Anesthesia Guidebook: Recent Episodes
Jon Lowrance
My guests today are Abigail Lee and Johanna Bennett, two Doctor of Nursing Practice graduate students at the University of New England who focused their DNP project on perioperative use of IV methadone.
Abigail Lee attended Southern Maine Community College and transferred to the University of Southern Maine to study nursing. She worked at Maine Medical Center in the Cardiothoracic Intensive Care Unit. She intends to head down to North Carolina to work as a CRNA.
Johanna Bennett went to Saint Anselm College. She started her career in healthcare in the Medical/COVID ICU as a new graduate nurse and worked there for three years before starting CRNA school at the University of New England. Jo will be joining our team at Maine Medical Center to work as a CRNA.
This episode is on the longer side, so here’s your TL:DL, too-long; didn’t listen summary of perioperative IV methadone – the opioid-spairing opioid.
Standard short-acting pure mu-agonists—like fentanyl, hydromorphone, and morphine—often leave our patients trapped in a roller coaster of ‘peaks and valleys,’ leading to oversedation, unexpected pain spikes, and high total opioid consumption in the PACU.
In this episode, we explore why methadone is uniquely positioned as the ‘opioid-sparing opioid.’ Beyond its strong -receptor agonism, methadone boasts NMDA receptor antagonism and serotonin/norepinephrine reuptake inhibition, targeting pain at multiple pathways to blunt central sensitization and wind-up phenomenon.
Key Clinical Takeaways from the Literature:
- The Effective Dose: An ideal single dose on induction is 0.2 to 0.25 mg/kg ideal body weight (or roughly 10-20 mgIV). Underdosing (<0.1 mg/kg) eliminates the long-term benefit, while dosing over 0.3 mg/kg slightly increases transient PACU sedation without adding extra analgesia.
- Where it Shines: Greatest reductions in PACU pain scores and overall post-op opioid consumption occur in high-nociceptive surgeries—like multi-level spinal fusions, cardiac, thoracic, and major reconstructive procedures.
- Safety Profile: A single intraoperative dose displays a safety profile comparable to short-acting opioids—with no increased incidence of delayed respiratory depression, PONV, or QT prolongation in acute, single-dose settings.
I want to share one particular guideline that I’m familiar where the hospital developed a clinical guideline to help their team incorporate IV methadone as a perioperative analgesic.
The key points in this guideline include:
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Consider using methadone in surgeries lasting greater than an hour which are at high risk of significant postoperative pain, especially when patients are not candidates for epidurals or regional blocks.
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Avoid the use of methadone in patients who have a baseline prolonged QTc or with those patients who are on buprenorphine or in surgeries less than one hour since the peak respiratory depression is about 45 minutes after administration.
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The typical dose proposed in the guideline is 0.2 mg/kg of ideal body weight IV with consideration to reduce the dose to 1.5 mg/kg for surgeries that have a same day discharge plan. Rescue doses of 3 to 5 mg are used instead of hydromorphone after the end of the procedure if needed for post-operative analgesia.
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This center continues to use standard PACU orders for IV and PO analgesia following the use of methadone
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On the buprenorphine point: Methadone has a significantly lower binding affinity for mu-receptors than buprenorphine so in patients who are actively taking buprenorphine, single dose perioperative methadone is relatively ineffective without alternative strategies like weaning the buprenorphine or interventions tailored for patients with chronic pain or opioid use disorder – which are both beyond the scope of this podcast.
If you want to hear a little more about the challenges around pain management with patients on buprenorphine in particular, please go listen to episode 13 of Anesthesia Guidebook with Aurora Quaye, MD, one of the leading researchers in this space and a pain management specialist at Maine Medical Center in Portland. We recorded that show way back in March of 2020, so it probably is time to check back in and get the latest on all the research and amazing work her and her team have been doing in the last several years.
So, that’s a little primer on where we’re headed today. I want to thank Johanna and Abigail for their incredible walk through of methadone in this conversation, as all as for the tips they share on navigating the DNP project process.
If you’re looking to eliminate PACU pain spikes, optimize your patient’s chance for enhanced recovery, or rethink your perioperative analgesic strategy, this deep dive is for you.
And with that, let’s get to the show.
Bennett, J. & Lee, A. (2026) Intraoperative Intravenous Methadone in Adult Surgical Patients: An Integrative ReviewDownload
Adrian Moran, MD, MBA currently serves as the Chief Medical and Transformation Officer of MaineHealth, a not-for-profit, integrated health system with over 2000 providers and 23,000 care team members serving patients across Maine and New Hampshire.
Dr Moran joined me to talk about his views on transformational leadership and his professional journey from a pediatric cardiologist at Boston Children’s Hospital to executive organizational leadership roles.
I’m excited to share his story with you because we don’t talk enough about how to transition from being specialized clinicians to working in healthcare leadership.
I asked Dr Moran to join me for this interview given his unique vantage point and journey to executive leadership. MaineHealth’s flagship level 1 trauma center, Maine Medical Center, is where I serve as the Director supporting the Department of Anesthesiology and Perioperative Medicine. Over the last decade, I’ve watched Dr Moran move from his clinical role as a pediatric cardiologist to MaineHealth board member to Associate Chief Medical Officer. I then saw him leave MaineHealth to take on a system level CMO role for a large health system in Wisconsin and then back to MaineHealth as the Chief Medical and Transformation Officer.
Over the years, I’ve seen his leadership style in action and recently heard him describe how the principles of high reliability organizing and servant leadership inform his work, which are ideas we’ve talked about here on the podcast over the last year or so.
In this conversation, we talk about:
- the challenges facing healthcare organizations today and what leaders can do to be effective in supporting their teams
- what transformational leadership looks like
- the value of gaining practical experience and credibility as a healthcare leader
- when and why additional education, like an MBA, might make sense for leaders
- what motivates Dr Moran and what he sees as his core purpose
In full transparency, this interview was imbedded in a qualitative research course I’m taking as part of the PhD in Leadership & Organizational Develop at the University of Southern Maine. My goal was to explore the narrative arc of Dr Moran’s professional story and hear more about his leadership philosophy and work with MaineHealth.
I think yall are really going to enjoy this episode. Dr Moran is a remarkable leader, a pretty good story teller and incredibly generous for taking time out of his busy schedule to meet with me and share a bit of his story.
With that… let’s get to the show!
MaineHealth Announces Adrian Moran, MD, MBA as Chief Medical and Transformation Officer
This is part 3 of a 3 part series titled The Pressure is On: Enhancing Anesthesia Care for Parturients with Hypertensive Disorders of Pregnancy.
In the first episode, Joe Navarrete walked us through the baseline physiologic changes of pregnancy. In the last episode, David Barksdale covered the pathophysiology of hypertensive disorders of pregnancy. And in this episode, Isabella Sosa is here to tell us what to do about it.
Isabella, Joe & David are each SRNAs at Yale New Have Hospital’s Nurse Anesthesia program and are completing this 3-part series as their doctoral project for anesthesia school.
Isabella was a nurse in the cardiac-surgical ICU at Montefiore Medical Center in the Bronx, NY. She decided to pursue anesthesia because she saw what a positive difference anesthesia providers can make on what is the hardest day of many patient’s lives. When she did her OB rotation, she saw the direct impact CRNAs make in the delivery process and how we impact outcomes in these high risk patients. She was inspired by how we can improve the quality of care and birthing experience for patients.
Her and her colleagues who produced this series, Joe Navarrete and David Barksdale, are all advocates of women’s health and through this doctoral project hope to empower other providers to cultivate excellence at their facilities when caring for patients with hypertensive disorders of pregnancy.
This three part series will equip anesthesia residents and providers alike with the core knowledge to effectively manage hypertensive disorders of pregnancy. Many thanks to Joe, David & Isabella for putting this series together!
Please see below for full show notes and references.
Show Notes: #124 – How to Manage Hypertensive Disorders of Pregnancy with Isabella SosaDownload
This is part 2 of a 3 part series on hypertensive disorders of pregnancy. Part one with Joe Navarrete covered the baseline physiologic changes with pregnancy. In this episode, David Barksdale is going to walk us through the pathophysiology of hypertensive disorders of pregnancy. And in the next episode, Isabella Sosa joins us to walk through how to manage hypertensive disorders of pregnancy as anesthesia providers.
