the show!

Careers at Maine Medical Center:

If you’re interested in joining our team at Maine Medical Center, reach out to me at Jon.Lowrance@mainehealth.org or apply for one of our CRNA positions in Portland, Maine at https://www.mainehealth.org/careers-job-opportunities

References

•Afonso, A., Oskar, S., Tan, K.S., Disa, J. J., Mehrara, B. J., Ceyhan, J., & Dayan, J. H. (2017). Is enhanced recovery the new standard of care in microsurgical breast reconstruction? Plastic and Reconstructive Surgery,139(5), 1053-61. https://doi.org/10.1097/PRS.0000000000003235.

•Barkho, J. O., Li, Y. K., Duku, E., & Thoma, A. (2018). Ketorolac may increase hematoma risk in reduction mammaplasty: A case-control study. PRS Global Open, 6, 1-5. https://doi.org/10.1097/GOX.0000000000001699

•Blomqvist, L, Sellman, G., & Strömbeck, J. O. (1996). NSAID as pre- and postoperative medication —a potential risk for bleeding complications in reduction mammaplasty. European Journal of Plastic Surgery 19, 26–8. 

•Bongiovanni, T., Lancaster, E., Ledesma, Y., Whitaker, E., Steinman, M. A., Allen, I. E., Auerbach, A., & Wick, L. (2021). A systematic review and meta-analysis of the association between non-steroidal anti-inflammatory drugs and surgical bleeding in the perioperative period. Journal of the American College of Surgeons, 232(5), 765-90. https://doi.org/10.1016/j.jamcollsurg.2021.01.005.

•Cawthorn, T. R., Phelan, R., Davidson, J. S., & Turner, K. E. (2012). Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty. Canadian Journal of Anaesthesia, 59(5), 466-72. https://doi.org/10.1007/s12630-012-9682-z.

•Conrad, K. A., Fagan, T. C., Mackie, M. J., & Mayshar, P. V. (1988). Effects of ketorolac tromethamine on hemostasis in volunteers. Clinical Pharmacology & Therapeutics, 43(5), 542-546.

•Corsini, E. M., Zhou, N., Antonoff, M. B., Mehran, R. J., Rice, D. C., Roth, J. A., Sepesi, B., Swisher, S. G., Vaporciyan, A. A., Walsh, G. L., & Hofstetter, W. L. (2021). Postoperative bleeding and acute kidney injury in esophageal cancer patients receiving ketorolac. Annals of Thoracic Surgery, 111, 1111-7. https://doi.org/10.1016/j.athoracsur.2020.07.028.

•Dowbak G. (1992). Personal experiences with Toradol. Plastic and Reconstructive Surgery, 89(6), 1183. https://doi.org/10.1097/00006534-199206000-00051.

•Firriolo, J. M., Nuzzi, L. C., Schmidtberg, L. C., & Labow, B. I. (2018). Perioperative ketorolac use and postoperative hematoma formation in reduction mammoplasty: A single-surgeon experience of 500 consecutive cases. Breast, 142(5), 632e-8e. https://doi.org/10.1097/PRS.0000000000004828.

•Garcha, I. S., & Bostwick, J. (1991). Postoperative hematomas associated with Toradol. Plastic and Reconstructive Surgery, 88(5), 919-20. https://doi.org/10.1097/00006534-199111000-00050.

•Gobble, R. M., Hoang, H. L., Kachniarz, B., & Orgill, D. P. (2014). Ketorolac does not increase perioperative bleeding: A meta-analysis of randomized controlled trials. Plastic and Reconstructive Surgery, 133(3), 741-55. https://doi.org/10.1097/01.prs.0000438459.60474.b5

•Gupta, A. K., & Parker, B. M. (2020). Bleeding after a single dose of ketorolac in a postoperative patient. Cureus, 12(6), 1-6. https://doi.org/10.7759/cureus.8919

•Klifto, K. M., Elhelali, A., Payne, R. M., Cooney, C. M., Manahan, M. A., & Rosson, G. D. (2021). Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Cochrane Database of Systematic Reviews 2021(11), 1-3. https://doi.org/10.1002/14651858.CD013290.pub2.

•Lexicomp. (n.d.). Ketorolac: Drug information. UpToDate. Retrieved September 14, 2022, from https://online-lexi-com.une.idm.oclc.org/lco/action/doc/retrieve/docid/patch_f/1797828?cesid=6fX6XGxK6EG&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dketorolac%26t%3Dname%26acs%3Dtrue%26acq%3Dketorolac#fbnlist

•Macario, A., & Lipman, A. G. (2001). Ketorolac in the era of cyclo-oxygenase-2 selective nonsteroidal anti-inflammatory drugs: A systematic review of efficacy, side effects, and regulatory issues. Pain Medicine, 2(4), 336-51. https://doi.org/10.1046/j.1526-4637.2001.01043.x.

•Majumdar, J. R., Assel, M. J., Lang, S. A., Vickers, A. J., & Afonso, A. M. (2022) Implementation of an enhanced recovery protocol in patients undergoing mastectomies for breast cancer: an interrupted time-series design. Asia-Pacific Journal of Oncology Nursing, 9, 1-5. https://doi.org/10.1016/j.apjon.2022.02.009

•Martinez, L., Ekman, E., & Nakhla, N. (2019). Perioperative opioid-sparing strategies: Utility of conventional NSAIDs in adults. Clinical Therapeutics, 14(12), 2612-28. https://doi.org/10.1016/j.clinthera.2019.10.002

•Maslin, B., Lipana, L., Roth, B., Kodumudi, G., & Vadivelu, N. (2017). Safety considerations in the use of ketorolac for postoperative pain. Current Drug Safety, 12, 67-73. https://doi.org/10.2174/1574886311666160719154420

•McCormick, P. J., Assel, M., Van Zee, K. J., Vickers, A. J., Nelson, J. A., Morrow, M., Tokita, H. K., Simon, B. A., & Twersky, R. S. (2021). Intraoperative ketorolac is associated with risk of reoperation after mastectomy: A single-center examination. Annals of Surgical Oncology, 28(9), 5134-40. https://doi.org/10.1245/s10434-021-09722-4.

•McNicol, E. D., Ferguson, M. C, & Schumann, R. (2021). Single-dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database of Systematic Reviews, 5, 1-91. https://doi.org/10.1002/14651858.CD013263.pub2

•Mikhaylov, Y., Weinstein, B., Schrank, T. P., Swartz, J. D., Ulm, J. P., Armstrong, M. B., & Delaney, K. O. (2018). Ketorolac and hematoma incidence in postmastectomy implant-based breast reduction. Annals of Plastic Surgery, 80(5), 472-474. https://doi.org/10.1097/SAP.0000000000001409

•Motov, S., Yasavolian, M., Likourezos, A., Pushkar, I., Hossain, R., Drapkin, J., … & Fromm, C. (2017). Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Annals of emergency medicine, 70(2), 177-184.

•Nguyen, B. N., Barta, R. J., Stewart, C. E., & Heinrich, C. A. (2018). Toradol following breast surgery: Is there an increased risk of hematoma? Plastic and Reconstructive Surgery Journal, 141(6), 814e-7e. https://doi.org/10.1097/PRS.0000000000004361

•O’Neill, R. C., Hayes, K. D., & Davidson, S. P. (2019). Safety of postoperative opioid alternatives in plastic surgery: A systematic review. Plastic and Reconstructive Surgery Journal, 144(4). 991-9. https://doi.org/10.1097/PRS.0000000000006074

•Rojas, K. E., Fortes, T. A., Flom, P., Manasseh, D. M., Andaz, C., & Borgen, P. (2019). Intraoperative ketorolac use does not increase the risk of bleeding in breast surgery. Annals of Surgical Oncology, 26, 3368-73. https://doi.org/10.1245/s10434-019-07557-8

•Sharma, S., Chang, D.W., Koutz, C., Evans, G. R., Robb, G. L., Langstein, H. N., & Kroll, S. S. (2001). Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction. Plastic and Reconstructive Surgery, 107(2), 352-5. https://doi.org/ 10.1097/00006534-200102000-00009.

•Singer, A. J., Mynster, C. J., & McMahon, B. J. (2003). The effect of IM ketorolac tromethamine on bleeding time: A prospective, interventional, controlled study. American Journal of Emergency Medicine, 21(5), 441-3. https://doi.org/10.1016/S0735-6757(03)00100-1

•Stephens, D. M., Richards, B. G., Schleicher, W. F., Zins, J. E., Langstein, H. N. (2015). Is ketorolac safe to use in plastic surgery? A critical review. Aesthetic Surgery Journal, 35(4), 462-6. https://doi.org/10.1093/asj/sjv005

•Strom, B. L., Berlin, J. A., Kinman, J. L., Spitz, P. W., Hennessy, S., Feldman, H., Kimmel, S., & Carson, J. L. (1996). Parenteral ketorolac and risk of gastrointestinal and operative site bleeding: A postmarketing surveillance study. JAMA, 275(5), 376–82.

•Tan, P., Martin, M., Shank, N., Myers, L., Wolfe, E., Lindsey, J., & Metzinger, S. (2017). A comparison of four analgesic regimens for acute postoperative pain control in breast augmentation patients. Annals of Plastic Surgery, 78(6), S299-304. https://doi.org/10.1097/SAP.0000000000001132.

•Walker, N. J., Jones, V. M., Kratky, L., Chen, H., & Runyan, C. M. (2019). Hematoma risks of nonsteroidal anti-inflammatory drugs used in plastic surgery procedures: A systematic review and meta-analysis. Annals of Plastic Surgery, 82(5), S437-45. https://doi.org/10.1097/SAP.0000000000001898

•Wick, E., Grant, M. C., Wu, C. L. (2017). Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review. Journal of the American Medical Association Surgery, 152(7), 691-7. https://doi.org/10.1001/jamasurg.2017.0898

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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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Anesthesia Education Anesthesia Equipment and Technology Business/Finances Preparing for Grad School/Residency

#96 – Virtual Reality in Anesthesia Education: SIMVANA with Peter Stallo

What up yall this is Jon Lowrance and this is episode 96 – virtual reality in anesthesia education: SIMVANA with Peter Stallo.  

This show is coming out in early August of 2023.

First up: I want to give a quick heads up that our team from Maine Medical Center where I currently serve as chief CRNA will be at the American Association of Nurse Anesthesiology Annual Congress in a couple of weeks in Seattle.  If you’re headed to AANA’s Annual Congress this year, be sure to swing by the exhibit hall and check out the MaineHealth booth.  My friends & colleagues April Bourgoin, Cat Godfrey & Steve Breznyak will be there to tell you all about career opportunities at our level 1 trauma hospital, Maine Medical Center, and other MaineHealth hospitals.  We have everything from independent, CRNA-only practices to a high acuity level 1 trauma center within MaineHealth, so if you’re interested in finding out more about what life looks like in the upper right hand corner pocket of the US, come chat with us!  I believe Peter Stallo with SIMVANA – who we’re talking with today on the show – will also be at Annual Congress, so be sure to swing by and tell him you listened to this episode and see what SIMVANA is about in person!  

This show is very interesting for a couple of reasons:

  1. I’m stoked to talk with Peter Stallo.  Peter created Prodigy Anesthesia back in 2004.  This was probably the very first computer-based anesthesia educational & board preparation study tool.  Kids these days can’t imagine getting through anesthesia training without programs like this.  And Prodigy is what Kristin & I exclusively used to study for boards back in 2015… so I’m personally very grateful for Peter’s development of that program.  (side note… I have no financial ties with Peter, Prodigy or SIMVANA to disclose… this just pure gratitude I’m working with here).
  2. I’m also stoked about what we’re going to chat about.  Virtual reality simulation will likely become a central aspect of anesthesia training in the future.  As the technology becomes more widely available and the user experience further developed and refined, programs like SIMVANA will likely become ubiquitous… just like with Prodigy over the last 20 years.

I’m reminded of something Elon Musk stated in a documentary about SpaceX.  Now, I don’t know how you feel about Twitter becoming X & how Elon is reshaping that organization or many of his other decisions.  But I think we can agree on the fact that the man has created & lead some remarkable organizations built on tenacious visions of what’s possible for the future.  In this documentary on SpaceX, Elon talked about how progress isn’t inevitable.  Some people just assume that the future will be better… that space travel will become routine or that will we become a multi planetary species or that we’ll solve for global warming & climate change.  But these things won’t actually happen unless individuals first imagine that they’re possible and then 2) put the work in to bring them into fruition.  Elon is someone who has devoted himself into putting the work into creating paths to a better future.

Similarly, Peter Stallo is someone who didn’t stop progressing after he passed boards back in 2004.  I always say that boards is an amazing finish line & culmination of years of preparation & hard work.  We’re in that season again right now as anesthesia programs & residencies wrap up between May, June, July & August.  It’s awesome to watch trainees make that transition from graduation into clinical practice.  So while boards is a finish line of sorts, it’s also a starting line.  It’s when the start gun goes off for the rest of your career.  And back in 2004, just after Peter took boards, he got back to work.  With 2 master’s degrees in healthcare behind him, he set about creating Prodigy Anesthesia.  Then in 2014, he completed a Graduate Certificate in Orchestral Composition for Film and Games from Berkley College of Music… I didn’t even know there was just a thing.  And in 2018, he began developing a virtual reality anesthesia training program which would eventually become SIMVANA.  Peter picked up his third Master’s Degree – yes, his THIRD, in 2021 from the University of Alabama in healthcare simulation and is currently working towards completing a PhD in healthcare simulation from Massachusetts General Hospital Institute for Health Professions.  

What’s remarkable, is that Peter’s career has spanned the timeframe from when anesthesia boards was a pen & paper exam, through his development of one of the leading digital board preparation programs and now into the first virtual reality anesthesia simulation program.  Peter has embodied the very idea that Elon Musk talked about:  progress isn’t inevitable.  Having virtual reality as an available tool for anesthesia training – whether you’re in Cincinnati, Canberra or Cape Town – isn’t automatically going to be a thing.  Someone’s got to put the time in.  Or better yet, a team of someones, which Peter will talk about in this show.  

So with that, let’s get to the story… 

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Anesthesia Education Anesthesia Equipment and Technology Business/Finances Preparing for Grad School/Residency

#95 – Could ChatGPT be a CRNA?

Quick 5-Question Post Podcast Survey HERE

Today I’m joined by John Fratianni who created the content for this episode as part of his Doctorate in Nurse Anesthesia Practice at Virginia Commonwealth University in Richmond, Virginia.  John earned a Bachelor of Science in Nursing at the University of North Carolina at Chapel Hill, a Master of Science in Nursing at the University of Alaska Anchorage, and completed his critical care nursing training with the United States Air Force where he served 7 years on active duty. John conducted a study to determine if ChatGPT, an artificial intelligence (AI) program, can assist us in providing anesthesia care to our patients.  

I want to give a special shout out to Peter Stallo who founded Prodigy Anesthesia and SIMVANA, both of which are digital educational tools for anesthesia trainees. Peter worked closely with John to grant access to Prodigy’s vast database of board-style anesthesia questions. If you haven’t checked out Prodigy or SIMVANA – which is a virtual reality based anesthesia education platform, links are in the show notes. I also want to personally thank Peter for creating a great board prep program in Prodigy… it’s all my wife and I and several of our classmates used to study for boards and we passed on the first try. Nice job, Peter and thank you!