David Barksdale is a Nurse Anesthesia Resident at Yale New Haven Hospital School of Nurse Anesthesia and Central Connecticut State University. Before CRNA school, he worked for three years as a Surgical Intensive Care Unit nurse at Rhode Island Hospital and is a combat veteran. He served in the United States Army from 2012-2015 as a combat engineer. In 2013, he deployed to East Paktika Province, Afghanistan, conducting route clearance operations to provide freedom of movement to the infantry and local populations.
David framed his doctoral project around this topic to deepen his understanding of hypertensive disorders of pregnancy and to explore how podcasting can support learning for anesthesia providers.
This three part series will equip anesthesia residents and providers alike with the core knowledge to effectively manage hypertensive disorders of pregnancy. Many thanks to Joe, David & Isabella for putting this series together!
References:
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American College of Obstetricians and Gynecologists. Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020;135(6):e237-e260. doi:10.1097/AOG.0000000000003891
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Dimitriadis E, Rolnik DL, Zhou W, et al. Pre-eclampsia. Nat Rev Dis Primers. 2023;9(1):8. doi:10.1038/s41572-023-00417-6
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Torres-Torres J, Espino-Y-Sosa S, Martinez-Portilla R, et al. A narrative review on the pathophysiology of preeclampsia. Int J Mol Sci. 2024;25(14):7569. doi:10.3390/ijms25147569
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Sibai BM, Dekker G, Kupferminc M. Pre-eclampsia. Lancet. 2005;365(9461):785-799. doi:10.1016/S0140-6736(05)17987-2
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Hall JE. Guyton and Hall Textbook of Medical Physiology. 14th ed. Philadelphia, PA: Elsevier; 2020.\Chestnut DH, Wong CA, Tsen LC, et al. Chestnut’s Obstetric Anesthesia: Principles and Practice. 6th ed. Philadelphia, PA: Elsevier; 2019.
This episode is part of a three-part series on titled “The Pressure is on: Enhancing Anesthesia Care for Parturients with Hypertensive Disorders of Pregnancy.” In this first installment, Joe Navarrete, a third-year student registered nurse anesthetist (SRNA) at the Yale New Haven Hospital School of Nurse Anesthesia, delivers a high-yield, system-by-system breakdown of the expected physiologic changes of pregnancy.
Part 2 will be #123 – Pathophysiology of Hypertensive Disorders of Pregnancy with David Barksdale
Part 3 will be #124 – How to Manage Hypertensive Disorders of Pregnancy with Isabella Sosa
In this episode, Joe Navarrete guides listeners through changes in the respiratory, gastrointestinal, renal, endocrine, musculoskeletal, nervous, hematologic, and cardiovascular systems, with an emphasis on how these changes impact anesthetic management. Joe covers pertinent topics including airway considerations, anesthetic requirements, dilutional anemia, hypercoagulability, neuraxial anesthesia, cardiac output, and fluid shifts throughout pregnancy. The episode concludes with a brief recap of clinical pearls for anesthesia providers to remember when caring for obstetric patients.
This is an in-depth review for SRNAs, CRNAs, and all anesthesia providers alike looking to refresh their understanding of maternal physiology. Whether providers are preparing for clinical rotations, board exams, or managing complex obstetric cases in practice, this review attempts to cover the bases.
At the time of this recording, Joe Navarrete was a 3rd-year SRNA at the Yale New Haven Hospital School of Nurse Anesthesia in Connecticut, pursing his Doctor of Nurse Anesthesia Practice (DNAP) degree. He earned his Bachelor of Science in Nursing from Rhode Island College in 2019. Joe began the first year of his nursing career on the surgical stepdown unit at Rhode Island Hospital (shoutout to 5 stepdown!).
Within his first year of nursing practice, the COVID-19 pandemic transformed the stepdown unit into a COVID ICU. There, Joe gained experience in managing critically ill patients and often worked alongside anesthesia providers during emergent intubations. These experiences sparked his interest in nurse anesthesia, and he never looked back. He went on to work in the Surgical Intensive Care Unit for 2.5 years before matriculating into anesthesia school and moving to Connecticut with his significant other Rebekah and their beloved cat, Bubba.
References
- Chestnut DH. Chestnut’s Obstetric Anesthesia: Principles and Practice. 6th ed. Philadelphia, PA: Saunders; 2020.
- Bleeser T, Vally JC, Van de Velde M, Rex S, Devroe S. General anaesthesia for nonobstetric surgery during pregnancy: A narrative review. European Journal of Anaesthesiology and Intensive Care. 2022;1(2). doi: 10.1097/EA9.0000000000000003
- Bauer ME, Arendt K, Beilin Y, et al. The society for obstetric anesthesia and perinatology interdisciplinary consensus statement on neuraxial procedures in obstetric patients with thrombocytopenia. Anesth Analg. 2021;132(6):1531-1544. doi:10.1213/ANE.0000000000005355
122 – Physiologic Changes of Pregnancy Show NotesDownload
What’s up y’all! I’m back at it after a summer hiatus. I actually wrote/recorded this episode back in May 2025, but then summer hit with camping trips, work projects, grad school, home renovations… you know, life! I’m pumped to bring this episode to you finally and this will be followed pretty quickly by a three-part series on hypertensive disorders of pregnancy, which is going to be stellar!
Check out these continuing education conferences with Encore Symposiums if you want to connect in person, as I’ll be speaking at each of them:
2025 October 20-23: New England at the Cliff House, Maine
2026 October 19-22: Autumn in Bar Harbor, Maine
2026 November 14-18: O’ahu Turtle Bay, Hawaii (Ritz Carlton)
This episode dives into tactical empathy: how to turn resistance into momentum in your conversations. This could be useful whether you’re negotiating with your 4-year old on taking a bath, rebooking a flight after yours got canceled or in the boardroom trying to implement a new project or proposal.
In this episode, we’ll walk through:
- The role of loss aversion in negotiation
- Techniques of tactical empathy: naming, mirroring
- The power of “yes, and…” (a tool from improv comedy)
- How to “start with no” in a negotiation by asking “how am I supposed to do that?” in a kind, vulnerable way.
Why listen to this episode? If you want to become a better communicator, get the best deal in a negotiation or learn how to have entertaining conversations from over the drapes in the OR to a cocktail party, this is for you. Tactical empathy is about leveraging what really matters to you and other people with clarity when communicating.
Don’t hesitate to reach out with questions, comments or feedback. Remember, the work you do is extremely important and incredibly valuable. You are the provider your patients need. Keep up the hard work. Be well and enjoy the journey!
References
Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement. https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com
Camp, J. (2002). Start with no: The negotiating tools that the pros don’t want you to know. Crown Currency.
Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Harvard business press.
Kahneman, D. (2011). Thinking, fast and slow. Farrar, Straus and Giroux.
Voss, C., & Raz, T. (2016). Never split the difference: Negotiating as if your life depended on it. Random House.
Want to work on changing things? Want to learn about your team and listen better? Interested in a pretty good pathway to do that?
Appreciative Inquiry is process of:
- Discovering what’s working well
- Dreaming about what could be
- Designing for future change & success
- Realizing the Destiny that this process will bring about
In this podcast, we’re gonna walk through Appreciative Inquiry and Theory U and how these 2 organizational development processes meld together to create a powerful tool for listening to and helping to improve the work your team does. It’s so good!
Our CRNA team at Maine Medical Center worked through this process – really, we’re still working through it – this spring. The full story is in the podcast.
I made a video for this podcast but I haven’t been able to get it loaded to YouTube yet and apparently, it’s too big for this website. In the meantime, you can see the core show notes to the podcast in the PDF below. There’s photos of the Theory U and our list of 10-questions we developed as our Appreciative Inquiry survey we used at Maine Medical Center.
I hope this episode gives you some very practical tools for how to engage with your team better. I’ve found appreciative inquiry to be a great way to have a conversation with groups and find a new way forward. Let me know how it goes for you!
120 – Appreciative InquiryDownloadReferences
Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons.
Hollnagel, E. (2020). Synesis: the unification of productivity, quality, safety and reliability. Routledge.
Scharmer, O. (2016). Theory U: Leading from the future as it emerges. Berrett-Koehler Publishers.
Scharmer, O. (2025). Theory U process of co-sensing and co-creating. Presencing Institute. https://www.presencing.org
Whitney, D., & Cooperrider, D. (2005). Appreciative inquiry: A positive revolution in change. Berret-Koehler Publishers.
Yo yo! Today, we close out our 3-part series on systems thinking with this episode on psychological safety & just culture.
Part 1 (Episode 117) introduced systems thinking & high reliability organizations.
Part 2 (Episode 118) walked through resilience engineering, safety differently and synesis.
Part 3 (this episode) threads these topics together with psychological safety & just culture.
This three part series invites you to think about your home team and professional practice.
How does your team handle errors & mistakes? Are you safe to fail and be honest about mistakes & near misses? Are mistakes and mishaps talked about?
Do you usually take feedback well and look for ways to grow or get defensive and think it’s always someone else’s fault? What about the other folks on your team?
Psychological safety is about the freedom to speak up without fear of embarrassment or punishment. Psychological safety doesn’t just happen. Organizational leaders need to talk about it and normalize it – truly, make it part of your team norms. Psychological safety doesn’t skirt accountability. Accountability is a key part of a psychologically safe culture. We’ll talk more about it in the show.
Just culture extends the idea of psychological safety to the organizational environment and the team’s approach to errors and mistakes. Just culture encourages teams to look at systems factors for why things break down. People don’t make mistakes willfully. Willful harm with malicious intent is recklessness or sabotage. That’s not a mistake. Mistakes are always unintentional because people don’t show up to work planning how they’re going to accidentally drop the ball and screw things up. Just culture looks at mistakes from the standpoint that perhaps the system is broken and sets frontline staff up for failure. A systems fix is like a rising tide that lifts all boats. Just culture sees the systems as the usual point of failure, not the frontline worker. Front line workers are often the source of resilience and capacity within systems.
We talk about these things and more in the podcast as we thread all three parts of this series together.
As a reminder, I’ll be in Hilton Head, SC next month teaching with Encore Symposiums and back at the Cliff House in Maine this October with Encore. Come check us out if you’re looking for a great continuing education conference!
Your values build your system, your system creates your culture, your culture generates your results.
References
Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com
Conklin, T. (2025). PAPod 540 – Swiss Cheese Actually In PreAccident Investigation Podcast.https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000702329202
Dekker, S. (2016). Just culture: Balancing safety and accountability. crc Press.
Dekker, S. W., & Leveson, N. G. (2015). The systems approach to medicine: controversy and misconceptions. BMJ quality & safety, 24(1), 7-9.
Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons.
Edmondson, A. C. (2023). Right kind of wrong: The science of failing well. Simon and Schuster.
Schein, E. H. (2010). Organizational culture and leadership (Vol. 2). John Wiley & Sons.
Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Broadway Business.
Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. John Wiley & Sons.
Willink, J. (2017, February 2, 2017). Extreme Ownership TEDx, TEDx Talks. https://www.youtube.com/watch?v=ljqra3BcqWM
This is Part 2 of a 3 part series on organizational development – how we work and live together as teams in healthcare so we can do our best work, master our craft, take amazing care of patients and actually enjoy the work we do. (no big deal)
In the first part (Episode 117), we talked about systems thinking and patterns of high reliability organizations (HROs). Systems thinking helps us zoom out to consider the complexity of situations and the various levers that influence outcomes. High reliability organizations adopt specific systems thinking practices to achieve consistent success in safety-critical, complex environments.
Resilience engineering builds on systems thinking and HRO theory by teaching us how to develop adaptive capacity, build for success (not just avoiding error) and bounce back when things don’t go well. Safety differently is about seeing safety as not the absence of mistakes and errors but the capacity for the right thing to happen. It also recasts the worker not as the weak link in a complex system (the point of failure), but as the source of resilience and capacity. Front-line healthcare workers – you and me – are often the ones who find the workarounds and get the job done despite suboptimal conditions.
No one shows up to their job with the intention to make mistakes, get hurt or put patients at risk. Mistakes are always unintentional. Willful acts of harm are something totally different. Blaming and shaming workers (forms of punishment & embarrassment) are counterproductive and stem from leaders who do not understand what’s actually going on or the best ways to run their organizations and build thriving teams.
Synesis, which sounds like a scary word, stems from the same Greek word that system and synergy come from and is actually kind of a cool idea. It’s the way we balance the often competing interests of productivity, safety, reliability and quality. We need to figure out how to do all of these things concurrently in healthcare. I’ll share some stories and examples of how to do that as an anesthesia provider in this episode.
So that’s where we’re headed with this podcast!
In Part 3, we’ll come back and talk about psychological safety and just culture, which thread all three episodes in this little mini-series together.
As a reminder, I’m teaching with Encore Symposiums next month in Hilton Head, South Carolina and back at the Cliff House in Maine this October. If you’re looking for a continuing education conference where we’ll talk more about all of this – or if you’re a resident or graduate student looking to check off one of your state/national meetings, come check us out! I’d love to see you there!
As always, you can come work with us at MaineHealth – Maine Medical Center. We have a phenomenal team of CRNAs, physician anesthesiologists, surgeons, OR nurses & CSTs, anesthesia techs and admin specialists. If you want to be part of a growing team of providers doing world class work at a level 1 trauma center in a spectacular city, check us out!
References
Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com
Conklin, T. (2025). PAPod 540 – Swiss Cheese Actually In PreAccident Investigation Podcast.https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000702329202
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.
Hollnagel, E. (2020). Synesis: the unification of productivity, quality, safety and reliability. Routledge.
Larouzee, J., & Le Coze, J.-C. (2020). Good and bad reasons: The Swiss cheese model and its critics. Safety science, 126, 104660.
Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Broadway Business.
Sutcliffe, K. M. (2011). High reliability organizations (HROs). Best practice & Research clinical anaesthesiology, 25(2), 133-144.
Wears, R., & Sutcliffe, K. (2019). Still not safe: patient safety and the middle-managing of American medicine. Oxford University Press.
Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. John Wiley & Sons.
World Health Organization. (2021). Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care (9240032703).
Yo! This episode introduces the concepts of systems thinking and high reliability organizations. It’s the first part in a 3 part series. Part 2 is gonna dive into resilience engineering and safety differently. Part 3 is all about psychological safety and just culture.
These 3 shows unpack crucial intel for front-line providers, equipping them to understand their roles and how to develop their clinical impact. It’s also for organizational leaders and practice managers and will help you think about how to design better systems and support your team so they can thrive.
Systems thinking is the process of zooming out beyond simple cause-and-effect understanding (i.e. linear causality models) of how errors happen. It encourages people to consider the complexity of their environments and the power of leveraging changes in your processes and systems.
In this episode we cover:
- Learning organizations and their 5 characteristics:
- Personal mastery
- Mental models
- Shared vision
- Team learning
- Systems thinking
- High reliability organizations and their characteristics
- Preoccupation with failure
- Reluctance to simplify
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise
- How these ideas link to resilience engineering and safety differently
“Every organization is perfectly designed to get the results it gets” (Batalden, 2015).
If you don’t like the results you’re seeing, you need to change the system. Whether this is your anesthesia team, hospital/OR or your personal life. If the outcomes are not what you desire, you need to adopt a systems thinking approach to change. This episode will walk you through how to do that.
The values you embrace shape your culture. Your culture builds your systems. Your systems generate your results.
Quick reminder: I’m teaching at Encore Symposium’s Hilton Head conference May 19-22 and then again with their fall conference at the Cliff House here in Maine that runs October 20-23, 2025. I love seeing y’all in person at these conferences. If you come because you heard about it here on the show or are just there and have checked the show out before, come holler at me! I’d love to chat with you about what you’re up to and what your practice is like.
Be sure to check out Part 2 and 3 of this series and I’ll see you there!
References
Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com
Conklin, T. (2025). PAPod 540 – Swiss Cheese Actually In PreAccident Investigation Podcast.https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000702329202
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.
Hollnagel, E. (2020). Synesis: the unification of productivity, quality, safety and reliability. Routledge.
Larouzee, J., & Le Coze, J.-C. (2020). Good and bad reasons: The Swiss cheese model and its critics. Safety science, 126, 104660.
Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Broadway Business.
Sutcliffe, K. M. (2011). High reliability organizations (HROs). Best practice & Research clinical anaesthesiology, 25(2), 133-144.
Wears, R., & Sutcliffe, K. (2019). Still not safe: patient safety and the middle-managing of American medicine. Oxford University Press.
Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. John Wiley & Sons.
World Health Organization. (2021). Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care (9240032703).
If you don’t like the results you’re seeing, you gotta change the system! Every system is perfectly designed to get the results it gets!