Since this episode is part of John’s doctoral work with Virginia Commonwealth University, he kindly requests that you take a quick survey that’s embedded in the show notes. It’s 5 questions and will literally take you 30 seconds… click the link and give John & me some feedback on how we did with this.

With that, let’s get to the show.  

Quick 5-Question Post Podcast Survey HERE

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Wellness

#94 – Shorts – Cue Ball

All right what’s up folks this is Jon Lowrance and it’s May 16, 2023.

This is episode 94 – and I’m calling it “shorts: cue ball.” 

And I don’t mean shorts like the things you wear but shorts like, this will be brief and there will be more episodes like this to come… you know, shorts.

But first… updates!  

Maine Medical Center will the at the AANA Annual Congress in Seattle this August. We’ll have a table in the exhibition hall and a couple of our CRNAs will be there to tell yall about our sweet gig and you can ask questions and see if where we’re headed is similar to where you want to head. Maybe you can join us. And we’ll join you. And we’ll move in the same direction. If you want practice a wide range of case types as part of a clinically excellent and supportive team while living in a super cool town that’s just big enough but doesn’t come with the downsides of huge metro areas, come check us out!

In other news, this fall I’m back on the teaching circuit… well, circuit might be a little generous – I’m teaching at 1 conference this year which is the New England at the Cliff House 2023 Encore Symposium in Cape Neddick, Maine.  The dates are October 16 – 19.  You can check out the other folks who will be presenting at the conference and register at Encore’s website, which is e-s-crnas.com.  Look for “New England at the Cliff House 2023 Encore Symposium” and again the dates are October 16-19.  This conference usually sells out by July.  Part of the reason is the location… the Cliff House is an iconic resort built in 1872 on a 70-foot cliff overlooking the Atlantic Ocean.  So if a fresh cool ocean air, granite cliffs and near by sandy beaches are your thing, this might be a great get-away to come get your learn on.  If you come, we’ll get the chance to talk about practical pharmacology for anesthesia providers, leadership in emergencies, best practices in neuromuscular blockage, monitoring & reversal, ERAS, airway management & a run down on what’s new in anesthesia… so much!  It’s going to be fantastic.  Encore Symposiums – October 16 – 19 – Cliff House.  I hope to see you there!   

All right, with that let me tell you about Neil deGrasse Tyson, the famed astrophysicist, and his take on cue balls. This will blow your mind…

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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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Categories
Anesthesia Education Case Studies Enhanced Recovery After Surgery Outpatient Anesthesia Preparing for Grad School/Residency

#92 – How to Prevent Periprosthetic Joint Infections with Brian McGrory, MD

If you get this post by email: THANK YOU! You’re in a select group of supporters of the show who have followed the posts on the website and I can’t thank you enough. Your interest, feedback and willingness to share these episodes with your friends & colleagues is much appreciated. Shoot me a reply, social media message or email any time… I’d love to hear from you and again, thank you for your support! – Jon

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

This is the second time Dr McGrory has joined me on the podcast, the first being way back in episode 25 when we discussed how to prevent hypothermia during joint replacement surgeries.  That episode included a special look at the controversy around various warming devices that are used in the OR and whether any of them are linked to surgical site infections.

In this episode, Dr McGrory and I take a more detailed look at how to prevent surgical site infections in periprosthetic joint replacement surgery.  The significance of these infections for patients cannot be overstated.  We discuss the particulars around why a joint infection is often considered a devastating outcome for patients that, at best, results in months of continued, aggressive therapy and at worst, can lead to amputation of the limb or even death.  I’m incredibly grateful for Dr McGrory’s continued focus on improving the quality of care that surgical teams can provide and his willingness to come on this show to speak directly to anesthesia providers concerning our role in helping create great outcomes for surgical patients.

Dr McGrory earned his bachelor’s degree in chemistry biology at Cornell, attended medical school at Columbia University, followed by residency in orthopedic surgery at the Mayo Clinic Graduate School where he also earned a Master’s degree in orthopedic research.  He 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.

References

Chaudhry, S. B., Veve, M. P., & Wagner, J. L. (2019). Cephalosporins: a focus on side chains and β-lactam cross-reactivity. Pharmacy, 7(3), 103. Retrieved from https://www.mdpi.com/505180

Hamilton, W. G., Balkam, C. B., Purcell, R. L., Parks, N. L., & Holdsworth, J. E. (2018). Operating room traffic in total joint arthroplasty: identifying patterns and training the team to keep the door shut. American Journal of Infection Control, 46(6), 633-636. Retrieved from https://www.ajicjournal.org/article/S0196-6553(18)30007-5/fulltext

McGrory, B. J. (2018). Letter to the Editor on “Hypothermia in Total Joint Arthroplasty: A Wake-Up Call”. The Journal of arthroplasty, 33(9), 3056-3057. Retrieved from https://www.arthroplastyjournal.org/article/S0883-5403(18)30506-0/fulltext

Wyles, C. C., Hevesi, M., Osmon, D. R., Park, M. A., Habermann, E. B., Lewallen, D. G., … & Sierra, R. J. (2019). 2019 John Charnley Award: increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. The bone & joint journal, 101(6_Supple_B), 9-15. Retrieved from https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.101B6.BJJ-2018-1407.R1

Zmistowski, Benjamin; Karam, M.D., Joseph A.; Durinka, Joel B; Casper, MD, David S; and Parvizi, Javad MD, “Periprosthetic joint infection increases the risk of one-year mortality.” (2013). Rothman Institute Faculty Papers. Paper 44.
https://jdc.jefferson.edu/rothman_institute/44

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Anesthesia Education Business/Finances Wellness

#91 – Vantage Point for January 2023

What up yall. This is Jon Lowrance. I’m still here. 😂 We’re still here. This is the first episode of 2023 and the first episode on Anesthesia Guidebook since October – October!

I’m so glad to get back to the podcast and bring you this update. This is a re-cap of the last few months of my world. It’s also a reminder of what Anesthesia Guidebook is about and a look forward into 2023.

I’ve got some very exiting news to share… my wife is pregnant with our second baby boy, due in March, and I’ve also transitioned in my role at Maine Medical Center from the SRNA Clinical Coordinator and into the role of chief CRNA.

In this episode, I talk about that transition and a bit about the philosophy of organizational leadership that I have found to be most compelling that’s shaping my approach to supporting my team and will undoubtedly continue to influence the podcast.

Thank you to everyone who reached out in the last couple of months! Your check-in’s, DMs, podcast reviews and emails have been encouraging and much appreciated! I’m honored to share this space with you and to be part of your runs, Peloton rides, commutes, baby naps and all the other times you tune into Anesthesia Guidebook to stay sharp and get your learn on.

I want to share the link for the group that I have the opportunity to support as chief CRNA here: Maine Medical Center. Search for the CRNA positions in Portland, Maine. Come work with us… I hope to share more about our team and the why behind what we do a little later in the year. It’s a special place with an amazing team. Reach out and we can talk about it.

That said, I will always work to maintain a professional degree of separation between my place of employment and this podcast in terms of the information and opinions I share.  My views and opinions – and those of my guests – do not necessarily represent those of any of our employers.  With any medical education content, you should always consult with other healthcare experts, medical texts and peer-reviewed journals before acting upon anything you hear in a podcast or social media post. 

Take care and welcome to 2023! 

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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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Categories
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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Leadership in Emergencies Preparing for Grad School/Residency Trauma

#88 – Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA – Part 3

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.

Resources:

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

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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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Categories
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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Categories
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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Categories
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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#82 – How Change Management can Build Value with Randy Moore & Desirée Chappell

Randy Moore, DNP, MBA, CRNA and Desirée Chappell, MSNA, CRNA join me to talk about change management in healthcare. They are both on the leadership team with NorthStar Anesthesia, which provides perioperative services at over 200 facilities across 20 states.

This conversation focuses on how leaders can navigate change, develop culture and build successful anesthesia practices. We discuss the challenges facing anesthesia providers right now after 2 years of the COVID-19 pandemic and what market forces are at play including provider shortages, pressure from reduced reimbursement rates and lower surgical volumes. This episode will be relevant for any anesthesia provider who’s looking to build value in their career and especially relevant for those practice managers, owners, leaders & entrepreneurs who want – and need – to know how to navigate change, find sustainable & deliberate growth and develop cultures where providers want to invest their careers.

Desirée Chappell, MSNA, CRNA is the Vice President of Clinical Quality at NorthStar Anesthesia. Desirée has an extensive background in education and quality improvement in anesthesia. She is the managing editor & lead anchor of TopMedTalk, a podcast on anesthesia, critical care & perioperative medicine with nearly 1600 episodes. She is also adjunct faculty for the Acute Pain Management Fellowship at Middle Tennessee School of Anesthesia and serves on the board of directors for the American Society for Enhanced Recovery. Desirée received her Master of Science in Nurse Anesthesia from Texas Wesleyan University.

Desirée Chappell, MSN, CRNA, VP of Clinical Quality at NorthStar Anesthesia

Dr Randy Moore, DNP, CRNA, MBA is the Chief Anesthetist Officer at NorthStar Anesthesia. He recently left his role as the Chief Executive Officer of the American Association of Nurse Anesthesiology and has a long background in organizational leadership. He retired as a Major in the United States Army after 22 years where he served as an active duty CRNA with tours in Afghanistan at Forward Surgical Bases. His doctorate of nursing practice is from the University of Alabama, his MBA from Southern Illinois University and Master of Science in Nursing anesthesia from Bradley University.

Randy Moore, DNP, CRNA, MBA, Chief Anesthetist Officer at NorthStar Anesthesia

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#81 – How to Navigate the Business of Anesthesia with Tracy Young, MSNA, CRNA, MBA

I caught up with Tracy Young, CRNA, MBA & CEO of YPS Anesthesia Services in Houston back in November 2019 to talk about the business of anesthesia.

Tracy is one of the most sought-after experts on the business of anesthesia not just at CRNA conferences but throughout the healthcare management & business industry.

In this episode we discuss a broad range of topics including anesthesia billing & staffing models, trends in reimbursement, differences between W2 & 1099 work, advice for establishing your first anesthesia staffing contract, how to succeed both in your career as an anesthesia clinician and how to transition into the business of anesthesia, how to maintain balance & wellbeing over the course of your career and other key insights.

Tracy covers the origin and mission of his business, YPS Anesthesia Services, which at the time of this interview (8 December 2019) supports over 450 anesthesia providers to staff over 60 endoscopy & ambulatory surgery centers and hospitals across seven states in the United States.

Tracy Young, CRNA, MBA, CEO of YPS Anesthesia Services

Tracy Young earned his Master of Science in Anesthesia (MSNA) from Texas Wesleyan University in 2000, found YPS Anesthesia Services in 2003 and went on to earn a Master in Business Administration (MBA) from George Washington University in 2008.

Leading YPS Anesthesia Services for nearly 20 years has provided Tracy a wealth of first hand experience in the anesthesia and healthcare business world. He enjoys giving back to the anesthesia community through teaching on business related issues for SRNAs at several anesthesia programs and for CRNAs through private conferences across the United States. Tracy also enjoys developing venture capital opportunities with both businesses in and out of healthcare. Tracy has been a long-time active member of the Louisiana State Association of Nurse Anesthetists, serving 2-terms as the president of the association.

All of this experience, coupled with Tracy’s easy-going Louisiana style, makes him one of the most sought-after expert presenters on the business of anesthesia. His presentations on business related topics are really some of the best I’ve heard. The power behind his talks comes from his deep personal knowledge coupled with an ability to communicate the relevance of business topics to practicing clinicians, both those working in employed W2 settings and those working in 1099 practices. But it’s not just this deep knowledge and keen teaching ability that Tracy brings to his talks. Perhaps the most powerful aspect of his ability to communicate is his character & integrity and emphasis on professionalism as a key to success in business.

Tracy often talks about the 3 A’s of Anesthesia.

The Three A’s of Anesthesia:

Amicable + Affable + Available

He encourages providers to understand that you’re in the service industry and your clients are diverse: it’s not just the patients, but the surgeons, the OR nurses & techs, the hospital administration and other staff. You’re in a service-oriented industry and embracing a positive attitude (being amicable & affable) while being available and supporting the delivery of efficient, high quality anesthesia care are critical aspects of developing a successful anesthesia practice or business.

I’m so glad you’ve found this podcast… it’s just an amazing conversation and I think you’re really going to enjoy it.

If you want to hear more from Tracy Young, I’ve linked in the show notes to another interview he did on the business of anesthesia with podcast host Jason Duprat of the Healthcare Entrepreneur Academy.

I should also mention, if it’s not obvious already, that Tracy is always recruiting physician anesthesiologists & CRNAs to join one of his many clinical sites or expand into new contracts. So if you’re looking for a great team to join with competitive benefits & compensation and flexible work schedules, be sure to drop them a line on their website at YPSAnesthesia.com.

Quotable moments:

“Some days you’re the bug & some days you’re the windshield.” – Tracy Young

“Trust takes a long time to build – 6 months, a year, multiple years to build that trust – but it only takes 5 seconds to loose that trust by one bad decision.” – Tracy Young

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#80 – How to do 1099 Anesthesia Work with Sandry Gaillard, MSN, CRNA

What’s up yall, this is Jon Lowrance with Anesthesia Guidebook. This is episode 80 – how to do 1099 anesthesia work with Sandry Gaillard, MSN, CRNA. This is the second episode in a short series on the business of anesthesia. I’m gonna do a little run of interviews and topics on the business of anesthesia in the next few weeks. In the last episode you heard from Navin Goyal, MD & Saket Agrawal, CEO, both with OFFOR Health on how physician anesthesiologists can expand their careers beyond their clinical practice. In upcoming shows you’ll hear from Tracy Young of YPS Anesthesia in an episode covering lots of topics on the business of anesthesia and another episode with Randy Moore & Desirée Chappell of NorthStar Anesthesia on change management & leadership in anesthesia.

These conversations are incredibly valuable for anyone in anesthesia even if you have no interest in running your own business or becoming a practice manager or leader. These podcasts are relevant for every staff CRNA, physician anesthesiologist & anesthesia resident because they help you understand the contexts that we all work in. A mentor shared with me that there’s four pillars of anesthesia: your clinical practice, which everyone has at least initially in your career, education & research, advocacy work & the business of anesthesia. While you might anchor yourself solely in your clinical practice as your primary or even only professional interest, it’s helpful to have a basic understanding of the other domains – education & research, advocacy & policy and the business of healthcare – so that you can be a more informed provider and adept at navigating your career.

This episode was first released on 14 February 2015. At the time, Sandry Gaillard, MSN, CRNA was working as an independent CRNA in a 1099 practice in rural Western North Carolina.

This episode was released as part of the initial launch of From the Head of the Bed, the podcast that preceded Anesthesia Guidebook. It’s an interview between Kristin Lowrance (formerly Kristin Andrejco) who at the time was a SRNA at Western Carolina University. Kristin and I both worked with Sandry while we were SRNAs at WCU and Kristin invited her on the show to talk about the basic difference between working as a W2 employee and 1099 contractor, as well as some of the unique characteristics of working in a small, rural independent CRNA practice.

Sandry clearly outlines the key differences between working as a W2 employee and working as a 1099 independent contractor. Her and Kristin discuss the financial & business considerations including filing taxes, hiring an attorney & accountant, setting up a business structure and insurance considerations. They also discuss the personal leap it takes to transition from working as a W2 employee to 1099 work where you have to learn to manage you finances & certain aspects of your career in much greater detail. Sandry shares her story of making this transition and gives some wonderful encouragement for others who might be considering making the switch.

Beyond discussing the financial & business considerations of working as a 1099 independent contractor, they discuss the unique characteristics of working in a small, rural CRNA-only practice.

It’s important to recognize that you can work as a 1099 “independent contractor” while still working in a group or with an anesthesia care team or with a larger company, whether that is a larger CRNA-only or physician-only group or an anesthesia care team model that includes both CRNAs & physicians. Filing taxes as a 1099 doesn’t mean you work in a CRNA-only or physician-only group. It’s simply a different business structure for your professional life and means you’re not a W2 employee. Working as a 1099 contractor brings certain tax benefits – as well as additional financial responsibilities – that W2 employees don’t have.

The bottom line is there are lots of opportunities for setting your work life up depending on what your interests and goals are. Many people prefer the relative ease of working in a W2 setting where an employer offers a benefits & compensation package including health insurance, retirement and professional liability insurance as well as a lot of other administrative support. Others prefer the flexibility and tax advantages of working in a 1099 setting. Layered on top of each of these fundamentally different financial & tax arrangements is the decision around whether you work as an independent provider or as part of an anesthesia care team or group.

This episode unpacks all of these considerations and is a great place to start if you’re wondering about what kinds of career opportunities or business structures are available for CRNAs and physician anesthesiologists.

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#79 – The Future of Healthcare with Navin Goyal, MD & Saket Agrawal, CEO with OFFOR Health

What’s up yall this is Jon Lowrance with Anesthesia Guidebook.  I’m really excited to bring you this episode on the future of healthcare with Dr Navin Goyal and Saket Agrawal of OFFOR Health.

This is episode 79 of anesthesia guidebook and it’s coming out on June 24, 2022.

This is one of the most interesting conversations I’ve had with contributors to this show.  Navin & Saket are here to discuss what the future looks like – or what it could look like – for physicians in healthcare.  They hit on something that’s not talked about very much in medical school or residency programs or every around the OR amongst your colleagues, which is “what more can you do” as a physician anesthesiologist?  What else is out there?  Graduating from medical school and completing your residency is really just the beginning – or as Navin puts it – fills one particular bucket in your career.  But there are other possibilities out there and now more than ever, he and Saket want to share with you how physicians can engage in new ventures and roles both in the healthcare sector and beyond as a way to leverage the value you bring as a highly trained clinician.

They unpack this story and create this invitation to look beyond your clinical practice through sharing the story of OFFOR Health and the path they’ve been on as business partners. 

So let me tell you a little about each of them and then we’ll get to it…

Navin Goyal, MD

Navin Goyal, MD is a physician anesthesiologist and a co-founder of SmileMD, a mobile anesthesiology startup that is aiming to change the accessibility of anesthesia to small practices. He is also a co-founder of Loud Capital, a venture capital firm that provides financial support to early-stage startups as well as value-added services such as business development and guidance in scaling sales operations.

Navin received his MD from the University of Cincinnati College of Medicine and trained in anesthesiology at the University of Chicago Medical Center.

Saket Agrawal 

Saket is the CEO of OFFOR Health, a company that brings access to specialists closer to home by partnering with local dentists and medical offices to deliver specialized care. Saket became CEO of OFFOR Health in 2016 after working for years in the technology space in Silicon Valley. 

Sakate graduated from The Ohio State University with training in computer science and engineering, earned his MBA in North Carolina, and worked in tech in San Francisco for nearly 10 years before SmileMD’s mission drew him back to Columbus.

So one of the contextual frameworks we worked off of in planning this discussion was physician anesthesiologist burnout.  Navin is going to share with you his own story of being over a decade into his clinical practice at a large academic medical center when he began to feel bored with the daily grind and started wondering what else was out there.  We talked before we recorded this about the MedScape 2022 Physician Burnout & Depression survey.  Now this is a survey I’ve been following for several years and sharing in my own talks at anesthesia conferences on wellness.  Each year, Medscape surveys around 13-15,000 physicians across 29 specialities and reports data on burnout, what contributes to burnout and how to mitigate it.  In their 2022 survey, they reported that 47% of physicians reported feeling burnt out last year.  

We certainly know the pandemic has created an incredible degree of stress on everyone’s lives – not just healthcare providers – and has served as a huge lever or catalyst for individuals across sectors to re-evaluate what they’re doing and why.  Physician anesthesiologists, along with CRNAs & other healthcare providers, are right in the middle of this cultural upheaval.  

And that’s another reason why I’m so pumped to bring you this talk.  Navin & Saket talk about what motivated them to create OFFOR Health and provide novel solutions – not only for patients in need – but for providers who are looking to shake things up in their own professional lives. 

You may remember back in episode 26 I spoke with Paul Samuels, a pediatric physician anesthesiologist about mobile pediatric dental anesthesia.  In that episode, he unpacked the nitty gritty of what SmileMD is all about – which an OFFOR Health company – along with the specific anesthesia considerations for practicing in mobile, pediatric dental settings.  Be sure to check that episode out if you want to hear a little more on SmileMD.

Stay tuned for lots of amazing things coming your way on the podcast… I’ve got several more shows on the business of anesthesia headed your way in the coming weeks along with one on the McLott Mix for opioid free anesthesia with Mr Jason McLott himself and ton of more content in the editing phase right now.  

As always, I’m stoked to hear from you.  Thank you so much for those of you who have reached out through email, Facebook, Instagram, Twitter – or even in person for all the SRNAs at the University of New England here in Portland, Maine.  

And with that, let’s get to the show!

Resources:

OFFOR Health

SmileMD

Anesthesia Guidebook episode on SmileMD: #26 – Mobile, pediatric dental anesthesia with Paul Samuels, MD

Physician Underdog, a book by Navin Goyal, MD

Beyond Physician – a professional development platform for physicians

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#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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#77 – Thrive in Training: how to land your first job in anesthesia with Jon Bradstreet, MSN, CRNA

In this episode, I talk with Jon Bradstreet, MSN, CRNA who at the time of this recording was the chief CRNA/Director of CRNA Services at Maine Medical Center, Maine’s only level 1 trauma center. Jon was the chief CRNA who gave me my first job in anesthesia. At the time he hired my wife and I, in June of 2015, there were around 50 CRNAs in our group. Seven years later, our group has more than doubled in size with just over 100 CRNAs. Jon has overseen that growth and the development of an incredibly healthy culture within the anesthesia team at Maine Medical Center. We originally recorded this interview in December of 2015.

In this episode we talk about how to prepare for the job hunt as a SRNA… everything from what to look for in a job and how to weigh various pros & cons, how to prepare your resume or CV and how to ace the interview & follow up communications with a prospective employer. You’ve worked incredibly hard during anesthesia school to develop the skills & knowledge to become a competent provider; following through with a similar degree of proactive ownership to land your first job is key to making a successful transition into working as an anesthesia provider. This episode will tell how to do just that.

Key topics:

  • CV Preparation – what works and what’s fluff on your CV
  • When to and how to contact prospective employers
  • Tips for interviews including:
    • What chief CRNAs are looking for in your interview
    • Questions you should be asking in your interview
    • Things to consider doing and avoid doing in an interview
    • When to follow up on an interview
  • Tips for promoting yourself as a CRNA
  • Advice for how to prioritize important aspects of jobs including location, practice type, group culture, compensation packages and more
  • Advice for CRNA couples who are in the job hunt together

Parting words from Jon Bradstreet, MSN, CRNA:

“Have fun… we have a great profession and we have a great lifestyle.  We’re very lucky to do what we do for a living.  Always keep that in mind – how fortunate we are in this profession.  And then finally I think I would say listen to your gut.  It’s taken you very far in life already… don’t repress what it’s telling you as you’re in that interview.”

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#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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#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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#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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#73 – Midlife Van Life: reinventing work-life balance with Kyle & Jen Steen

This show is so much fun and launching this now coincides with the launch date of my friends’ journey, which you’ll hear all about in this episode.  

Kyle & Jen Steen have been friends of mine for the last 7 years.  Kyle’s been a CRNA for 13 years, Jen is a fashion designer and farm-to-table chef.  The short story is they built out a custom Sprinter van into a tiny home on wheels, sold pretty much everything they own, including their house, and hit the road this week on a mid-career van life adventure with no end date on the calendar.  Kyle is 41, Jen is 39.  They’re in the middle of their careers.  

Kyle Steen, MSN, CRNA, van builder, adventurer, husband to chef & creator Jen Steen.

In this episode we talk about the why behind their decision and the how – both financially and specifically: like what kind of van they built, how they paired down 25 years of accumulated stuff to the absolute bare necessities and what they hope to do while they’re on the road.

This is a long-form interview.  We take our time over the next hour to talk through their decision & dream.  I can remember talking with Kyle & Jen when they first hatched this plan and I’ve watched them pull this dream together over the last couple of years.  We did this interview from their van on the day before their epic road trip kicks off this week.  You can see photos of the van in the show notes to this episode, on Anesthesia Guidebook’s Instagram page or in the biggest and best way by following Kyle & Jen on Instagram @FrankvannSteen. 

It’s not every day you see a highly intelligent, socially well-connected couple quit their high income day jobs and hit the road full time in a tiny home van.  We talk in this episode about the American Dream and the accumulation of wealth, status & possessions.  What I love about Kyle & Jen’s story is that they kept seeing people embrace the mantra of delayed gratification all the way up to retirement and then hit walls:  walls like ailing health, limited physical ability, cancer, strokes or just the fear of change that security & stability can subtly bring to one’s life… and they didn’t want that.  They didn’t want to just keep contributing to retirement accounts and doing the same thing every day while the best years of their life passed them by.  So they’re doing something different.  They’re taking a break from their careers to travel & create an adventure and a life worth living.


I think it’s so interesting because many people who go into anesthesia get very used to the income and routine of their careers.  Kyle & Jen’s decision drops the gauntlet for the rest of us to re-evaluate our lives and the why behind our lifestyles.  Where do you really derive your sense of enjoyment from?  If money wasn’t an issue, what would you do with your time?  Are you able to get to the point, even for a short period of time like a month, 3 months or a year, where your financial situation would allow you to chase that dream? To do that thing that may right now already be fading from the front of your mind under the scrutiny of Common Sense, your Practicality or sense of “but what would people think?”  

And maybe it’s not about finding a bunch of days all strung together but the ability to drop down a day or two per week.  We work on average four 10-hour shifts at our hospital.  My wife just dropped a day and now only works three 10-hour shifts a week.  That extra day off each week has made a huge impact on her well being and satisfaction, especially because it gives her more time to spend with our little 9-month old munchkin.  We also both take around 10 weeks off a year.  We could certainly work more and make more money, but we value the time more than the money we would make.

I came across this idea years ago that “what’s not important will continue on without you.”  

Kyle’s decision to step away from full time anesthesia work to adventure with Jen came at the same time that a couple of our other CRNAs, physician anesthesiologists and even our lead administrative specialist, retired after long, long careers at one institution.  Those people will be missed and there was a lot of legitimate nostalgia shared when looking back over their careers.  But the patients keep coming, the department has hired replacement staff and the healthcare machine churns on.  

I’ve always been wary of the sense that CRNAs and physician anesthesiologists are just cogs in a giant healthcare wheel.  It can be de-personalizing, anonymizing and demoralizing.  When you think about the statement “what’s not important will continue on without you,” it’s a reminder that we have to actively build for purpose in our careers… 

Research shows* that if you can arrange for 20% of your time at work to be geared towards something you truly are intrinsically motivated for, it’s protective against burnout.

(*Swensen, S. J., & Shanafelt, T. (2017). An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice. The Joint Commission Journal on Quality and Patient Safety, 43(6), 308-313.)  

I wanted to share Kyle & Jen’s story with you as an opportunity for you to re-evaluate where you’re at, where you’re headed and whether you need to make changes so you can take a step in the direction of being more fully alive.  LOTS of people go into anesthesia because it’s an amazing field and a fascinating type of hands-on, brainy kind of work that can be very rewarding and a service to others, but also, because the income allows us to pursue other things in our lives.  This podcast is an invitation for you to re-calibrate your story.  I hope you enjoy it and what it does to you as much as I have! 

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Anesthesia Education Preparing for Grad School/Residency Wellness

#72 – Thrive in Training: finding balance with Temima Luchansky & Maya Kelkar

In this episode, I’m joined by Temima Luchansky & Maya Kelkar, the 2 current SRNA reps to the AANA Health & Wellness Committee, to talk about how to find balance in anesthesia training.

Now if that immediately sounds impossible to you, then you’re listening to the right podcast.  We’re going to talk about a very concrete way of looking at your life and specific tips for how to manage the incredible challenges we face as anesthesia trainees.  

Balance can be an elusive concept to understand and an even more elusive state of being to achieve. Thankfully, the National Wellness Institute provides a simple framework to help us better understand what finding balance looks like in real life. It’s called the Six Dimensions of Wellness.  You can think of it like this:  there are six domains in each of our lives: social, emotional, occupational, physical, spiritual and intellectual.  Temima & Maya share insights for what each of these domains means to them as anesthesia trainees, the specific challenges they face in each domain and specific tips for how to thrive in each of these domains.

Finding balance happens when we work towards putting equal energy & focus into each domain. In the US, especially for Finding balance happens when we work towards putting equal energy & focus into each dimension of our lives.  For anesthesia and other healthcare trainees, a disproportionate amount of energy is usually placed on developing the occupational domain as we work through school and towards passing boards. Now, there’s times in our lives when we are intentionally out of balance: when we charge in one domain harder than in the others. And that can be ok for a period of time.  It can resulted in a concentrated period of extreme growth and development.  But for the long term, understanding what each of these domains can look like in your life and working to put equal energy into each of them can help build real wellness, resiliency and a very tangible & practical sense of balance in our lives.  

I’m so grateful that Temima & Maya took time out of their busy lives to join me to discuss the Six Dimensions of Wellness in this podcast. Both of these women are SRNA representatives to the national AANA Health & Wellness Committee. Temima became interested in volunteering on this committee after listening to a prior podcast on Anesthesia Guidebook with other SRNA reps to the Health & Wellness Committee.  And Maya came up with the idea for doing a deep dive on this specific topic after listening to a talk I gave at last year’s Idaho State Association of Nurse Anesthetists virtual conference on provider wellness.  Both of these individuals have powerful voices and are on a mission to help other SRNAs thrive in their training.  I think you’re really going to enjoy hearing from them, which is why I couldn’t find any way to trim this show down from around an hour & twenty minutes… it’s a long podcast but we talk through so much and they give wonderful, practical examples of how to work towards a healthy state of balance & wellness during your anesthesia training.  So break up the show over a few commutes or work outs and let us know what you think on Instagram, Facebook, Twitter or as comments on the website.  Speaking of the internet webs… the show notes of this episode has links to journal articles and a quick PDF run down on the Six Dimensions of Wellness from the National Wellness Institute.  We also link to the American Association of Nurse Anesthesiology’s website for Student Wellness which hosts a ton of resources for SRNAs who are actively trying to make it all work during training.  The AANA has put in a huge amount of effort on fostering proactive wellness initiatives for SRNAs & CRNAs in the last few years and I know these are having far reaching impacts in the anesthesia community.