On the corner of Skyland Drive and 23 in a little town called Sylva in Western North Carolina, sit’s PJ’s gas station. One hot summer day back in 2005, I was filling up the tank in a convalescent transport van on my very first day as an EMT-Basic. That’s the most basic, entry-level certification of working as an Emergency Medical Technician or EMT. My convalescent transport van had a wheelchair ramp and my role as an EMT-B was not to do 911 calls, but to drive this glorified shuttle bus. My role was to transport people to and from their doctor’s appointments. Maybe to help them get home after being discharged from the hospital. If you were too sick for a taxi but not quite sick enough for an ambulance, I was your guy.
The guy training me that day, a senior paramedic, was actually a good friend of mine and happened to also be my boss at a local outdoor education company. Everyone affectionally called him “the Padj,” a shortened third-person version of his last name, Padgett. The Padj ran Landmark Learning, which offers wilderness medicine educational courses for outdoor guides and enthusiasts and eventually became the Southeast training center for NOLS Wilderness Medicine. Pretty much everyone who taught for NOLS Wilderness Medicine had a part time gig working in EMS and so that became my path too and this was my first day on the job.
I felt supremely important because of two things: as part of my standard issue uniform, on my thick polyester blue shirt, I was wearing a chrome name badge that said “J. Lowrance, Since 2005” and I had a big, heavy, professional walkie talkie. We had no more checked out the van and driven a mile down the road from base to fill up with gas at PJs when the tones went off on the walkie talkie, indicating a serious 911 call had just been dispatched. As I was pumping gas and the Padj was relaxing in the passenger seat, the radio crackled with the call: there was an unresponsive patient about a half mile down the road from where we were. We looked at each other and shrugged, knowing that even though we were essentially in a shuttle bus with next to no medical supplies, we wanted to see if we could help. We hurriedly paid for the gas, jumped in the van and ended up beating the ambulance to the house where the 911 call came from.
We were met by a distraught woman in her 60’s who told us she couldn’t wake her husband up. We went in the house through the side door, immediately finding ourselves in her kitchen. The bedroom was just off the kitchen and walking in, I remember the time on the bedside clock – one of those little rectangular digital clocks with red numbers: the time was 10:10 in the morning.
Photo credit: OpenAI (2025). ChatGPT 4o version. [Large language model]. https://chatgpt.com.
The man was large, heavy and not moving. He looked like he was still asleep except he was a deep shade of purple… not quite blue yet, but definitely not alive-looking.
The Padj called out to him and checked a pulse. Nothing. My heart, however, was racing.
As my palms began to sweat, the Padj looked at me serious, which he never did, and said quietly out of respect for the man’s wife, standing in the doorway, “dead on arrival or do you wanna run the code?”
I could hear the sirens of the ambulance approaching the house.
“Let’s do it.”
We heaved the man onto the floor… he was heavier than I thought he would be. It dawned on me that dead people don’t try to help you like our wilderness medicine students do when they’re trying to act like patients in simulated scenarios. This was not a scenario.
Padj said he’d get the O2 tank in the van and that I should start CPR.
I knelt down, looked left and right for our jump bag, which contained a bag-valve mask or BVM, which we used to breathe for patients in cardiac arrest. We left the jump bag in the kitchen. I was in rescue mode. No time to waste.
I looked at the man, zeroed in on those purple lips and scrubby, lifeless face, pinched his nose and leaned in to do mouth-to-mouth resuscitation. As time slowed down and I leaned in to my new career in EMS, a paramedic shouted from the front door, “STOP,” shaking his head. He had arrived just in time to yell at me and snarled, “JLo, we don’t do that! Somebody get him a BVM.” A bag-valve-mask was thrown at me from the kitchen. I quickly pumped two breaths with the bag into the man and started chest compressions.
We all worked together as hard as we could to save that man’s life but our efforts were in vain. Who knows when he had died before his wife found him that morning. We ran the code, started an IV, intubated him and did CPR the mile and half back up the road to the hospital, where the code was called. I walked out as his wife, crying, walked in to see him.
It was my first day on the job. It would be her first day without him.
Two things happened that day for me:
I became hooked on resuscitation.
And I realized that the people and teams doing this kind of work have their own special flare in the midst of the chaos. For the first time, I saw the human factor in emergencies.
Not just my ignorance and naiveté. But how more experienced providers find work arounds. How seasoned clinicians have unspoken rules that govern the work they do. A certain sort of knowing that only comes with experience. I’ll come back to that in a minute.
That first call on my first day in EMS in Western North Carolina seared into some deep squishy corner of my brain a true love of resuscitation. I was hooked. I thought this is definitely the kind of work I want to do, and I want to learn how to do it better and how teams can do this kind of thing better. That drive would become a central theme of my professional career moving forward and is why I’m writing this now.
The other thing it did was create a certain level of cognitive dissonance. It interjected the reality of human factors in resuscitation and emergencies in an incredibly powerful way.
There was my ignorance coupled with an overwhelming desire to do the right thing. I’m going to breathe for this patient because that’s the right thing to do! And then there’s the disruption to that plan; the alternative approach; the wisdom of a senior clinician. Here I am about to follow the algorithm and get the job done despite my immediate resource limitation… adapt and overcome and all that and then there’s the senior paramedic saying, “What are you doing? We don’t do that!” I was like: but we’re supposed to save lives! In every TV drama I’ve ever seen – which I happen to be literally in the middle of right now on my first day on the job – EMS people are supposed to save lives; and now I’m an EMS people. WE are supposed to SAVE LIVES! Not wait for an AMBU bag because I left it in the kitchen.
This disruption to my preconceived notion of how things were supposed to go was a poignant introduction to the idea that humans will often deviate from expected work patterns to best get the job done.
What I learned was there is a way more senior people do things that the newbies don’t know about. They have that special kind of knowing that only comes with experience.
Check this out: the Greeks have several different words for different kinds of knowing. There’s knowing about something, like scientific facts & figures, which is where most new anesthesia trainees are with their knowledge. This is gnosis (‘nō-sis), to know about something in a general way. Similar to this is epistēmē (ep-uh-steam), which is knowing more scientific, academic knowledge. Epistēmē is where we get epistemology (eh-puh-stuh-mo-lo-gy) from, which is the study of how we know things, what we know and the limits of that knowledge.
There’s the work as imagined, which is informed by protocols and standards and expected norms of behavior or even expectations that society has on healthcare providers: we will save lives even if it means putting our own lives at risk. And then there’s the work as done, which is often shaped and determined by this special kind of knowledge about how to do things.
What I’m talking about with experienced resuscitationists is ginōskō (gi-know-sko). Ginōskō is an experiential knowledge that only comes through deep experience or relationship with the subject, practice or person. You only get this kind of knowledge through experience. If you know, you know, you know what I mean?
All right, so there’s your Greek lesson for the day and where my gnosis of the Greek language ends.
So, what this very first resuscitation taught me is that providers who do this kind of work have a very deep, experiential knowledge that guides their decision-making. This goes beyond the algorithms. Gary Klein talked about this within his recognition-primed decision-making model (Klein, 2017). Daniel Kahneman (2011) spoke of System 1 and System 2, with System 1 being our intuitive decision-making and System II our more deliberate, concentrated thinking.
These modalities of decision making are important parts of how people operate on a daily basis in jobs that require people to be very knowledgeable about their work.
There’s the work as imagined and then there’s the work as done.
There’s the protocols, rules & regs, expected behavior and then there’s the work arounds, real adaptations and the way the work actually gets done.
This little moment in my career taught me that resuscitation is a wild place. You have all kinds of experience levels converging on a moment and each of those people has a different mental model of what’s supposed to happen. And that’s just the front line staff that actually get their hands dirty during a resuscitation. We’re not even talking about safety or risk professionals yet who might review cases or senior leaders who don’t actually do the work that they’re charged with overseeing, supporting, reviewing or administrating.
The human factor in emergencies is a bit of a wild card.
When humans are managing emergencies, there will inherently be variability in performance despite the expectation for consistent execution of normal behavior.
While reducing variation is a noble goal that organizations and even individuals should work towards, we have to recognize that variable performance is likely normal in volatile, uncertain, complex and ambiguous (VUCA) settings (Edmonson, 2018).
Resuscitation is a classic VUCA setting. While not all resuscitations are volatile, most have uncertain outcomes, are complex and contain ambiguous elements to them requiring judgment, rapid differential diagnosis and decision-making.
Algorithms, rules & regs and policies guide care, but it’s people who actually do the care.
There’s the way we think healthcare providers will act – because of the incentives or constraints in place, the rules and regulations and the system we’ve set up. Then there’s the way healthcare providers actually behave. There’s the way we imagine work will be done and then the way work is actually done. And usually the folks on the sharp end find the most effective, expedient, efficient way to do things.
So, what does this mean for you?
If you’re a provider, keep practicing. Keep finding the best path forward. Don’t stagnate with what you know. There may be better ways to do something. You may need better systems to operate in. You may need more experience to develop judgment and wisdom beyond the rule book, protocols and algorithms. Why was the BVM not brought to the bedroom on this call in the first place? Whose responsibility was it to haul the gear in the house? Did we talk about the plan ahead of time? Were we following a pattern of performance or just winging it and seeing what would happen? Remember, the way you do anything is the way you do everything.
As healthcare providers on the path towards mastering our craft, we have the responsibility to engage in self-reflection about our practice and our habits.
Elaine Scarry, a professor of English at Harvard, has this quote which I love:
“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” (Scarry, 2011).
What this means to me, especially when coupled with all of the science on deliberate practice and expertise from Anders Ericsson and others, is that we have a responsibility to develop good work habits. Because when push comes to shove in an emergency, we don’t rise to the occasion, we fall back on our training and our practice… we fall back on our habits.
Now, if you’re a practice leader, be open to the fact that your team may not follow the rules because the rules may not be in their best interest. It’s not your job to get your team to follow the rules. It’s your job to build an environment that optimizes your team’s ability to do their job – yes, safely; yes, in congruence with standards & regulations. But you may have dumb rules that need to be re-written. You may have policies that don’t align with work as done or as it should be done. You might need to do some really boring background work to clean up your rules and regs, and more importantly, to improve your processes, so that your team can do their jobs better, more efficiently and more effectively and in a way that is in alignment with what the organization expects.
By the way, don’t punish people when you hear they’re not following the rules. Think: why did they do it that way? What kind of work environment are they adapting to? What incentives are they operating with right now? Are there ways we can improve the environment or change the incentives in which these really smart people work?
I was out on a run yesterday listening to Todd Conklin’s Pre-Accident Investigation podcast (Conklin, 2025). Conklin is a leading thinker in the organizational safety & development space. He was talking with another safety scientist and said something to the effect that if you’re best people are breaking your most important rule, something in the system is wrong. It’s not the people’s fault. They’re just trying to do their job. As a leader, you need to improve the system.
It’s not about finding bad apples and weeding them out. It’s about improving the entire system. Because safety is not about minimizing errors but rather building a capacity for the right kind of work to happen. Errors will be inevitable in complex environments – VUCA environments (volatile, uncertain, complex and ambiguous). Things will not always go as planned or imagined. Safety is about recognizing that the people on our teams don’t show up to work planning to make mistakes and hurt people or get hurt themselves. Mistakes are not intentional or willful acts. Safety is about figuring out how we as providers and all yall out there who are leaders can build more resilient systems with a higher probability of the right kind of work happening.
So I know we’ve wandered a bit today. There’s something about that very first resuscitation that I was a part of that stuck with me.
Actually, since we’re on the topic… there was actually a resuscitation, or an accident, before that one on my first day as an EMT that really sparked things for me. I’ll share this quickly as it does tie in to the whole trajectory that I’ve been on for quite some time now.
On another hot summer day… this one in southwest Missouri when I was in between my junior and senior year of high school, I was on a flat-nosed school bus leaving a summer church camp when our bus crested the hill of a highway going about 60 miles per hour and we hit a tractor that was pulling a trailer full of hay. For whatever reason, the bus drive didn’t see this tractor, which was probably going about 25 miles per hour at best, was straddling the shoulder and the right-hand lane. By the time we crested the hill and he could see, it was too late; we slammed into the back of that trailer and it seemed like everything on God’s green earth went airborne and time slowed down. A could see the little particles of broken glass suspended in the air, the hail bails exploding in the wind, the trailer and tractor being lifted off the hot pavement, and then we all came crashing down as time sped up and the bus screeched to a halt. I had just finished an Advanced First Aid & CPR class at my high school the previous semester. Advanced First Aid, mind you. I had my keychain CPR mask on me… one that was big enough to hold a pair of gloves and a little flimsy CPR mask… and I grabbed a blanket from the bus thinking the farmer on that tractor could be in shock and I jumped out of the bus and ran back to him along with some of the adult youth leaders. The guy’s head was split open from his forehead down between his eyes to over his cheek. He ended up living and making a reasonable recovery but standing there in the heat and sun, I was immobilized. I had no idea what to do other than feebly offer up a blanket even though it must have been over a hundred degrees on the pavement. I got to watch the firetrucks shut down the highway and the helicopter land, which was pretty cool. But I couldn’t do much. So like Elaine Scarry said: I became acutely aware that despite having some first aid training, I was pretty much unequipped with any serviceable habits so I just kinda stood there and waited for EMS to show up.
Fast forward a bunch of years and I was through college with an outdoor recreation degree, teaching wilderness first responder courses and on my first day as an EMT I found myself kneeling over a patient in cardiac arrest.
These moments highlight steps in my personal journey where I decided to level up. I knew I didn’t know everything, and I needed to keep training, keep studying.
They also serve as really interesting reference points on systems thinking and human factors in emergencies.
Mistakes and errors are going to happen. Progress is not inevitable or permanent. How we build systems and maintain systems of care has a profound impact on how people work and how we generate the outcomes that we want.
I hope this was fun for you and interesting. I hope this spurs some thinking for you on how you operate as a provider and maybe how your organization thinks and talks about risk, errors and safety.
Drop me email if you want to talk more. Leave a review on Apple podcasts if you like this show: that helps other people find and trust Anesthesia Guidebook.
Thanks for the work you do and for checking this show out!
Conklin, T. (2025, March 15). PAPod 537 – Unveiling the myths of modern safety: a conversation with Todd and Georgina. . PreAccident Investigation Podcast. https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000699305329
Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons.
Kahneman, D. (2011). Thinking, fast and slow. Farrar, Straus, and Giroux.
Klein, G. A. (2017). Sources of power: How people make decisions. MIT press.
Scarry, E. (2011). Thinking in an Emergency. W. W. Norton & Company, Ltd.
“If we act, we act out of the habitual…”
Elaine Scarry
Hey y’all! First of all: thank you to those of you who have subscribed to the website and get these posts right to your email inbox. That’s all that happens: the podcast is free and subscription to the show just means you get the content straight to you as soon as it’s live. I never sell or use your contact info for any other means. I’m just simply thrilled to have your support and interest in the show as the whole thing is geared to support you and help you thrive in your career as an anesthesia provider. Thank you!
This podcast covers a run down on the NBCRNA’s Maintaining Anesthesia Certification (MAC) Program. The MAC Program is how CRNAs maintain and rectify their license with the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA).
The MAC Program launched in 2024 as a revamped version of the old CPC (Continued Professional Certification) Program. There are some substantial changes that CRNAs should be aware of. First off, you need to know if you’re in the MAC Program yet. Most CRNAs (new grads and those who’ve re-licensed after 2024) ARE in the new MAC Program.
This show will coach you on how you can log into NBCRNA’s website to see where you’re at and what you need to know about MAC Ed (Class A) & MAC Dev (Class B) credits and the quarterly MAC Check exam questions that you can take on an app on your phone.
All the details are in the show! For the truth of what’s up with the MAC Program and your license, as always, check with NBCRNA! Things change over time. Be sure NBCRNA has an updated email for you. 30% of the emails they send to CRNAs bounce back as invalid addresses. That’s insane! Updatechur email!
You can follow along with the podcast by checking out the attached PDF that outlines the show with lots of helpful graphs and more info than what I spoke about in the podcast.
Two last points:
First: Overall, I think the MAC Program is a really healthy and needed evolution to the CPC Program. NBCRNA has listened to CRNAs and made needed adjustments to the continuing education/relicensure program. We have to have a continuing education/certification program for the CRNA license to have meaning and value. The current iteration is the best it’s been, so there’s that.
Second: Remember that your STATE Board of Nursing may require additional steps for you to re-license as a CRNA. For instance, NBCRNA does NOT require pharmacology-specific continuing education credits (MAC-Ed/Class A); however, the State of Maine (where I’m at) does!