Which reminds me, Temima & Maya will be hosting a live Zoom session for SRNAs they’re calling SRNA Shared Experiences through the AANA.  These are free, live Zoom sessions with a focus on peer-to-peer support in a judgment free zone.  Participants talk about the SRNA experience and how to be successful and well in anesthesia training.  The next session is in 2 days… Monday, March 21.  They run every other month, so if you miss Monday’s SRNA Shared Experience, you can circle back in May to hear from and talk with SRNAs around the nation in these free peer-to-peer support sessions.  

So a bit on Temima & Maya and then we’re on to the show… 

Temim Luchansky was born & bred in Baltimore, Maryland. She worked in Baltimore at a medical ICU for 2 years and then did 2.5 years of travel nursing in several hospitals throughout New York City in a mix of ICUs including CICU, SICU, CTICU, getting a variety of experience before CRNA school. She’s currently in the inaugural DNP Nurse Anesthesia class at Johns Hopkins University with an anticipated graduate date of 2023.

Maya Kelkar is a 2nd year nurse anesthesia student in the Gonzaga University/Providence Sacred Heart Medical Center Nurse Anesthesia Program. She’s from Atlanta, Georgia and her nursing background is in the pediatric ICU at Children’s Healthcare of Atlanta. The PICU is where she became passionate about healthcare provider wellness, after seeing high levels of burnout and compassion fatigue among her colleagues, and she was involved in wellness initiatives in her unit and for the hospital. She continues to promote wellness among anesthesia providers as one of the student representatives to the AANA Health & Wellness Committee. She also remembers citing From the Head of the Bed in her grad school interview and is THRILLED to be on the podcast.

Resources

AANA SRNA Wellness website

Wondering When to Ask for Help? Check this out from AANA…

Check out #54 – Hardship in Anesthesia School where I talk about my own path in anesthesia training and offer insights for how to keep moving even when the path gets incredibly difficult.

NWI-Six-Dimensions-ToolDownload
Stress-Anxiety-and-Well-being-in-Nurse-Anesthesia-Doctoral-StudentsDownload

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Anesthesia Education Anesthesia Equipment and Technology Human Physiology and Pathophysiology Preparing for Grad School/Residency Wellness

#71 – Thrive in Training: destroying didactics with Jenny Finnell, MSN, CRNA

Jenny Finnell, MSN, CRNA joins me to talk about how anesthesia trainees can master the didactic phase of their training. We cover lots of tips in this show: everything from how to make challenging content stick to how to get organized, which apps & resources are helpful and how to maintain mental wellbeing during anesthesia training.

This episode will help you dial in your plan for success in didactics. Our goal is for you to thrive and not just survive in school. The volume of information you have to master is immense and the learning curve is incredibly steep, especially when you begin to integrate clinical training into your journey. Creating early success in didactics is key to progressing in anesthesia school.

There’s 3 domains of knowledge in any kind of training:

  • the know-what
  • the know-why and 
  • the know-how.

The know-what is the core information, principles & facts.  

The know-why is understanding the situationally-specific rationales for actions & processes.

And the know-how is where we learn to put the know-what & the know-why into practice: it’s the experiential, practical application of knowledge. 

The didactic portion of training is where we pick up most of the know-what.  What you need to know is learned by studying, being taught, reading, watching video & listening to lectures & podcasts.  It’s here where we also learn a lot of the know-why: the rationales behind why we do things the way we do them in anesthesia.  You’re only able to develop the art of anesthesia if you have a solid foundation in the science of anesthesia.  Learning the know-how: the actual mechanics and flow of putting everything together, the timing & art of anesthesia is learned best by doing… especially when that experiential education is under the guidance of a skilled preceptor, clinical coach or mentor.  

Jenny Finnell, MSN, CRNA runs the CRNA School Prep Academy, which is a mentoring and professional coaching community designed for those who want to pursue a career as a CRNA.  Her team offers a blog, podcast and public & private forums as well as individualized coaching for every phase of preparing for anesthesia training.  She’s active on Facebook & Instagram if you want to see what the CRNA School Prep Academy is all about or you can certainly cruise over to her website at CRNAschoolprepacademy.com. 

Resources:

The CRNA School Prep Academy Ultimate Resource Guide:

…this is Jenny Finnell’s Six-Page Free Resource Guide. In it, she lists the best podcasts, YouTube channels, apps, websites, books related to anesthesia, studying/learning, grad school interviews and professional resources.

Chipas, A., & McKenna, D. (2011). Stress and burnout in nurse anesthesia. AANA journal, 79(2).

Vargo Anesthesia Mega App. This is an incredibly thorough app covering run downs on surgeries, pathological conditions, pharmacology and detailed weight-based guides to pediatric anesthesia. While you have to pay for this app, the cost is definitely worth what you get.

Master Anesthesia app in App Store: check out the story from app creator Matthew Willis in Episode 38 of Anesthesia Guidebook. This app is FREE and growing in its scope of surgeries & medications but rolled out with a phenomenal calculator for quickly seeing max doses of multiple local anesthetics.

Writing in the Sciences: FREE course on professional/scientific writing from Stanford University. Take this course to improve your professional writing.

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Anesthesia Education Preparing for Grad School/Residency Wellness

#70 – Thrive in Training – Growth Mindset with Jenny Finnell, MSN, CRNA

Jenny Finnell, MSN, CRNA, the creator behind the CRNA School Prep Academy joins us today to talk about growth mindset.

Learning to develop a growth mindset is key to pushing beyond where you’re at currently to where you want to go.

Carol Dweck is a psychologist and the Lewis and Virginia Eaton Professor of Psychology at Stanford University. Her research found that people generally work from two mindsets: a fixed mindset or a growth mindset. Dweck argues that intelligence is not fixed trait but something that can be developed and expanded with the right kind of training, effort and encouragement. Your IQ and certainly your SAT/ACT/GRE scores and even GPA are not the final word on your capacity, intelligence or potential. They’re merely snapshots of your performance at particular points in time on particular assessments. The way you see intelligence, challenges, obstacles, the success of others, the value of effort and your potential all relate to which mindset you work from. Her book, Mindset: the new psychology of success, is a worthy read for any one looking to master their craft and/or help others along the way. Whether you’re on the path to becoming an expert clinician, want to train the next generation of providers or even parent more effectively, Dweck’s work will show you the path.

Two Mindsets Chart.  (2016).  GLT Carol Dweck: Two Mindsets Chart and Compelling Questions.  Guidline Leaders and Teams.  Retrieved from https://guidingleadersandteams.com/resources-glt/carol-dweck-two-mindsets-chart-and-compelling-questions-glt/.  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/.

Jenny Finnell, MSN, CRNA runs the CRNA School Prep Academy, which is a mentoring and professional coaching community designed for those who want to pursue a career as a CRNA.  Her team offers a blog, podcast and public & private forums as well as individualized coaching for every phase of preparing for anesthesia training.  She’s active on Facebook & Instagram if you want to see what the CRNA School Prep Academy is all about or you can certainly cruise over to her website at CRNAschoolprepacademy.com.  We’ll talk a little bit more about what she’s been up to with her company at the end of this show but first…

I’m so glad Jenny joined me to talk about growth mindset.  Learning to develop a growth mindset is key to pushing beyond where you’re at currently to where you want to go.  Whether you’re an experienced anesthesia provider, a current anesthesia resident or someone who’s on the path towards anesthesia training, understanding how to embrace a growth mindset and move beyond the limitations and shackles of a fixed mindset will help you actually thrive on the journey.  If you don’t just want to survive anesthesia training – or worse, not even make it, but you actually want to thrive, you need to understand how to develop a growth mindset. 

Resources:

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/

Jenny Finnell’s podcast: Growth Mindset & Why This Single Thing Can Allow Your Journey To Be Easier

Grant, A.  (2018, December 8).  What straight-A students get wrong.  The New York Times.  Retrieved from https://www.nytimes.com/2018/12/08/opinion/college-gpa-career-success.html

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Anesthesia Education Preparing for Grad School/Residency Wellness

#69 – Thrive in Training: how to start strong

The key to thriving in training is setting a trajectory in life based on your deep interest, learning to embrace deliberate practice in your craft, remembering your why and locking on to the hope that comes with knowing your goal is worth the work you will put in.

This series is designed to help physician and nurse anesthesia residents succeed in anesthesia training.

Topics covered include:

  • 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

I originally released this on February 21, 2015 on From the Head of the Bed (the predecessor podcast to Anesthesia Guidebook). I talk with Mason McDowell, DNAP, CRNA and Kara Michalov, MSN, CRNA on their top tips for success in anesthesia school. This is a bit of a 10,000-foot overview of how to thrive in anesthesia school. In later episodes in this series, we’ll dive into many of these topics in more detail. In this episode, we discuss:

  • how to start strong
  • should you work or moonlight during training?
  • advice for starting clinical
  • how to socializing (or not) in the OR as a resident
  • how to recover from novice mistakes and keep going
  • goal setting with preceptors
  • project/thesis identification & tips
  • advice on studying for boards

At the time of this interview, Mason McDowell, DNAP, CRNA was the Associate Professor and former Assistant Director of the Nurse Anesthesia Program at Western Carolina University.   His Doctorate of Nurse Anesthesia Practice (DNAP) from Texas Wesleyan University included research focused on perioperative patient management and cardiac risk assessment.  He is the co-author of the Hepatobiliary and Gastrointestinal Disturbances and Anesthesia chapter in Nagelhout’s Nurse Anesthesia.  A few weeks after this interview in 2015, Mason moved with his wife and two daughters to Bere, Chad to provide anesthesia. You can hear more about his story in episode 61 & 62 of Anesthesia Guidebook. You can also read about his experiences in Chad at http://www.whyweshouldgo.blogspot.com. 

At the time of this interview, Kara Michalov, MSN, CRNA was a CRNA in Asheville, North Carolina. Kara and Mason are co-authors of Intravenous Acetaminophen and Intravenous Ketorolac for Management of Pediatric Surgical Pain: A Literature Review, which was published in the February 2014 edition of the AANA Journal (Vol. 82, No.1).

A remarkable note on her paper:  her and her primary co-author, Kit Baley, submitted their paper for publication and received no request for corrections from their peer reviewers.  This is an incredible accomplishment as they essentially wrote a perfect paper on this topic prior to submitting it for publication.  Nice job, Kara & Kit! 

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Anesthesia Education Preparing for Grad School/Residency Wellness

#68 – Thrive in Training: how to prepare for anesthesia school

The Thrive in Training series is designed to help physician and nurse anesthesia residents succeed in anesthesia training.

The key to thriving in training is setting your trajectory in life based on your deep interest, learning to embrace deliberate practice in your craft, remembering your why and locking on to the hope that comes with knowing your goal is worth the work you will put in.

Topics covered include:

  • 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

In this episode, the second in the series, I talk with Mason McDowell, DNAP, CRNA and Kara Michalov, MSN, CRNA about the following:

– advice for how to prepare for nurse anesthesia school
– advice for students with families, significant others & pets
– what to study (or not) ahead of time
– how to prepare for the Big Interview to get into school

I released this episode originally on February 21, 2015 on the podcast From the Head of the Bed. Today, exactly 7 years later, it’s coming back to Anesthesia Guidebook as part of the Thrive in Training series with a fresh introduction. I also summarize tips for preparing for anesthesia school at the end of the show. What Mason & Kara share remains relevant and they offer keen insights from their personal experience. You’ll definitely enjoy this conversation!

At the time of this interview, Mason McDowell, DNAP, CRNA was the Associate Professor and former Assistant Director of the Nurse Anesthesia Program at Western Carolina University.   His Doctorate of Nurse Anesthesia Practice (DNAP) from Texas Wesleyan University included research focused on perioperative patient management and cardiac risk assessment.  He is the co-author of the Hepatobiliary and Gastrointestinal Disturbances and Anesthesia chapter in Nagelhout’s Nurse Anesthesia 5th Edition.  A few weeks after this interview in 2015, Mason moved with his wife and two daughters to Bere, Chad to provide anesthesia. You can hear more about his story in episode 61 & 62 of Anesthesia Guidebook. You can also read about his experiences in Chad at http://www.whyweshouldgo.blogspot.com.

At the time of this interview, Kara Michalov, MSN, CRNA was a CRNA in Asheville, North Carolina. Kara and Mason are co-authors of Intravenous Acetaminophen and Intravenous Ketorolac for Management of Pediatric Surgical Pain: A Literature Review, which was published in the February 2014 edition of the AANA Journal (Vol. 82, No.1).

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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 Business/Finances

#66 – The CPC Assessment (Exam) Overview

This is run down specifically on NBCRNA’s Continued Professional Certification (CPC) Program Assessment (or Exam) for CRNAs.

Episode 64 was a 10-minute run down on the whole CPC Program – a quick overview. In episode 65, I did a whole hour-long deep dive on the program, including the CPC Assessment. This episode cuts out all the other content on the CPC Program and just focuses on the exam. This is the element of the CPC Program that causes the most anxiety for CRNAs so it’s worth doing a whole show on. I talk about the background of the exam, the layout & nature of the exam, the decision about taking in person at a Pearson Testing Center or at home on your own computer and tips for preparing (or not) for the exam.

In April of 2019, I interviewed John Preston, DNSc, CRNA, FNAP, APRN and Lisa Kamen, CAE of the NBCRNA on the CPC Program for the podcast From the Head of the Bed. At the time, Dr Preston was the Chief Credentialing Officer at NBCRNA; he is now the CEO of NBCRNA. Lisa Kamen is an association manager who supports the work of NBCRNA as a full time staff member. Several elements of the CPC Program have changed since 2019 so the last 3 episodes on Anesthesia Guidebook are all new.

Drop me an email or comment on Instagram/Facebook if you’ve got questions on the exam after listening to these 3 episodes. Links below for content from NBCRNA to help you naviaged the CPC Program along with the powerpoint outline I’ve used to present on the CPC Program at state & national conferences for CRNAs.

The CPC Program at a glance.

Check your progress in the CPC Program here: NCBRNA Website

More on the CPC Program:

NBCRNA CPC Program

CPC Program Overview: Lowrance 1-hour presentation PDFDownload

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Anesthesia Education Business/Finances

#65 – 1-hour CPC Program Overview

This is an all-new 1-hour overview of the NBCRNA’s Continued Professional Certification (CPC) Program for CRNAs.

In April of 2019, I interviewed John Preston, DNSc, CRNA, FNAP, APRN and Lisa Kamen, CAE of the NBCRNA on the CPC Program for the podcast From the Head of the Bed. At the time, Dr Preston was the Chief Credentialing Officer at NBCRNA; he is now the CEO of NBCRNA. Lisa Kamen is an association manager who supports the work of NBCRNA as a full time staff member. Instead of brining that episode forward to Anesthesia Guidebook, I’ve decided to complete re-write this update because the CPC Program has evolved even since 2019.

Episode 64 of Anesthesia Guidebook includes a brief 10-minute run down on the CPC Program that you can share with friends who just want a quick overview. I recorded the 1-hour run down first and then realized that there’s probably some CRNAs out there who just want a quick overview, so I hammered episode 64 int0 just over 10-minutes.

The CPC Program at a glance.

Check your progress in the CPC Program here: NCBRNA Website

More on the CPC Program:

NBCRNA CPC Program

CPC Program Overview: Lowrance 1-hour presentation PDFDownload

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Categories
Anesthesia Education Business/Finances

#64 – 10-minute CPC Program Overview

This is a short overview of the NBCRNA’s Continued Professional Certification (CPC) Program for CRNAs.

In April of 2019, I interviewed John Preston, DNSc, CRNA, FNAP, APRN and Lisa Kamen, CAE of the NBCRNA on the CPC Program for the podcast From the Head of the Bed. At the time, Dr Preston was the Chief Credentialing Officer at NBCRNA; he is now the CEO of NBCRNA. Lisa Kamen is an association manager who supports the work of NBCRNA as a full time staff member. Instead of brining that episode forward to Anesthesia Guidebook, I’ve decided to complete re-write this update because the CPC Program has evolved even since 2019.

Episode 65 of Anesthesia Guidebook includes an all-new 1-hour run down on the CPC Program. I actually recorded that show first and then realized that there’s probably some CRNAs out there who just want a quick overview, so I’ve hammered this episode out in just over 10-minutes. I covered the basics of the CPC Program but if you want to know more details, some back story on the program and more tips on crushing the CPC Assessment (exam), be sure to check out the next podcast!

The CPC Program at a glance.

Check your progress in the CPC Program here: NCBRNA Website

More on the CPC Program:

NBCRNA CPC Program

CPC Program Overview: Lowrance 1-hour presentation PDFDownload

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Anesthesia Education Business/Finances Preparing for Grad School/Residency

#63 – Anesthesia Billing Models with Ian Hewer, CRNA

Dr Ian Hewer is the program director of Western Carolina University’s Doctor of Nursing Practice in nurse anesthesia program.  At the time of this interview, Ian had been a CRNA for 20 years, was an assistant professor in WCU’s nurse anesthesia program, held two master’s degrees – one in sociology, the other in anesthesia – and was enrolled in his PhD program at the University of North Carolina-Charlotte.  His PhD is in Health Services Research and the focus of his dissertation was economics & billing practices in anesthesiology.

I originally recorded this interview with Ian back in February of 2015 when I was still a SRNA at WCU and Ian was one of my professors and clinical preceptors.

We discuss the differences in billing models such as medical direction, medical supervision and independent practice in the United States.  We talk about the Tax Equity and Fiscal Responsibility Act of 1982 and how TEFRA – again that’s the Tax Equity and Fiscal Responsibility Act – requirements influence reimbursement and anesthesia practices.  We go over opt out and what that means – how in nearly half of all states, CRNAs are not required to have supervision by any physician, podiatrist or dentist in order to bill directly for their services.  We discuss how market forces such as an evolving payor mix can influence decisions on billing models and practice structure for anesthesia groups, hospitals and individual providers.  We talk about the challenge of studying big data in establishing differences in quality outcomes between CRNAs and physician anesthesiologists. We also discuss the future of anesthesia economics and concrete steps healthcare organizations and providers can take to lower costs and maximize efficiency while maintaining high quality outcomes.

If you want the inside scoop on economics in anesthesiology, start with this podcast. 

I’ll also mention here that Western Carolina University is likely opening their bridge program for Master’s prepared CRNAs to obtain their DNP in the summer of 2022.  So if any of you master’s prepared CRNAs out there are looking for DNP programs, keep WCU on your radar.  

Resources:

Lewis SR, Nicholson A, Smith AF, Alderson P. Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD010357. DOI: 10.1002/14651858.CD010357.pub2

Hewer, I. (2018). ANESTHESIA CARE TEAM TYPE AND HOSPITAL CHARACTERISTICS: ARE INCREASED LEVELS OF SUPERVISION ASSOCIATED WITH DIFFERENT ACUITIES AND OUTCOMES?. (Thesis). University of North Carolina at Charlotte. Retrieved from https://repository.charlotte.edu/islandora/object/etd%3A1088 

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

#62 – How to do Anesthesia for Global Outreach – Part 2 with Mason McDowell, DNAP, CRNA

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. 

Recommended reading:

Mason’s blog: whyweshouldgo.blogspot.com

When Helping Hurts: How to Alleviate Poverty Without Hurting the Poor . . . and Yourself by Steve Corbett & Brian Fikkert

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

#61 – How to do Anesthesia for Global Outreach, Part 1 – Mason McDowell, DNAP, CRNA

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.  

Recommended reading:

Mason’s blog: whyweshouldgo.blogspot.com

When Helping Hurts: How to Alleviate Poverty Without Hurting the Poor . . . and Yourself by Steve Corbett & Brian Fikkert

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Anesthesia Education Business/Finances Personal Finances Preparing for Grad School/Residency

#60 – Kate Balzano-Cowan Paid Off >$100k Debt in a Year

All right y’all, you’re about to hear from Kate Balzano and how she paid off over $100,000 in student loan debt in a year.

There’s three reasons I wanted to bring Kate’s story to you:

The first is that Kate is all around an amazing human.  I have the privilege of working with her on a regular basis and get to see her passion for anesthesia, the balance she brings to her life and her interest in training SRNAs as a top notch clinical preceptor. 

The second is that Kate and her husband paid off close to $140,000 of student loan debt in just about a year after she passed boards as a CRNA.  She’s gonna unpack the why and how behind that decision in this podcast.

And the last is that she is a rare human in that she wholeheartedly believes that anesthesia training was actually easier having 2 young children than what she imagines it would have been prior to having kids.  You heard that right.  Kate thought it was easier to do anesthesia school as a mother WITH kids than without them.  She’ll explain why during this show.

Kate Balzano-Cowan, MSN, CRNA currently practices anesthesia as a CRNA in the Department of Anesthesiology and Perioperative Medicine at Maine Medical Center in Portland, Maine.  Prior to nursing, Kate was an organic chemist with research and management experience in both industrial as well as pharmaceutical research labs.  Kate has earned a Master’s of Science in Nurse Anesthesia from the University of New England, a Bachelor’s of Science in Nursing from the University of Massachusetts, and an American Chemical Society certified Bachelor’s of Science in Chemistry with a minor in Biology from Northeastern University.

If you’ve been following Anesthesia Guidebook, you know that I started a podcast called From the Head of the Bed back in 2015 and having been pulling some of those episodes over to Anesthesia Guidebook before phasing out the old show.  This is one of my favorite conversations and Kate and I released this back in October of 2019.  Bringing this forward to Anesthesia Guidebook here at the end of December in 2021 is super special because just last week I made my final payment on my own student loans.  While I was nowhere close to Kate’s 1-year pay off timeline, I can’t tell you how good it feels to pay back all $197,000 of my student loans in 6 years and 6 months.  That’s an average of $2700 a month for 6 & half years.  And I’m am stoked to be done with those loans.  When I got out of anesthesia school, I had 17 different student loans and opted to consolidate all those bad boys down to one behemoth monster.  Doing that brought my overall interest rate way down and just made my repayment plan more manageable… I only had to make one payment.  I also signed on with a group who happened to have a rolling student loan repayment program that didn’t phase out after a 3-year sign on bonus or specific amount like many groups.

It hasn’t really sunk in yet that I’m done paying off almost $200,000 in student loans.  I’m 38 years old and I’ve been in debt with student loans for 20 years, over half my lifetime.  While my payoff time of 6 & 1/2 years after graduation can certainly be classified as aggressive, Kate’s is otherworldly.  Another colleague we work with had over $200k in student loans and got hers paid off in right around 4 years.  That’s super aggressive and I saw her put in the hard work of delayed gratification and working epic amounts of overtime for those four years.

While I’m going to talk more about finances and why you shouldn’t do anesthesia for the money in the future on the podcast, I want to just say right here that Kate’s story and my story and that of so many other CRNAs who pay their loans off quickly and move forward towards their financial goals are testament that you can do it, too.  As Kate says in this show, where there’s a will there’s a way… anesthesia school can seem daunting, especially now with it shifting to a doctoral degree for entry to practice for CRNAs.  But it’s worth it.  It’s totally worth the financial hardship you’ll endure up front.  The pay off is totally worth it.  You’ll be able to handle your student loans in stride and have more than enough to be well and happy! 

Check out the links below to think more about student loan debt.

Death, Sex & Money podcast series on student loan debt.

Take the Quiz… see where you line up on WNYC’s Death, Sex & Money student loan project quiz.

Beyond the Mask with Jermey Stanley:  Episode 23 – The Wealthy CRNA. Get tips on financial management specific to CRNAs in the above podcast and through Jeremy’s company: CRNA Financial Planning. Cycle back to Episode 18 of this show to hear Jeremy talk through freelancing options for CRNAs.

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Anesthesia Education Business/Finances Preparing for Grad School/Residency Wellness

#59 – How to Achieve Your Goals

This is episode 59 – How To Achieve Your Goals.  This is one of my favorite episodes and the content here is something that I come back to again and again.  I’ve listened to it probably 5 or 6 times since I first released it and every time I come back to this, I leave with refreshed clarity around what’s important and a renewed sense of how to move forward.

This episode was first released in January 2020 on From the Head of the Bed – the podcast that was the podcast before Anesthesia Guidebook.  You know, the thing we did before we did this thing.  Cause there’s always a thing before the thing.  Or the thing behind the thing.  There’s evolutions to what we do.  Chapters.  Seasons.  Change and growth and movement.  I talked about that a bit on the last episode about the rhythms in your life…

This episode is a follow up to that.  The last episode was really about how to rest and carve out time to restore your energy and clear you mind.  This one is about how to set a trajectory in your life and do the work to achieve your goals.  

Transcript: #59 How to Achieve Your GoalsDownload

References

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

Dweck, C. S. (2008). Mindset: The new psychology of success. Random House Digital, Inc.. 

Dalio, R. (2018). Principles. Simon and Schuster. 

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Anesthesia Education Preparing for Grad School/Residency Wellness

#58 – How to Recharge & Create Rhythm in Your Life

When’s the last time you put your cell phone down and did something relaxing or to recharge your energy?

When’s the last time you felt relaxed and refreshed?

Can you imagine feeling refreshed & relaxed, clear-minded and rested on a regular basis? Tanked up? Ready to charge?

Finding rhythm and downtime to recharge seems wildly counterproductive at first and like a luxury serious people can’t afford (or successful people… or people who are on the path to become successful).

That’s what this podcast is about. This is about how to recharge yourself and be well. You can find space for this even during anesthesia training. It’s actually crucial that you do so. It will help you perform at your top level and crush school & clinical.

You can find space for this even if you lead a busy life with kids & jobs and a never-done to-do list. It’s actually crucial that you do so.

Brené Brown talks about in her research on vulnerability and shame, she “discovered” that people who rated their lives high on markers of life satisfaction and well-being all consistently engaged in unstructured time designed to rejuvenate themselves. It turns out she wasn’t the first person to realize this. Other researchers and sociologists have studied this and call it “play.” That’s right. Like playtime. Time set aside to do things for fun. Things that fill your cup, restore your energy and help you whether the demands of the rest of your life. That’s what this podcast is about.

I originally put out what you’re about to hear in February of 2019 on the podcast From the Head of the Bed. In the show I mention taking van trips and that references the Sprinter van that my wife and I built out a few years ago as a camper van. You can hear more about that and how one SRNA converted an old ambulance into his home on wheels for grad school in episode #6 of Anesthesia Guidebook, titled Van Life in Anesthesia School with Marcus House.

AANA Ask For Help website

AANA Student Wellness website

References:

  1. Tarantur, N., Deshur, M. (2018).  Anesthesia professional burnout – a clear and present danger.  APSF Newsletter. 33(2), 43-44.
  2. Chipas, A., & McKenna, D. (2011). Stress and burnout in nurse anesthesia. AANA journal, 79(2). 
  3. 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), S49. 
  4. De Oliveira, G. S., Chang, R., Fitzgerald, P. C., Almeida, M. D., Castro-Alves, L. S., Ahmad, S., & McCarthy, R. J. (2013). The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesthesia & Analgesia, 117(1), 182-193.  
  5. Raj, K. S. (2016). Well-being in residency: a systematic review. Journal of graduate medical education, 8(5), 674-684.  
  6. Hettler, B. (1976). Six dimensions of wellness model. National Wellness Institute. Retrieved from https://cdn.ymaws.com/www.nationalwellness.org/resource/resmgr/tools/SixDimensionsFactSheet_Tool.pdf.  Screenshot by author.
  7. 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/. 
  8. Grant, A.  (2018, December 8).  What straight-A students get wrong.  The New York Times.  Retrieved from https://www.nytimes.com/2018/12/08/opinion/college-gpa-career-success.html

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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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Wellness

#56 – Guided Relaxation with Matt Zinder, MS, CRNA, CH

In this podcast, Matt Zinder, MS, CRNA, CH walks us through a fifteen-minute guided relaxation session that is sure to leave you feeling refreshed and renewed. You should try this at home, on your lunch break or to help you go to sleep at night.  Get to a place where you can close your eyes and tune out distractions.  Hopefully, you’ll find yourself relaxed and refreshed, ready to move forward with renewed energy or simply fast asleep.

Matthew Zinder, MS, CRNA, CH has worked in some level of healthcare for close to 25 years, starting as an EMT in a volunteer fire station. Matthew owns and operates the Maryland-based mobile anesthesia practice Zinder Anesthesia, LLC, that has been in business since 1984. It consists of 20 practitioners and covers 50 locations throughout the state of Maryland.

Matthew speaks at many professional conferences, both nationally and internationally, involving topics such as stress management, business of anesthesia, hypnosis, and the practice of anesthesia. Matthew also has an active hypnotherapy practice that caters mainly to healthcare providers. He is the founder and director of Maryland Emergency Response, a disaster relief 501(c)(3) non-profit organization that works to aid victims following natural and/or man-made disasters. Matthew is currently the District IV director for the Maryland Association of Nurse Anesthetists.

Check out episode #55 – How to Be Well During the Pandemic where Matt and I talk about the stress management and mindfulness for healthcare providers in more detail. Be well!

Meditation apps:

10% Happier – healthcare providers get a free 6 month membership in light of the pandemic. 10% Happier has guided meditation and stress management content. Email care@tenpercent.com, let them know you’re a healthcare provider and they will give you instructions for accessing the content.

Insight Timer – 35,000 free guided meditations.

Books (for your self-quarantined downtime):

Why We Sleep by Matthew Walker, PhD

10% Happier by Dan Harris

Meditation for Fidgety Skeptics by Dan Harris

The Biology of Belief by Bruce Lipton

Why Zebras Don’t Get Ulcers by Robert Sapolsky

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Wellness

#55 – How to Be Well During the Pandemic – Matt Zinder

#60 – Peace of Mind During COVID19 Pandemic with Matt Zinder, MS, CRNA, CH
Why Zebras Don’t Get Ulcers, by Robert Sapolsky is a book explaining the physiology of chronic stress and techniques for managing it. Sapolsky is a professor of biology and neurology at Stanford University. Matt Zinder recommends this book, saying, “It’s the seminal text on stress. This author describes to minute detail what stress is, what stress does to the body and ends with some techniques for managing stress.” Image retrieved from https://animals.desktopnexus.com/wallpaper/2068315/.

This podcast was originally published on From the Head of the Bed on March 17, 2020. That was during the early stages of the COVID-19 pandemic. Now, in December 2021, as the pandemic has stretched out nearly 2 years, we’re revisiting Matt Zinder’s advice on how to be well and cope with the stress and change that the pandemic has brought.