For example, Maine CRNAs must obtain 60 MAC-Ed/Class A and 40 MAC-Dev/Class B credits for recertification with NBCRNA every 4 years but we have to have 50 credits every 2 years, 15 of which (every 2 years) must be pharmacology credits, to re-license as CRNA in the State of Maine. So the requirements to re-license as a CRNA in the State of Maine are slightly more stringent (and more frequent) than to maintain the national license with NBCRNA.
Follow along with the powerpoint for more details:
MAC Program Overview – Anesthesia GuidebookDownloadGo get you some deliberate practice!
This podcast is for leaders, clinicians, residents & students who need to get wildly important things done. It’s about how to prioritize when so much of your work seems important. How to find balance when so much seems to be coming at you. How to get started at achieving your biggest goals.
This episode will walk you through the 4 Disciplines of Execution by Chris McChesney, Sean Covey & Jim Huling.
I have no financial relationship with these folks, the book or their publishers. It’s just a great concept that will help you get organized, identify your wildly important goal and figure out the work you actually need to do and CAN do to accomplish your goals.
The 4 Disciplines of Execution (4DX) model will ask you to identify your wildly important goal. You’ll then create several lag measures (subgoals) and several lead measures (objectives) for each lag measure. These lead and lag measures are where the real work is. The wildly important goal may seem out of reach. Even the lag measures (which lag behind the work you’ll do in the lead measures) may seem a bit ambitious. That’s ok. The lead measures should be the specific actions you will take on a daily or weekly basis that will chip away at the lag measures. As you put the work in on the lead measures, your lag measures will come into sight and slowly be realized. As you stack up achieving the lag measures, your wildly important goal will become within reach.
The next components of the 4DX model is the scoreboard where you track your progress on each lead & lag measure. This can be any relevant metric on any kind of progress tracker: a list on a whiteboard, a data point in an Excel file, the pounds on the scale, dollars in the investment account or left on the loan. Whatever.
Lastly, is the cadence of accountability. You need to either personally set up a check in on your progress with yourself or you need to set this up with your team, mentor or coach. The authors of the 4DX model recommend this be a short weekly meeting where you review progress from the last week and plan actions for the coming week. Accountability is about follow through, taking steps (as small as they might be) and slowly, setting up the cadence of consistency.
I was on the Peloton last night and heard Matt Wilpers say that the order of priorities in exercise is developing consistency, then duration, then load. You can’t go out hard all of a sudden and expect big results. Develop consistency. Show up a little bit each day or each week. Then put the time in. Build the duration of your investment towards your goals. Then you’ll know when to put the extra effort in.
Check out the show and if you want to dig deeper, definitely check out the 4 Disciplines of Execution.
McChesney, C., Covey, S., & Huling, J. (2012). The 4 disciplines of execution: Achieving your wildly important goals. Simon and Schuster.
What’s your Wildly Important Goal?
Matt & Alison Moody took a year off of working as CRNAs to live and travel in Spain with their then 4-year old daughter.
This is part of that story.
Matt & Alison Moody in Granada, SpainThe two were living and working as CRNAs in Asheville, North Carolina when they caught the idea to take a year off of work and live in Spain. Their journey to Spain went from the fall of 2023 to the fall of 2024 and over the last few months, they’ve been re-integrating back to the United States and Western North Carolina and back to their careers as CRNAs. Part of their inspiration to take a year off work came from listening to the episode I did with Kyle & Jen Steen on their decision to sell everything, build out a sprinter van and hit the road. That story is in episode 73. Side note: Kyle & Jen took about 18 months off from work before Kyle returned to his career in anesthesia through locum assignments. They’re still in the van full time and still crossing off new places to live & explore. I hope to have them back on the show soon!
Matt & Alison wanted to head to Spain to work on their Spanish language skills and take time to connect with each other as a family. What they discovered along the way may surprise you. In this conversation with Matt, he walks us through what they set out to do and how that changed over time – from before they left through how their experience evolved while they were over in Spain.
I think you’ll enjoy this story and hopefully find some inspiration for yourself to think outside of the box and consider what might be possible in your own life. It doesn’t have to be taking a sabbatical or selling everything and hoping in a custom built Sprinter van. It might be about re-prioritizing your work-life balance in other ways. It might be going back to school or picking up pottery like my wife, Kristin. It might be about moving to that area of the country you’ve always wanted to live in or finding a new way to explore your passions. Finding a way to prioritize your own story, dreams and aspirations along the way is possible and I loved chatting with Matt to hear how he & Alison arranged their life to pursue their goals.
Matt grew up in coastal North Carolina; went to college and nursing school at UNC Chapel Hill; and then received his CRNA degree at Wake Forest. His heart and soul have always belonged in the Pacific Northwest, so after graduate school he moved west and started his career at the University of Washington Medical Center in Seattle, WA. Eventually, the pull of family brought him back to NC, and he has called Asheville home since 2017. Thus far in his career, Matt has had the fortune to gain experience in many practice areas – from major trauma hospitals to small surgery centers – and has experience in many subspecialties of anesthesia.
In his free time, Matt loves to spend time being active outdoors, but he’s especially passionate about rock climbing and skiing. Lately, he and his wife, Alison, have been experiencing the joys (and frustrations!) of introducing their 5 year-old daughter to these activities.
While in Spain, Alison created an Instagram page that they invite you to follow. It’s @ La Moody Aventura. @lamoodyaventura Matt also offers his email to anyone who might have questions about how they did what they did. In the show, he talks about how they felt like they were the only ones crazy enough to do something like this but then actually met several folks abroad – including another CRNA family from the States – who were pursuing similar dreams. Matt would love to help you take the next step and you can reach him at mattwmoody@gmail.com.
And with that, let’s get to the show! – Jon
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Jon Lowrance | Anesthesia Guidebook
What’s up y’all! This is Jon Lowrance and this is episode 112 – How to Transition from Clinician to Chief CRNA.
Y’all are going to love this conversation.
So… I almost don’t know where to begin cause there’s so much to talk about…
This is an episode about chief CRNAs but so much more. It’s like when you watch one of those food documentaries about the best pizza kitchens in the world and you’re like: oh, a documentary about pizza, but then it’s really about the experience of chefs, small business owners, friendship and passion. This episode is like that.
It’s about chief CRNAs. And we have a couple of guests that are going to talk with us about an article they published on the research they did into the professional experience of chief CRNAs. But this story is really about the transition that most healthcare providers take when they take the step from expert provider to clinician-leader, practice manager or owner. You’re going to see this through the lens of what these 2 researchers saw when they did a qualitative analysis of chief CRNAs across the state of North Carolina. But you might take something away from this about the physician who leads your team or the CMO or health system president that runs the show where you’re at.
If you work in healthcare, cause you probably do – again, unless you’re my mom, who listens to all these podcasts – hey Gail! But for the rest of you, if you’re in healthcare, this episode will likely help you understand your clinical leaders better.
I never set out to be a chief CRNA or practice manager. I wanted to be the best clinician I could. I wanted to stand in the gap between the chaos and the outcome. I wanted to master my craft as an anesthesia provider and take the best care of patients possible.
Literally, like 6 months before our chief CRNA announced that he was going to step down after 8 years in his role, I had the opportunity to become a daily shift supervisor – like a board runner in the OR. I was like: I’m never going to do that. It seems way too hard. Then our chief stepped down and his role opened up and I was like… wellllllllll…
This episode hopefully will be relevant to any clinician who, like me, has stepped into a role or is thinking about taking on a clinical practice leadership role that maybe they’re not totally ready for. You’re not alone.
So we’re going to talk with Austin Cole and Robert Whitehurst, co-authors of an article about the competencies & professional development needs of chief CRNAs that was published in April 2024 in the AANA Journal.
Austin framed his doctoral project at Duke University around this study. Austin Cole, DNP, CRNA began his career after graduating from the school of nursing at UNC-Chapel Hill. Following graduation, he spent two years as a Registered Nurse in a cardiothoracic critical care unit. He received his DNP and nurse anesthesiology training at Duke University and currently practices as a CRNA at Duke Regional Hospital in Durham, NC.
Robert Whitehurst is the President of Advanced Anesthesia Solutions, a CRNA practice providing anesthesia services to a variety of outpatient practices. He graduated in 1997 from East Carolina University School of Nursing with his Bachelor of Science in Nursing and in 2004 from Duke University School of Nursing with his Master of Science in Nursing. Bob Whitehurst is also the Chairperson for the North Carolina Association of Nurse Anesthetist’s Political Action Committee and he’s passionate about patient access to high quality anesthesia care. He’s happily married to Amy Whitehurst; they have 4 children and in his spare time he enjoys hanging out with his family and playing tennis with friends.