Matt walks us through several techniques for stress management and mindfulness in this podcast. This episode, and the one to follow, where Matt actually guides us through a 10-minute spoken meditation, are just as helpful if not more so now as they were nearly 2 years ago. Just this week, my local health system in Maine has been hit harder with COVID-19 patients than at any time in the pandemic. Our local level-1 trauma center is completely full with patients. We’ve suspended all surgical cases with the exception of true emergencies. Just today, we stood up an emergency ICU/IMC unit in one of our PACUs to help alleviate the strain on our regular ICU staff and build capacity.

After each wave that comes & goes in the pandemic, another one seems to follow. This has resulted in fatigue, stress, burnout and frustration in many healthcare workers. Tens of thousands of healthcare works have either left their jobs or hit the travel circuit. The reasons they are motivated to quit or take travel assignments are complex and multifactorial. However, this phenomenon in the middle of the pandemic has exacerbated the staffing crisis and strained health systems to levels not seen in modern times. Responding to COVID-19 and its variants with vaccines, boosters and other therapies is crucial but only one part of addressing the broader healthcare crisis in the US. Systemic change is needed. Research shows that about 80% of individual burnout can be attributed to factors that need to be addressed at the organizational or system level. While it’s important to recognize that and put energy and attention into creating more functional organizations and healthcare systems, this podcast is about what we can do as individuals to bolster our resiliency during the pandemic.

Matthew Zinder, MS, CRNA, CH has worked in some level of healthcare for close to 25 years, starting as an EMT in a volunteer fire station. Matthew owns and operates the Maryland-based mobile anesthesia practice Zinder Anesthesia, LLC, that has been in business since 1984. It consists of 20 practitioners and covers 50 locations throughout the state of Maryland.

Matthew speaks at many professional conferences, both nationally and internationally, involving topics such as stress management, business of anesthesia, hypnosis, and the practice of anesthesia. Matthew also has an active hypnotherapy practice that caters mainly to healthcare providers. He is the founder and director of Maryland Emergency Response, a disaster relief 501(c)(3) non-profit organization that works to aid victims following natural and/or man-made disasters. Matthew has also served as the director for the Maryland Association of Nurse Anesthetists.

Matt Zinder has made his email address public for questions, comments or speaking engagements: zinderllc@gmail.com  

Meditation apps:

10% Happier – healthcare providers get a free 6 month membership in light of the pandemic. 10% Happier has guided meditation and stress management content. Email care@tenpercent.com, let them know you’re a healthcare provider and they will give you instructions for accessing the content.

Insight Timer – 35,000 free guided meditations.

Books (for your self-quarantined downtime):

Why We Sleep by Matthew Walker, PhD

10% Happier by Dan Harris

Meditation for Fidgety Skeptics by Dan Harris

The Biology of Belief by Bruce Lipton

Why Zebras Don’t Get Ulcers by Robert Sapolsky

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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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Anesthesia Education Preparing for Grad School/Residency Wellness

#53 – Overcoming Setbacks in Anesthesia Training

I originally released this podcast on April 4, 2020 to offer advice & encouragement to SRNAs who had been furloughed from clinical due to the COVID-19 pandemic. While elements of this show speak specifically to that context, the themes ring true for overcoming any set back during anesthesia school.

At the time, our level 1 trauma center, along with hospitals across the nation, clamped down on all non-essential staff, removing medical students, nursing students, SRNAs and others from the clinical environment in order to reduce their risk of exposure to COVID-19 and reduce transmission rates in general. This was an unprecedented moment for SRNAs across the nation. Adrienne Chavez and Kelly Gallant and I talked about that on the last episode of Anesthesia Guidebook. They were SRNA representatives to the AANA Health & Wellness Committee at the time and shared their stories of what they were facing and how they were keeping their focus on moving forward as the pandemic spread worldwide.

With anesthesia school, you gotta believe that the juice is worth the squeeze and keep your eyes on the finish line while finding ways to cope and be successful along the way. So again, while this show was originally focused on how SRNAs can deal with the set back of being furloughed from clinical because of the pandemic, the themes and advice I share is applicable to almost any set back you may be facing. So with that in mind, let’s get right to the show!

References:

Edmond Eger NYTimes Tribute:

Grady, D.  (20 September 2017).  Dr. Edmond Eger II, 86, Dies: Found Way to Make Anesthesia Safer.  The New York Times.  Retrieved from https://www.nytimes.com/2017/09/20/obituaries/dr-edmond-eger-ii-86-dies-found-way-to-make-anesthesia-safer.html.Audio Player

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Anesthesia Education Preparing for Grad School/Residency Wellness

#52 – SRNA Wellness in COVID-19 with Adrienne Chavez & Kelly Gallant

This podcast was originally posted on April 13, 2020, in the early stages of the COVID-19 pandemic. At the time of this podcast both Kelly Gallant and Adrienne Chavez were SRNAs completing their anesthesia training. They have both completed their training and passed boards as CRNAs. This show continues to have value for SRNAs & anesthesia residents as the themes we discuss around wellness & resiliency remain as relevant as ever.

At the time of this recording, Kelly and Adrienne were the immediate past and current SRNA Representatives to the American Association of Nurse Anesthestists’s Health and Wellness Committee, with Kelly serving in 2019 and Adrienne in 2020. I caught up with them to discuss how SRNAs were facing the challenges and concerns of the COVID-19 pandemic as well as resources that Kelly and Adrienne created, along with the rest of the Health & Wellness Committee, that are available on aana.com.

Kelly Gallant, PhD, SRNA is wrapping up her training this spring 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 and will graduate from Northeastern’s Nurse Anesthesia program with her Master of Science in May 2020. Kelly was the fiscal year 2019 SRNA Representative to the AANA Health & Wellness Committee.

Adrienne Chavez, BSN, SRNA is currently training at the University of Maryland. Adrienne received two Bachelor’s of Science degrees from the University of Maryland, one in psychology and the other in nursing. She is currently enrolled in the University of Maryland’s Doctor of Nursing Practice program with an anticipated graduation date of May 2021. Most recently she worked at the National Institutes of Health as a critical care Registered Nurse. She is the fiscal year 2020 SRNA Representative to the AANA Health & Wellness Committee.

Resources from the AANA Health & Wellness Committee:

aana.com/covid19 – AANA developed this great resource which has answers to questions SRNAs and CRNAs are asking. The website is constantly updated to include the latest news & information relevant to the current pandemic with topics including clinical practice, critical care management, COVID-19 employment issues, the SRNA experience and more.

AANA COVID19 Well-being. This site includes CRNA-produced content on wellness related to the current pandemic, including other  podcasts and Aly McLean, CRNA’s “Mindfulness while wearing an N95 mask” video, which is also linked here.

aana.com/thrive
The THRIVE initiative provides resources for the general public and AANA members in regards to career transitions related to the CRNA role. RNs looking to become nurse anesthesia students, new graduate CRNAs looking for their first job, transitioning in mid- to late-career, and retirement are all covered with a multitude of resources. 

AANA COVID19 Infographic:  https://www.aana.com/docs/default-source/marketing-aana-com-web-documents-(all)/2020_ppr02_flyer_corona_wellbeing_v6.pdf?sfvrsn=e6e394ca_4

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Preparing for Grad School/Residency Wellness

#51 – Provider Wellness with Christine Hein, MD

This is one of my favorite podcasts that I’v recorded. If you’ve had the privilege of working with or getting to know Dr Christine Hein, MD, – or once you listen to this podcast – you’ll know why!

Christine Hein, MD is an emergency medicine physician and the Chief Wellness Officer at Maine Medical Center, Maine’s only level 1 trauma center and academic teaching hospital.

We recorded this episode in August of 2017 when Dr Hein was developing the Provider Well-being and Peer Support program at MMC. Since that time, the well-being program has grown substantially with continued support from the medical center and numerous volunteers. Maine Medical Center made a substantial statement of supporting provider wellness by establishing the Chief Wellness Officer position and Dr Hein was selected to serve as the first Chief Wellness Officer.

She’s in the trenches as an emergency medicine physician and actively engaged in resident education. She’s an absolute master at all things related to provider wellness, a wife and mother of 5 kids and an elite distance runner. She has somehow found a way in her professional life to maintain a since of joy & optimism that is truly authentic and infectious. It’s like she walks around just spilling joy everywhere; she’s like an overflowing glass of water just sloshing a refreshing positive vibe wherever she goes, leaving the rest of us better off for having interacted with her. Yet that vibe is not some shallow surface level corporate smile campaign. With Christine, it’s actually rooted deep in a career as an emergency medicine provider and as a proficient healthcare leader & administrator. She’s someone who’s been in the arena, with her face mared by dust & sweat & blood*, to borrow from Theodore Roosevelt’s speech. And it’s from her personal story as an emergency medicine physician and from some dark places in her personal life – which she talks about in this episode – that she’s developed this deep desire to improve the lives of other healthcare providers around her through her work on provider wellness.

So all that comes through in this episode. That’s who were talking to today. You’re going to love it. And not only that, but we also had the immense pleasure of being joined for this discussion by Dr Hein’s daughter, Ms Abby Irish. This is the first time that a guest has brought one of their children along to a podcast recording and that, again, speaks to how important this topic is to Dr Hein and one of the reasons why I love this episode. At the time of this recording Abby was an 8th grader who was interested in becoming a physician. She had just finished surgery summer camp in Boston and talks about her experience at the start of the show.

We run the gamut of provider wellness in this conversation. We discuss burnout, wellness, resiliency, organizational drivers of burnout and ways hospitals, med schools & anesthesia programs can build structural components to eliminate burnout and foster well-being. We talk about peer support & how that’s different than professional counseling. We touch on substance abuse, suicide and the stigma of mental health concerns and getting help & support. We share personal stories from our careers and those of others that bring these concepts to life and give them real traction. As healthcare providers, we spend an incredible amount of time, energy and money becoming highly qualified in our fields yet rarely create space for deliberately developing a sense of well-being in our professional and personal lives. We should remember that as health is more than the absence of disease, joy in work is more than the absence of burnout. We owe it to ourselves, our colleagues and our patients to be whole people, grounded in a deep sense of well-being. This show explains why doing that matters and gives actionable steps we can take to minimize burnout and foster joy in our work.

One more thing before I introduce you to Dr Hein and Abby: we discuss a shocking statistic that 300-400 physicians commit suicide each year in the United States. That’s 1 to 2 medical school classes of physicians each year. It’s remarkable. I had a classmate in anesthesia school who took her own life and last year a SRNA reached out to talk after her roommate and classmate took her life just months before the end of their program. Research shows that upwards of 21% of SRNAs experience suicidal ideation during their training. If that’s you, or someone you know, I want you to know that you’re not alone and there’s a wealth of resources created by people who understand what you’re going through and who care deeply about your wellbeing and safety. I’ve got links in the show notes to people you can call or even text. The Crisis Text Line is 741741. You can text any message to the number 741741 and a trained volunteer will respond to you anytime of day or night. It’s a free service. That number is 741-741. Put it in your phone. Post it in your break rooms & locker rooms. And don’t hesitate to text the number. Help is available – just a text message away.

And with that, let’s get to the show…

Quotes:

“As health is more than the absence of disease, joy in work is more than the absence of burnout.” – Jon Lowrance

“300-400 physicians each year in the United States commit suicide… essentially two medical school classes of physicians each year.”  Christine Hein, MD

“I think that it has professionally been probably the most satisfying experience of my career – to be involved in [Provider Wellness].”  Christine Hein, MD

“[Resilience is] the capability of a strained body to recover its size and shape after deformation caused especially by compressive forces.”  Christine Hein, MD

Dr Hein completed Dr Hein completed medical school at Dartmouth in 2001 followed by her residency in emergency medicine at Maine Medical Center where she was Chief Resident in her final year. At the time of this recording, she served as the Associate Medical Director for the Department of Emergency Medicine and the Director of Provider Well-being and Peer Support at Maine Medical Center as well as the Director of Emergency Medicine for MaineHealth.  She is an Associate Professor of Emergency Medicine at Tufts University School of Medicine and is well-respected as a medical educator, receiving in 2009 the American College of Emergency Physicians National Teacher of the Year award.  Her research interests include burnout, resiliency, critical care and women’s issues in medicine.  Outside of work, Dr Hein is married, has five children and is an avid marathoner, completing over 23 marathons including posting highly competitive times in the Boston Marathon.

*”It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.” – Theodore Roosevelt

Resources:

AANA Health & Wellness and Peer Assistance Website

Attending:  medicine, mindfulness and humanity Ronald Epstein, MD

TEDTalk:  Everything you think you know about addiction is wrong by Johann Hari

Epstein, R. M., & Krasner, M. S. (2013). Physician resilience: what it means, why it matters, and how to promote it. Academic Medicine, 88(3), 301-303.Raj, K. S. (2016). Well-being in residency: a systematic review. Journal of graduate medical education, 8(5), 674-684.

Swensen, S. J., & Shanafelt, T. (2017). An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice. The Joint Commission Journal on Quality and Patient Safety, 43(6), 308-313.

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Anesthesia Education Business/Finances Preparing for Grad School/Residency Wellness

#50 – Parenting during Anesthesia Training with Lien & Nate Woodin

I’m joined today by Nate & Lien Woodin who are married and the parents of two boys – aged 6 & 9 as this show comes out on the first of October 2021.

If you’re a critical care nurse, medical student, resident or SRNA – or a spouse or partner to one of these folks – and you’re wondering how to hold it together as a parent & partner during anesthesia training or even if it’s possible for you to go back to anesthesia school – this podcast is for you! 

We don’t hit a list of bullet points on this one.  There’s no simple how-to here.  Instead, we walk through Lien & Nate’s story and in it you’ll find some incredible insights of how they prepared for anesthesia school, parented during anesthesia school and stuck together as a couple all the way through.  

Lien just wrapped up her Master’s of Nursing in Anesthesia at the University of New England a couple of weeks ago and decided to go back to school after working as a nurse for 20 years – 17 of which were as a critical care nurse in a cardiothoracic intensive care unit.  Nate is a Licensed Marriage and Family Therapist who focuses his practice on child & adolescent therapy.  He completed his Bachelor of Arts in Psychology at the University of New Hampshire in 2000 and his Master’s of Arts in Marital & Family Therapy from the University of San Diego in 2007.  He completed a post-master’s Certificate of Studies in Play Therapy in 2009 from the University of California, San Diego.  

Lien worked as a critical care Registered Nurse at Maine Medical Center and came back to train for a couple of months with the anesthesia team at Maine Med, where I work as the SRNA Clinical Coordinator.  We got to spend a few days in the OR together and that’s where I first heard snippets of her story.  When she talked about how hard it was to make the decision to go back to school after working as an ICU nurse for 20 years, how her & Nate have a son with PANDAS which encompasses a set of neuropsychiatric disorders and how Nate is a child & family therapist who Lien always bragged about as being such a huge support to her as a SRNA and their boys, I knew I wanted to get them on the podcast and hear more about their story.  And it’s a remarkable story.  I think you’ll really enjoy hearing it.  

A couple other things before we get to the show… 

Lien was in the same class as Robert Montague.  You may remember Robert and his wife Jenny from episode 15 titled “Significant Others and Anesthesia School.”  That episode came out in December of 2020.  Robert also just successfully passed boards and became a CRNA along with Lien.  He and Jenny are doing well and are also enjoying life after anesthesia school.  I think both this and that podcast would be key shows to listen to if you’re considering going back to anesthesia school as parents – or if you’re in an anesthesia program or residency now and need a little encouragement to keep going and find ways to make it work.  They’re great shows for you and your partners.