Austin & Bob’s paper is titled “A mixed-methods exploration of competencies and professional development needs among chief Certified Registered Nurse Anesthetists.” For the study, the authors contacted 85 chief CRNAs across North Carolina and conducted structured interviews and qualitative analysis with 10 of them. They set out to understand the competencies and professional development needs of chief CRNAs.
I gotta say, when I read their article, so much of it resonated with me as a chief CRNA. The path for so many practice managers – including physician anesthesiologists and other Advanced Practice Providers, like PAs & NPs, is that a senior clinician with several years of clinical experience often steps into a practice management & leadership role that’s been vacated and their learning curve in leadership happens through on the job training.
That’s kinda suboptimal.
Yet it’s pretty rare for groups or hospitals to have dedicated mentorship and professional development programs established and to encourage clinicians to develop as practice leaders. It’s even more rare for clinicians to have formal leadership & management training prior to stepping into leadership roles. In the show, we hit on 2 important concepts – the double loss phenomenon and the halo effect. The double loss phenomenon is where the group looses a senior clinician when they step into a leadership role since they’re not doing clinical work as much and they gain an inexperienced leader & manager… someone with little to no experience in that kind of role.
No bueno.
The halo effect is the cognitive bias where people believe that because they’re really good at doing one thing – like being an expert anesthesia provider – they’ll automatically be really good at another – like being a practice leader. Competency in your clinical practice does NOT translate to competency in leadership & management. They’re two wildly different skill sets and you need to train, study and work hard at leadership & management just like you trained, studied and worked hard to become an expert clinician.
So I think you’re going to enjoy this show. Regardless of your clinical background – whether you’re a CRNA, a med student or resident, physician anesthesiologist or some other Advanced Practice Provider. Even though we’re talking about chief CRNAs here, we’re really talking about the phenomenon of clinicians transitioning into leadership & practice management roles. I’m a big believer that if healthcare is going to change for the better… become more effective, efficient, safer and just better for both patients and the people providing the care, we will need expert clinician-leaders. We need these clinician-leaders to learn the art & science of practice management. We need clinicians to develop the key competencies to become expert leaders. That transition and development is not a given. It doesn’t just happen with on the job experience. You can be a very experienced practice leader and be terrible at your job.
This episode is a great place to start for new and future clinician-leaders. I hope you enjoy it as much as I did! I’ve got links in the show notes to the article that Austin & Bob published.
And with that, let’s get to the show!
Cole, A. L., Simmons, V. C., Turner, B. S., Whitehurst, R., & Tola, D. H. (2024). A Mixed-Methods Exploration of Competencies and Professional Development Needs Among Chief Certified Registered Nurse Anesthetists. AANA journal, 92(2), 105–113.
What’s up yall! This is Jon Lowrance and this is episode 111 – How to Prepare for Medical Mission Trips with Stacey Such, MSN, CRNA. (Stacey pronounces her last name, Such, like “Suke/Duke.”) Before we get to this show, I’d like to give a quick shout out to the CRNAs, SRNAs & physician anesthesiologists who […]
What up yall. This is Jon Lowrance with Anesthesia Guidebook. This is episode #110 – How we do interviews with Alison Kent, MSN, CRNA & April Bourgoin, DNAP, CRNA. In this episode, April, Alison & I talk about how we conduct CRNA interviews as a leadership team with our Department of Anesthesiology at MaineHealth – […]
What’s up yall! This episode dives into fundamental concepts related to leadership and casts a message for why it matters to all of us.
Whether you’re primarily a clinical CRNA/physician anesthesiologist, resident/SRNA, a practice leader/manager, business owner, educator, researcher or policy advocate, leadership has a fundamental role in your day to day life.
In this episode, we talk about:
- The art & science of leadership
- Position, power, influence
- Leadership & management
- Leadership & followership
- Culture, and how we influence it
- The Servant Leadership Model
- Jocko’s leadership principles
I’m pulling from my time as an instructor with Landmark Learning and NOLS (National Outdoor Leadership School), both outdoor education schools that thread leadership principles through their risk management and wilderness medicine programs. I’m also pulling from my experience as the chief CRNA at Maine Medical Center, a level 1 trauma center with over 200 staff in the anesthesia department. And some of the content is coming from the work I’m doing as I pursue a PhD in organizational leadership with a research focus on how high performance teams operate in emergencies.
Hopefully you’ll find something you can hang your hat on here.
Leadership is the art and science of influencing others to achieve shared goals.
There’s a ton of different leadership styles & theories out there and I’ll touch on some in the podcast. My personal approach is the Servant Leadership Model, which flips the traditional organizational chart – a pyramidal/triangular structure – on its head and puts the leader at the bottom of the triangle and the most important staff up at the top. The most important folks in any organization are those who are doing the front line work to deliver on the mission and vision of the organization. In the Servant Leadership Model, these folks are the top and the leaders and managers are positioned below them. The job of leaders and managers is to support and empower the folks above them to do their best work in robust and resilient environments where the capacity for the right thing to happen flourishes.
No big deal right? To find out more, check out the podcast!
Servant Leadership ModelDownloadLeadership Tactics
By Jocko Willink
- Be humble
- Don’t act like you know everything
- Listen, ask for advice & heed it
- Treat people with respect
- Take ownership of failures
- Pass credit for success up & down the chain of command
- Work hard
- Have integrity – do what you say, say what you do
- Be balanced – avoid extreme actions/opinions
- Be decisive
- Build relationships = this is the main goal of a leader
- Get the job done
Willink, J. (2023). Leadership strategy and tactics: field manual expanded edition. St. Martin’s Press.
Thank you to everyone who subscribes to the website & podcast… wherever you do that! YOU are the reason Anesthesia Guidebook is here. Take care and have fun out there!
Jon Lowrance
What up yall! This is a quick shout out to those of you headed to the AANA conference this weekend, August 2nd, 2024 in San Diego.
I hope that yall have an incredible time and meet tons of new colleagues, see old friends and have fun gettin’ your learn on.
I was talking to one of the SRNAs from the University of New England this morning in clinical and she’s was getting psyched for the conference this weekend. AANA Annual Congress is one of those times where you can kind of lift your head up from the daily grind and look around & see thousands of other CRNAs & SRNAs or RRNAs from around the nation who are all out there doing their thing in anesthesia. It’s such an inspiring time!
While I will NOT be there reppin’ Anesthesia Guidebook, my clinical team from Maine Medical Center and MaineHealth will be.
So first, why am I not putting up a booth and talking about Anesthesia Guidebook… first & foremost, I’m not trying to sell you something. Anesthesia Guidebook is still anchored in the concept of free open access medical education. There’s no subscription fee and I’m not trying to make money off of CE credits. There’s a hundred other ways out there for you to make Class A credit and that just hasn’t become a professional focus on mine. Which brings up the reminder that any anesthesia related podcast you listen to will qualify for free Class B credit in the CPC program. If you’re a CRNA and you routinely listen to anesthesia podcasts, all you have to do is self-report your credits to the AANA and you’ll rack up those Class B credits super fast.
I actually did a brief podcast on this topic way back in Episode #9 of the podcast if you want to hear more about how to do that.
So while there’s no Anesthesia Guidebook table at AANA Annual Congress, you CAN go meet my good friends and colleagues from Maine Medical Center in the exhibition hall. April Bourgoin, Jill Guzzardo and Danielle Beaumont will be there staffing the MaineHealth booth to tell yall about the amazing career opportunities within MaineHealth. We have everything from level 1 trauma center work with my team at Maine Medical Center where I serve as chief CRNA to a full independent practice location in Conway, NH to several other smaller town medical centers throughout Maine, including Pen Bay Medical Center in Rockland, where Jill is the chief CRNA.