There’s never really a good time to go to anesthesia school and having a significant other and kids can make the process very challenging.  And while both of these families have found ways to thrive during their programs, others are frankly not.  For, I think the first time ever on the podcast, in this episode, I talk a little about my own path in anesthesia school which involved going through a divorce in the fist six months as well as meeting my wife in the program who I now share a life with along with our 3-month old son and how helpful marriage therapy has been for both of us.

I know other SRNAs who are either in or have gone through extremely challenging family situations including the loss of a child, or a partner, severe illnesses, trauma & surgery, ugly divorces, restraining orders, physical & emotional abuse and more.  For those of you out there who are struggling I want you to know that you’re not alone and that help is available.  The AANA has a wealth of resources available that I’ll link to in the show notes.  There’s also a free 24-hour Crisis Text Line if you need support right now… you can text anything to the number 741741 and a trained counselor will reach out with support over text.   You can also find support at your university or hospital through wellness committees and student or employee health services… there are usually always free, confidential counseling & therapy resources available.  Don’t struggle alone.  Reach out to one of these resources.  Get help.  It’s a very human thing to do.  

And hopefully you’ll find a little hope & encouragement through Lien & Nate’s story…

Resources:

AANA SRNA Wellness

Crisis Text Line text “hello” or “help” or whatever to 741741 and a trained counselor will respond. It’s free and it’s over text.

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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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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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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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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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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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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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Anesthesia Education Business/Finances Personal Finances Wellness

#39 – The 5 Keys to Achieving Financial Independence with Shane Garner, MS, CRNA, NSPM-C

In this episode you’re going to hear from Shane Garner, MS, CRNA, NSPM-C on the 5 Keys for Achieving Financial Independence.  This show was originally released in April of 2020 on From the Head of the Bed and I’m pulling it forward to Anesthesia Guidebook on August 30, 2021.  

I’m pumped Shane brought this intel to the podcast… anesthesia providers are high income earners but it’s rare to see any formal training on financial literacy as part of core medical & nursing education or during anesthesia training programs.  CRNAs & physician anesthesiologists get out and make great money but often fail to apply basic financial principals like living below your means, becoming debt free and saving & investing for the future.  It sounds like boring stuff but these are some of the keys that will create freedom and peace of mind for your future.  If you apply a fraction of what you’ll hear in the next 30 minutes, you’ll set yourself on a trajectory you can truly be stoked about and you’ll thank yourself down the road.  You owe it to your future self to check this episode out and apply what you hear.

The 5 Keys to Financial Independence are 1. Set goals to live below your means. 2. Pay yourself first. 3. Avoid debt. 4. Invest in low cost index funds. 5. Educate yourself.

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.  

Shane Garner, MS, CRNA, NSPM-C

Resources

The White Coat Investor

The Bogleheads‘ Guide to Investing (book)

The Simple Path to Wealth (book)

The Millionaire Next Door (book)

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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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Anesthesia Education Business/Finances Preparing for Grad School/Residency

#36 – DNP: The Future of CRNA Education with Shawn Collins, DNP, PhD, CRNA

This episode originally appeared on the podcast From the Head of the Bed on August 6, 2015. It’s re-released here on August 17, 2021. Dr Shawn Collins, DNP, PhD, CRNA and I discuss the transition from Master’s level training for CRNAs to practice doctorates, most commonly the Doctor of Nursing Practice degree or DNP.  

Every CRNA program must transition to the doctorate level for new classes by January 1, 2022, with every SRNA graduating from doctorate level training by 2025.  Most of the 124 CRNA programs in the US have already transitioned to doctorate degrees, with some having done so more than a decade ago.  Dr Collins and I discuss why CRNA training transitioned from the master’s level to the doctoral level and what this means for education, clinical practice and business.  

Beginning the fall of 2019, the Council on Accreditation of Nurse Anesthesia Educational Programs, which sets the standards for university programs, began revising those standards based upon recommendations from a “Full Scope of Practice Competency Task Force.”  The COA updated several standards and requirements of CRNA doctorate programs including increasing the number of required anesthesia cases, mandating specific training in the use of point of care ultrasound for diagnosis and therapeutic interventions, 12-lead ECG interpretation, radiology & flouroscopy use, chest X-ray interpretation and more.  You can read about these changes and the specific requirements for CRNA doctoral programs at the COA’s website.

At the time of the interview, Dr Shawn Collins was the nurse anesthesia program director at Western Carolina University and the interim dean of the College of Health & Human Sciences.  

He was the program director when I attended WCU and was a huge source of encouragement and support to me personally as I ran the gauntlet of anesthesia training.  He was also 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. 

Dr Collins has obtained both his doctor of nursing practice degree and his PhD and compares these degrees, along with other types of doctoral programs, in this podcast.

He was instrumental in developing the DNP program at WCU, transitioning the master’s-level nurse anesthesia program to a practice doctorate.  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. 

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Anesthesia Education Business/Finances

#35 – Asynchronous learning and the future of anesthesia education

This podcast follows up on the previous show which discussed free open access medical education (FOAM) and the use of social media in anesthesia education. Here, I discuss the power of asynchronous learning to shape the future of anesthesia education.

The power of asynchronous learning comes from the ability of content experts to produce something truly informative and engaging once and then make that widely available to learners over a prolonged span of time. 

The opportunity, the chance, the potential of asynchronous learning is to harness the best educators and minds to create engaging content to help raise the level of expertise of providers while reducing the upfront workload and cost of producing that content.  

Asynchronous learning challenges traditional paradigms of education. It brings up numerous questions for us to consider…

Why does every university need to have an expert in pharmacology on campus to deliver semester-long courses on anesthesia pharmacology year after year? 

Why do universities struggle to find and retain content experts when they could harness the power of asynchronous education to share a library of the best resources for cheaper tuition?

Why do universities, who charge astronomical tuition fees, then require their students to purchase third-party board preparation programs?  Shouldn’t the tens of thousands or even hundreds of thousands of dollars in tuition be enough to get students successfully over the hurdle of boards?

Why are continuing education conferences so boring and expensive? 

Why do continuing education conferences rarely improve clinical skills or change practice? 

Why are thousands of grand rounds presentations given every year across the US and only a very select few individuals who happen to show up hear what leading experts are saying?

Why does it take on average 17 years for new evidence to find its way into widespread practice?

Why do we too often put profits ahead of advancing our field and improving access to patient care?

We have the opportunity to redesign the way we do education in the future.  Harnessing technology to maximize the benefit of asynchronous learning can reduce costs and likely make education more efficient and effective.

Some of you are today’s thought leaders and content creators.  Some of you will be the content creators, professors, educators and clinical experts of the future.  How will you step into those roles?  How will you harness the technology available to us to create more compelling, more interesting and effective learning tools?

These are the questions that will help us redefine what is possible in the way we train anesthesia providers and build better continuing education.

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Anesthesia Education Business/Finances Preparing for Grad School/Residency

#34 – FOAM and social media in anesthesia education

Free open access medical education – or FOAM – is any medical educational content that’s shared freely on open access platforms, meaning the public can consume it without having to be a member of an organization or pay a subscription fee.  The reason it’s significant is that it brings evolving science & literature – and discussions around the art & science of medicine – into the hands of providers without the traditional paywalls that trade associations or peer-reviewed journals put up between you & their content in order to fund their work.  FOAM is all about the accessibility of information and given the rapid pace at which medical information evolves and podcasts, blogs & online journals can be updated, FOAM helps shape conversations around what’s happening right now in healthcare.  

It’s been said if you want to know the state of the literature 5-7 years ago, read the latest edition of any textbook.  If you want to know what was going on 2-3 years ago, read the print journal that just came to your mailbox.  And if you want to know what’s happening and changing right now, get on social media. 

In this episode, I discuss the history of FOAM and talk through the influence of social media in anesthesia education. We take a look at the incentives that shape the behavior of content producers in the social media world and look at ways of harnessing FOAM and social media platforms to leverage these tools for the greatest impact.

Resources:

Andrejco, K. (2017). Social Media in Nurse Anesthesia: A Model of a Reproducible Educational Podcast. AANA journal, 85(1).  Retrieved from https://www.aana.com/docs/default-source/aana-journal-web-documents-1/social-media-0217-pp10-16.pdf?sfvrsn=89cd48b1_6 

Chan, T. M., Stehman, C., Gottlieb, M., & Thoma, B. (2020). A short history of free open access medical education. the past, present, and future. ATS scholar, 1(2), 87-100. https://www.atsjournals.org/doi/pdf/10.34197/ats-scholar.2020-0014PS 

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Anesthesia Education Leadership in Emergencies Preparing for Grad School/Residency

#33 – Flow and the Can-O-Calm

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.

Mihaly Csikszentmihalyi’s Flow Concept.
Mihaly Csikszentmihalyi’s expanded Flow Concept

“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.

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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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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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Anesthesia Education Business/Finances Personal Finances Preparing for Grad School/Residency Wellness

#30 – The mid-to-late career phase with Cindy Farina, DNP, CRNA

In this episode Dr Cynthia Farina and I talk about the mid-to-late phase of your career as a CRNA.  Every stage of your career has unique challenges & opportunities. There’s so much attention focused on getting into CRNA school, the SRNA/resident/training phase and becoming a new CRNA… this conversation is for the part of your career farther down the road.

Dr Farina is a CRNA from Michigan whom, at the time of this recording (December 2019), served as the chair of the American Association of Nurse Anesthetists’ (AANA) Health and Wellness Committee and the Michigan Association of Nurse Anesthetists Wellness Committee.

Dr Farina completed her Bachelor of Science in Nursing at the University of Michigan, Ann Arbor and then her Master of Science in Nursing in the anesthesia track from Oakland University in 1996.  She then returned to the University of Michigan to complete her Doctor of Nursing Practice degree.

Cindy practiced full-time at a large suburban teaching hospital, where she also served as a clinical and didactic instructor in the Oakland University-Beaumont Graduate Program of Nurse Anesthesia. 

Cindy has a strong interest in creating and sharing educational material on personal and workplace wellness for CRNAs and SRNAs. In her most recent work, she has explored the topic of career phases and transitions for nurse anesthetists.

You may contact Cynthia Farina, DNP, CRNA, CNE at: cindy.farina@icloud.com or via her LinkedIn profile at www.linkedin.com/in/cynthiafarina

AANA Thrive: Resources for Career Stages

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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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Anesthesia Education Preparing for Grad School/Residency Wellness

#24 – Social media leverage & landmines with Jason Bolt, DNP, CRNA

Jason Bolt, DNP, CRNA is a social media influencer in the anesthesia community and can be found @bolt_crna.

Dr. Jason Bolt, DNP, CRNA is a YouTuber and social media influencer in the anesthesia community. He graduated from Union University with his doctorate in anesthesia in 2019 and now practices in a collaborative group in the Bay Area. He offers mentorship through his YouTube channel memberships and enjoys helping others reach their goals in nursing and in anesthesia. He volunteers as a member of the AANA Communications Committee and is active in advocating for CRNAs on a legislative level. He is better known online as Bolt CRNA and you can find him @bolt_CRNA on YouTube, Instagram, Tiktok and Facebook. 

We talk about the pitfalls and leverage points of social media for anesthesia learners and other healthcare learners including nursing & medical students.

10 tips for surviving anesthesia training and your social media life:

  1. Make your posts anonymous relative to your school & clinical sites. (Avoid posting your school or clinical site names… like HIPAA, but for your school & clinical sites.)
  2. Avoid posting protected patient health information. This is obvious… and all about HIPAA.
  3. Keep your posts POSITIVE about healthcare. Rep your career path and the path of others in healthcare in the best light possible. Your posts reflect you as a provider and the profession in general.
  4. Avoid posting anything that may offend someone else. This is a tough one… especially when folks like Joe Rogan score multi-million dollar contracts to speak their mind. But you’re not Joe Rogan. (#yourenotjoerogan) You’re a student/learner… the more you piss people off by your posts & opinions, the harder (not easier) your path may be.
  5. Post & surf on your own time. Social media & any electronic communication is time stamped and discoverable. Practice vigilance at work and your profile pic at home.
  6. Avoid the usual pitfalls of social media… politics, religion, racism, sexism, demeaning posts/tags/likes/shares, etc.
  7. For content producers: be authentic, be honest, be truthful and cite peer-reviewed, professional sources in your posts if you’re talking about medical information. Be legit. What you & others post is not “peer reviewed” or edited by experts, so be extremely careful if you’re producing medical education for the world.
  8. Understand that your preceptors, faculty, professors, attendings, employers, program directors and legal teams at institutions (if necessary) will check you out on social media… post only what you want your employer and your mother to see.
  9. Rep your style. Do you. Tell people who you are & the path you’re on… real life stories gain traction more than fabricated realities. Have fun, find the others, connect with people, network and believe in the open, beautiful, hopeful world that social media is great at promoting.
  10. Be well. Shun the unbelievers, haters, trolls & hateful people. Block ’em. Don’t even engage. Watch the Social Dilemma. And then limit your time on social media with alerts on your phone. Go live your real life and be well.
Jason Bolt, DNP, CRNA making it look easy. Follow him @bolt_CRNA. #boltCRNA

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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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Categories
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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Categories
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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Categories
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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Anesthesia Education Personal Finances Preparing for Grad School/Residency Wellness

#15 – Significant Others and Anesthesia School with Jen & Rob Montague

Jennifer & Robert Montague moved across the country from Montana to Maine with their young children for Rob to attend anesthesia school.

Today I’m joined by Jennifer & Robert Montague to talk about the experience of significant others in anesthesia school. Rob is currently a second-year SRNA at the University of New England and Jen, his wife, is a Master’s-prepared Registered Dietitian who has taken on the lioness’ share of providing child care and homeschooling responsibilities for their two children while Rob attends anesthesia school. Jen and Rob moved across the country from Montana to Maine for Rob to pursue a mid-life career change from working as an international mountaineering guide to becoming a CRNA.

This podcast is like something from Death, Sex & Money or Joe Rogan – it’s narrative, it’s a story and unfolds over the hour & half we talk.

You’ll love hearing Rob & Jen’s humor and love for one another and their kids… how resilient their children are and how they’ve made the move work financially & emotionally as individuals and a couple.

If you’re getting ready for anesthesia school, wondering if you can do it with your family and children and how it all works, we talk through all of that. Who better to learn from than a couple, with kids, who are going through not only anesthesia school but doing it all in the middle of a worldwide pandemic?

I’ve been looking forward to doing a show on this topic for a long time and I’m so grateful to bring you Jen & Rob’s story! So settle in to the conversation, break it up over a couple of commutes or an evening on the couch with your significant other and enjoy the story.

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Anesthesia Education Preparing for Grad School/Residency

#14 – Board Preparation with LTC Peter Strube, DNP, CRNA

Lieutenant Colonel Peter D. Strube is a CRNA who graduated from St. Mary’s University school of anesthesia in 2006 with a master’s degree. His undergraduate degree is from Luther College in Decorah, Iowa. He was awarded the Doctor of Nurse Anesthesia (DNAP) in June of 2017 and is currently enrolled in his MBA. Lieutenant Colonel Strube is soon to be retired from the United States Army Nurse Corps.  Dr Strube has mobilized and deployed four times during current military operations which includes service in both Iraq and Afghanistan. 

Dr Strube is the Assistant Program Director at the University of Wisconsin-Oshkosh CRNA Program.  He owns and operates Trollway Anesthesia that covers several critical access hospitals.  Dr Strube has authored several professional articles and training programs, speaks professionally both nationally and internationally, and tutors at risk students on their anesthesia boards.  He has been elected to serve on the Wisconsin state association board and is currently the AANA Region 3 Director.  He has served his community as a member of the Mount Horeb Board of Education and is a Commissioner on the Dane County Ethics Board and is a court appointed mentor for veterans in crisis.  

You connect with LTC Peter Strube, DNP, CRNA, APNP through Prodigy Anesthesia’s website at the following link.

Matt Zinder, MS, CRNA, CH may be reached through his anesthesia business, Zinder Anesthesia, LLC and his Going Viral podcast here.

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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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Anesthesia Education Personal Finances Preparing for Grad School/Residency Wellness

#12 – Ten Things Every Anesthesia Provider Should Know

The following ten ideas have the power to change your attitude towards and even the trajectory of your professional career and life.  There’s three core domains to developing as an anesthesia provider:  your knowledge base, skill set and attitude.  Each are unique and require different kinds of effort or deliberate practice to grow & improve.  This guide is predominately about tweaking & improving the attitude you approach your career with.  If you’re gonna show up in your life, why not show up with a level of stoke that pulls you through the doldrums & pushes you towards where you want to be?  These ten ideas may help you do just that.

1.  What you do matters because you hold the lives of your patients in your hands.

2.  You’re only as good as the decisions you make today (sort of).

3.  You provide a service and you are replaceable. 

4.  You have an incredible capacity to develop your skills, knowledge, attitude and even intelligence.  

5.  We work in systems that are designed by people, and people work in relationships.  

6.  No one cares about your money, career, scope of practice, time off, goals, wellbeing and success more than you do.

7.  Embracing delayed gratification and understanding the power of compounding interest are critical to creating a brighter financial future for yourself.

8.  You have more power, influence and capacity than you think, and so does everyone else.  

9.  Location – Compensation – Autonomy.  You can pick 2.  

10.  Joy is more valuable than your income or job.

Ten-Things-Every-Anesthesia-Provider-Should-KnowDownload

Resources

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.

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/.

Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.  Retrieved from https://www.hmhbooks.com/shop/books/Peak/9780544947221.

Jebb, A. T., Tay, L., Diener, E., & Oishi, S. (2018). Happiness, income satiation and turning points around the world. Nature Human Behaviour, 2(1), 33-38.

Oliver, M. (2020). Devotions: The Selected Poems of Mary Oliver. Penguin Books.

The Notorious B.I.G. (1997). Mo money mo problems [Song]. On Life after death. Bad Boy Records; Arista.

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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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Anesthesia Education

#9 – How to Earn Class B Credits with Podcasts

The NBCRNA CPC Program allows for CRNAs to earn Class B Credits by listening to podcasts; this episode tells you how.

The National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA) recognizes anesthesia-related podcasts, like Anesthesia Guidebook, as valid sources of Class B credit in their Continued Professional Certification (CPC) Program that all CRNAs participate in. Class B credits are designed to encourage professional development and CRNAs must obtain 40 hours of Class B credit every 4-year cycle of the CPC Program. If you follow Anesthesia Guidebook, you’ll easily get 10 hours of content each year and all you have to do is claim your credit – FOR FREE – with NBCRNA! The podcast tells you how and the PDFs below show you how. Earning Class B credit has never been easier!

How to Report Class B Credits from Podcasts.PDF

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NBCRNA Class B Reporting FORM
Download

NBCRNA Class B Credits Website:

https://www.nbcrna.com/continued-certification/class-b-credits

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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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Anesthesia Education Personal Finances Preparing for Grad School/Residency

#6 – Van life in anesthesia school with Marcus House

Marcus House, BSN, SRNA rocking his 1995 E350 Ford ambulance as his home on wheels while pursuing his doctorate in nurse anesthesia practice.

Today I talk with Marcus House, BSN, SRNA about his decision to live in an ambulance during remote clinical rotations in anesthesia school. Marcus is currently working towards completing his Doctor of Nurse Anesthesia Practice at Missouri State University. He holds Bachelor of Science degrees in Education and Nursing, both from Southeast Missouri State University. Marcus worked for 7 years as a high school science teacher alongside his wife, Casey, also a high school teacher, before returning to nursing school. He spent 3 years working in a CVICU prior to pursuing his doctorate degree in anesthesia. He would like you to know that he “knows when to hold ’em, AND when to fold ’em, [he] once owned a Nintendo Power Glove and [he’s] comfortable being either ‘big spoon’ or ‘little spoon’.”

In all seriousness, choosing to go mobile for your housing arrangements during graduate school or residency, depending on your clinical rotations, may make a lot of sense. As Marcus points out in the podcast, he’s saving money compared to the cost of rent while enjoying a personalized home on wheels that will be his to keep after anesthesia school. With many graduate anesthesia programs sending their SRNAs wide and far for clinical rotations, it can be extremely challenging to find affordable housing on the fly in grad school while still maintaining rent or a mortgage at a home base.

You don’t have to look far on the internet webs to find a virtual plethora of blog sites, Instagram & Pinterest feeds and YouTube channels dedicated to #vanlife for ideas & guides on build outs.

I put a few photos of Marcus’ ambulance, Bernice, below and you’ll find several more at Anesthesia Guidebook’s Instagram page. I’ll also include some photos on Instagram from a Sprinter van build that my wife and I completed after we finished anesthesia school. While we were able to get through our program in traditional housing, we’ve thoroughly enjoyed having a van for weekend to multi-week road trip adventures after grad school.

Don’t hesitate to reach out to Marcus via Facebook or email (Marcus.House1@gmail.com) (that’s Marcus-dot-house, the number one, at gmail.com) or drop a question/comment below, on Instagram or directly to me via email (jon@anesthesiaguidebook.com) if you want to talk about van life in anesthesia school in more detail.

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Anesthesia Education Preparing for Grad School/Residency

#5 – The CRNA Chase with Kiki Mattress, MSNA, CRNA

Kiki Mattress, MSNA, CRNA runs the blog The CRNA Chase.

Kiki Mattress, MSNA, CRNA runs the blog The CRNA Chase which seeks to “empower, inspire, and educate” people who are interested in becoming CRNAs.

In this episode, I talk with Kiki about her journey to become a CRNA and her passion for helping others understand and be successful on that same path.

“Don’t just talk about it, be about it!” Kiki Mattress, MSNA, CRNA on what it takes to become a CRNA.

Kiki’s professional career started after an Associate’s Degree in Engineering from Tri-County Technical College.  After working in engineering and deciding it wasn’t the path she wanted to continue on, Kiki returned to Tri-County for a diploma as a surgical technologist.  While she was working in the OR as a surgical tech she first met a CRNA who became a mentor to her and encouraged her to return to nursing and then anesthesia school.  Kiki took up that path with another Associate’s Degree in Nursing from Tri-County followed by her Bachelor of Science in Nursing from the University of South Carolina Upstate and then her Master of Science in Nurse Anesthesia from the University of New England.  Upon graduating from UNE, Kiki moved back to South Carolina where she works as an independently contracting CRNA. 

You don’t want to miss this episode and if you’re already a SRNA or CRNA, forward this show on to the people you know who are thinking about becoming CRNAs!

Resources:

The CRNA Chase Blog

Follow The CRNA Chase on Twitter

Connect with Kiki Mattress on LinkedIn

Itzkoff, D. (2020, September 16). Chris Rock Tried to Warn Us. The New York Times. Retrieved from https://www.nytimes.com

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Anesthesia Education Wellness

#4 – Front Line Heroes with M.J. Hiblen

Front Line Heroes by M.J. Hiblen

MJ Hiblen is an illustrator from Norwich, United Kingdom who’s first book of art titled, Front Line Heroes is available now from Eyewear Publishing. 

This book is incredibly powerful.  I’ve followed MJ’s work on Instagram since the early days of the COVID19 pandemic when he began drawing images depicting the coronavirus as a classic comic-book style menacing villain with healthcare workers squaring off as the front line heroes the world has come to know them as.  When I saw that this collection of art was coming together in a limited edition hardcover, I immediately put my order in.  The book went to print in August 2020 and over the last few weeks I’ve shared it with colleagues in my anesthesia department.  Their first glance at the artwork – during busy shifts at our level 1 trauma center – was often much like mine:  at first intrigued and then within pages, fighting back tears as we realize the beauty and power of what M.J. Hiblen has captured in his images.  His work is evocative & heart wrenching, at once it powerfully represents the human toll and suffering this virus has brought around the world while also casting healthcare workers as the defiant, battle-worn and ultimately triumphant care providers they are.

You owe it to yourself, after the year we’ve all experienced, to look M.J. Hiblen up on Instagram and get a copy of this book for yourself.  You can find it on Amazon or directly from the publisher at Eyewear Publishing.  Links to the book are in the show notes and if you hurry, you might still be able to get one only 1000 first edition hardcovers, signed by M.J. Hiblen.

Click here: M.J. Hiblen on Instagram

Order your copy of Front Line Heroes, art by M.J. Hiblen here.

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Pharmacology

#3 – Succinylcholine – Michael Mielniczek, BSN, SRNA

This episode on succinylcholine will unravel the mysteries and controversies around the medication – from it’s molecular shape and how that influences which receptors subtypes and locations it exerts its effects on to practical information on dosing and how to optimize airway management while mitigating the side effects of succinylcholine. 

At the time of this recording in March of 2018, Michael was a second-year Student Registered Nurse Anesthetist at the University of Scranton and a student representative for the AANA Foundation.  He has since passed his boards as a CRNA and began his anesthesia practice in the greater Boston area. His background includes experience as a cardiac critical care Registered Nurse in Austin, Texas.   As part of his graduate studies, Michael completed an in-depth project regarding the history, latest research and controversies surrounding succinylcholine. Michael has presented on succinylcholine at state association conferences and went on to give a podium presentation at the 2018 AANA Annual Congress in Boston titled “Succinylcholine:  From Discovery to Current Evidence for Everyday Practice.” 

Resources:

Alvarellos, M. L., McDonagh, E. M., Patel, S., McLeod, H. L., Altman, R. B., & Klein, T. E. (2015). PharmGKB summary: succinylcholine pathway, pharmacokinetics/pharmacodynamics. Pharmacogenetics and genomics, 25(12), 622.

Barash, P. G. (Ed.). (2009). Clinical anesthesia. Lippincott Williams & Wilkins.

Fukano, N., Suzuki, T., Ishikawa, K., Mizutani, H., Saeki, S., & Ogawa, S. (2011). A randomized trial to identify optimal precurarizing dose of rocuronium to avoid precurarization-induced neuromuscular block. Journal of anesthesia, 25(2), 200-204.

Lee, C. (2003). Conformation, action, and mechanism of action of neuromuscular blocking muscle relaxants. Pharmacology & therapeutics, 98(2), 143-169.

Nagelhout, J. J., & Plaus, K. L. (2014). Nurse anesthesia. Elsevier Health Sciences.

Miller, R. D. (2015). Miller’s anesthesia (8th ed.). Philadelphia, PA: Churchill Livingstone/Elsevier.

Schreiber, J. U., Lysakowski, C., Fuchs-Buder, T., & Tramer, M. R. (2005). Prevention of Succinylcholine-induced Fasciculation and MyalgiaA Meta-analysis of Randomized Trials. Anesthesiology: The Journal of the American Society of Anesthesiologists, 103(4), 877-884.

Tran, D. T., Newton, E. K., Mount, V. A., Lee, J. S., Wells, G. A., & Perry, J. J. (2015). Rocuronium versus succinylcholine for rapid sequence induction intubation. The Cochrane Library.

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Opioid Free Anesthesia Pharmacology

#2 – Dexmedetomidine – Matt Poirier, MSNA, CRNA

Matt Poirier, MSNA, CRNA joins Anesthesia Guidebook to give a run down on dexmedetomidine. We cover the pharmacology & dosing right off the bat in this episode and then we take some time to discuss the art of using dexmedetomidine peri-operatively.

Matt Poirier is a Certified Registered Nurse Anesthetist at Maine Medical Center, a level 1 trauma center in Portland, Maine.  He obtained his Bachelor of Science in nursing from the University of Southern Maine and his Master of Science in nurse anesthesia from the University of New England.  Prior to Matt’s nursing career, he attended Assumption College in Worcester Massachusetts and obtained a Bachelor of Arts in biology and chemistry and subsequently worked as both an analytic and synthetic chemist.

References

Kaur, M., & Singh, P. M. (2011). Current role of dexmedetomidine in clinical anesthesia and intensive care. Anesthesia, essays and researches, 5(2), 128. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173414/.

Liu, Y., Liang, F., Liu, X., Shao, X., Jiang, N., & Gan, X. (2018). Dexmedetomidine reduces perioperative opioid consumption and postoperative pain intensity in neurosurgery: a meta-analysis. Journal of neurosurgical anesthesiology, 30(2), 146-155.

McEvoy, M. D., Scott, M. J., Gordon, D. B., Grant, S. A., Thacker, J. M., Wu, C. L., & … Miller, T. E. (2017). American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1–from the preoperative period to PACU. Perioperative Medicine, 61. doi:10.1186/s13741-017-0064-5

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Anesthesia Education

#1 – Anesthesia Guidebook Origin Story

the go-to guide for anesthesia providers

Welcome! You made it! This is episode 1: the origin story, the backdrop, the context to who we are, where we’re from and where we are headed. Check out the podcast in your favorite player or right here on the website to hear our story, which is all about YOUR STORY!

You’re on a path to becoming an expert anesthesia provider… we’re here to help guide you.

Everything we do is designed to help you master your craft. 

Anesthesia providers hold their patients’ lives in their hands during every case. You never know when you will face crashing hemodynamics, a lost airway or a life-threatening surgical problem… and each of these emergencies can be complicated by your patients’ pathophysiology, suboptimal systems of care that surround you and/or your individual preparedness for the moment.

Anesthesia Guidebook will help you deepen your practice so that you can come through for your patients when it counts.

If you’re just starting to explore the absolutely fascinating world of anesthesia, maybe as a critical care Registered Nurse, medical student, anesthesia resident or SRNA, we have stories, guides and resources specifically designed with you in mind.

Anesthesia Guidebook is also for those seasoned providers who are looking to level up, dig deeper, stay fresh and develop new skills. We’ll bring you the latest on evidence-based medicine and emerging trends & techniques in the anesthesia community, so you can stay sharp and give your patients and students your best.

Renowned psychologist and best selling author on human performance & expertise, Anders Ericsson, has said:

“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.” (Ericsson, 2004)

Ericsson’s words throw down the gauntlet for anesthesia providers. And the stakes couldn’t be higher. The most vulnerable times in our patients lives often begin when we say “hello.” We have an esteemed responsibility to meet the demand for clinical expertise & assure high functioning systems of care that our patients expect, deserve and entrust their lives to.

Anesthesia Guidebook will bring you compelling stories, e-books and other resources built around pathophysiology, pharmacology, airway management, human performance and team dynamics, all tailored to the high stakes environment you work in.  Your path to becoming an expert anesthesia provider – to mastering your craft – will be the focus of everything we do.

Sources:

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.

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