So April Bourgoin will be out there this weekend. Dr April Bourgoin one of our CRNA Supervisors at MMC, and she’s been on the show before talking about OR fires back in episode 93. I actually just recorded an episode that I’m editing now with April and our CRNA Manager, Alison Kent, on how we do interviews as a leadership team at MMC. That show is targeted towards other practice managers out there but is obviously also probably valuable for SRNAs as it gives you a behinds the scenes look at how we plan team interviews for people applying to be on our team. So April’s out there… you can also meet Danielle Beaumont, our SRNA Clinical Coordinator at Maine Medical Center. Danielle is amazing in that role as she supports SRN As from the University of New England and Middle Tennessee School of Anesthesia. Danielle also just helped us establish clinical affiliations with Boston College and Northeastern University. We’re pumped to start welcoming primary anesthesia trainees from BC and NU in 2025. And then last but not least is Jillian Guzzardo. Jill is one of our per diem CRNAs at MMC but she also serves as the Chief CRNA at one of our MaineHealth sister hospitals, Pen Bay Medical Center in Rockland, Maine. If you’re looking for a small town, coastal Maine community hospital to practice at, Jill is your girl! Pen Bay is literally on a bluff overlooking the Atlantic Ocean. You have close up water views from work. It’s amazing…. I mean, you can also see the ocean from the top floors of Maine Medical Center, but at Pen Bay, you can probably see what the lobstermen are having for breakfast as they motor by in the morning… it’s right there. Jill is one of my favorite CRNAs… after a few years of holding down the fort at Pen Bay as the chief CRNA, she reached out to me and asked if she could come work off shifts and weekends at Maine Medical Center to keep her high acuity patient care skills up. She literally asked if I would give her the shifts that my core team doesn’t want to work… nights, evenings and weekends. I was blown away.
All three of this CRNAs – April, Danielle and Jill – are baller clinicians. I would let any of them take care of me or my family and just love working alongside them in the OR. They’re also incredible CRNA leaders with a deep passion for helping SRNAs & CRNAs thrive in their practices. And they’re generally just inspiring, friendly humans… Kind, generous, optimistic people… who are wicked smahat as we say here in New England.
So if you’re headed to AANA Annual Congress, even if you’re not looking to move your practice to Maine, do yourself a favor and go meet these incredible people. April, Danielle and Jill will be pumped to meet you.
So that’s it… just wanted to drop a quick shoutout to those of you headed to AANA Annual Congress this weekend and say I hope it’s an amazing conference. Go get your learn on, meet some new friends and stop by the MaineHealth booth and tell my friends I said hello.
And with that… I’ll see ya next time!
What’s up yall this is Jon Lowrance and this is episode 107 – No Peace In Quiet with Keli Rueth.
I’m pumped to bring you this conversation with Keli where we discuss her first published novel, No Peace In Quiet.
This episode was so much fun to record and I think you’re really going to enjoy it. It’s a story that is worth sharing on an anesthesia podcast because it’s a story about how we as anesthesia providers explore the rest of our lives… how we can step out from our clinical roles as anesthesia providers to express our creativity and joy in a different way than being mixologists and potion makers in the OR.
In this episode, Keli and I talk through her process and approach to finding her passion for writing and how she has snuck that in to the nooks and crannies of her life between working as a mother, full time CRNA and professor of anesthesiology at the University of New England.
Keli Rueth is the pen name of Dr Keli Scrapchansky, who, by the way, was one of my favorite people on planet earth even before I knew she was a novelist. Keli started her career at Maine Medical Center just a few months before my wife, Kristin, and I did back 2015. She graduated with her Master’s in Anesthesia from Old Dominion University in 2014 and went on to complete her Doctor of Nursing Practice at the University of North Florida. Keli is one of those people who shows up anywhere with a smile on her face and brightens up the room she walks into. It’s incredibly difficult to get through a conversation of any length with her without laughing about whatever topic is on the table. She’s an easy conversationalist, a masterful clinician and educator and now, a published novelist.
No Peace In Quiet is Keli Rueth’s first novel in a trilogy, the next volume of which has a planned release for later this summer. I thoroughly enjoyed reading No Peace In Quiet and literally couldn’t stop turning the pages as the story developed and unfolded in the small town and surrounding mountains of Quiet, North Carolina.
You can check out Keli’s book at kelirueth.com.
And with that, let’s get to the show!
What’s up yall! I am back after a few months off from the podcast. This is episode 106 – following up: what we know about anesthesia school formatting with Cassie Capps.
This is a follow up show to the episode that Cassie brought to us back in December on the effects of anesthesia school didactic formatting on resident wellbeing… whether in-person, online, synchronous or asynchronous styles have any effect on your wellbeing as a trainee.
Before we get to this show, I’ve got a couple updates for you… our crew at Maine Medical Center has been on a bit of tour this spring attending conferences, job fairs and universities telling the story about our team and why we may be where you want to invest your career as an anesthesia provider. Cat Godfrey & April Bourgoin were just down at AANA’s Mid Year Assembly in Washington D.C. and then Cat made her way on to University of North Carolina at Greensboro to chat with the residents at Terry Wick’s program. She followed up dropping in on UNC-G with a virtual lunch & learn session with Mary Baldwin University’s anesthesia program over in Virginia. And then, Kristin and I just returned last week from Florida International University’s job fair down in Miami. We were so happy to know that even the locals thought it was super hot cause oooooooo….eeeeeeee… it was swimmy humid and all kinda hot down in the Sunshine State. We were stoked to meet a bunch of FIU anesthesia residents and tell yall about our absolutely gorgeous summers and four season climate up in Maine and how we’re probably where you want to start your career if you’re looking for a top notch level 1 trauma center to be at where you’re treated with respect, well-supported and want to join a thriving team that has a ton of fun working together. Just saying.
Part of my intention with Anesthesia Guidebook is to help CRNAs make a successful transition to practice and if you’re looking to do high acuity work in a busy tertiary medical center surrounded by an amazing team and in a phenomenal location, drop me a line and we can chat. I’d love to tell you more about our crew and see if we’re a good fit for where you’re headed.
In other news, this fall I’m teaching at Encore Symposium’s Autumn in Bar Harbor and Acadia National Park conference. If you’re looking for a spot to come knock out some continuing education this year, Encore is headed back to Bar Harbor, Maine, which is just outside of Acadia National Park, from October 14-17. If you’ve never been to Acadia, or Bar Harbor or Maine… this is your chance. Come check it out. Acadia in October is simply stunning… a national park, on an island, in Maine. With your anesthesia friends! You’ll be hard pressed to find a cooler spot to come get your learn on. Hope to see you there!
All right… with that, let’s get to this show. Cassie Capps is back. We first heard from Cassie in late December 2024 on episode 99 of Anesthesia Guidebook and now she’s back to walk us through the impact of anesthesia school didactic formatting on resident wellbeing. Thank to everyone who took Cassie’s survey and provided your insights… the data was actually a bit surprising so let me re-introduce Cassie to you and then she’s gonna get right to it.
This podcast was part of Cassie Capps’ Doctor of Nursing Practice in anesthesiology program at the University of Arizona. 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. Cassie continued 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 in May of 2024 and with that, let’s get to the show!
References
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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
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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.
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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
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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
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
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.DownloadBenumof, 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.
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:
- Ischemia Reperfusion Injury:
- “Pathophysiology of Reperfusion Injury” https://www.ncbi.nlm.nih.gov/books/NBK534267/#:~:text=Ischaemia%2DReperfusion%20injury%20(IRI),essential%20to%20salvage%20ischaemic%20tissues
- Postoperative pain and the Gut Microbiome
- Brenner, Shorten, & Mahony 2021
DNP Reference Tools
- AGREE II
- Overview
- https://www.ncbi.nlm.nih.gov/books/NBK525667/
- Manual
- https://www.agreetrust.org/resource-centre/agree-ii/
- Overview
- United States Preventive Service Task Force Grading
- Methods:
- https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes
- Grading System
- https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions
- Methods:
- Modified Delphi Technique Assessment of Appropriateness
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299905/
Dexmedetomidine-InfographicDownloadZimmerman-E-Narrative-1Download
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
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.
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.
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
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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
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Lowrance, J. (2023). Anesthesia Guidebook. https://anesthesiaguidebook.com
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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
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•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
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
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 […]
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 […]
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…
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
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
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!
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 […]
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 […]
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 […]
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 […]
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, […]
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 […]
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 […]
“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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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: help the SRNA gauge their progress in their training program help program faculty gauge how well they’re preparing students help SRNAs […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 – […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 & […]
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, […]
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 […]
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 […]
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 […]
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 […]
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, […]
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 […]
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 […]
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, […]
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 […]
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 […]
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 […]
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 […]
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: it’s packed with real-world information that’s evidence based from case […]
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 […]
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. […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 – […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 has a background in biology and EMS prior to pursuing a career as […]
“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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 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 […]
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 […]
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 […]
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 […]
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 […]
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. […]
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 […]
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 […]
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 […]
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 […]