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October 6, 2019
Kate currently practices anesthesia as a CRNA in the Department of Anesthesiology and Perioperative Medicine at Maine Medical Center.  Prior to nursing, Kate was an organic chemist with research and management experience in both industrial as well as pharmaceutical research labs.  Kate has earned a Masters of Science in Nurse Anesthesia from the University of New England, a Bachelors of Science in Nursing from the University of Massachusetts, and an American Chemical Society certified Bachelors of Science in Chemistry with a minor in Biology from Northeastern University. In this podcast, we talk about Kate choosing to go back to school for anesthesia as a mother of two small kids and about Kate’s remarkable effort to pay off $140,000 of student loan debt in just over a year. Check out the links below to think more about student loan debt. Death, Sex & Money podcast series on student loan debt. Take the Quiz… see where you line up on WNYC’s Death, Sex & Money student loan project quiz. Beyond the Mask with Jermey Stanley: Episode 23 – The Wealthy CRNA. Get tips on financial management specific to CRNAs in the above podcast and through Jeremy’s company: CRNA Financial Planning. Cycle back to Episode 18 of this show to hear Jeremy talk through freelancing options for CRNAs.
September 18, 2019
The Top Drawer Run Down covers the most common medications found in the top drawer of an anesthesia cart. Developing a mastery of these medications lays the foundation to a safe and effective anesthesia practice. This podcast is a start – or maybe a refresher – to developing that mastery. Here’s the medications we will cover in this series: Part 1 * Propofol* Etomidate* Ketamine* Lidocaine* Fentanyl * Morphine* Hydromorphone* Remifentanil* Sufentanil* Alfentanil* Succinylcholine* Rocuronium* Vecuronium* Cisatracurium Part 2 * Atropine* Glycopyrrolate * Neostigmine* Sugammadex * Metoprolol* Labetalol* Esmolol* Hydralizine* Phenylephrine* Ephedrine* Epinephrine* Calcium Chloride Part 3 * Heparin* Naloxone* Albuterol* Dexamethasone* Famotidine* Ondansetron* Haloperidol* Furosemide* Metoclopramide* Ketorolac* Oxytocin* Methylergonovine* Carboprost Michael Mielniczek, MSN, CRNA bio: Michael graduated from the University of Scranton with a Master’s in Nursing in December 2018. He currently practices anesthesia as a CRNA in Austin, Texas. He has an interest in pharmacology related to anesthesia and enjoys helping others understand this fascinating topic. Succinylcholine was the focus of Michael’s graduate research and he’s presented on the medication at both state CRNA conferences and national AANA Annual Congress. You may remember Michael from his previous contribution to From the Head of the Bed when he and I recorded a deep dive on succinylcholine back in March of 2018 (episode 39). Disclaimer Michael and I sourced our information from the leading anesthesia textbooks including Miller, Katzung, Oullette and Naglehout, as well as cross referencing with published journal articles and Up to Date.  That means that we’re bringing you the core, basic information about these medications.  It does NOT mean that everything we say is flawless and completely accurate.   Some of what we say may actually be a matter of opinion, personal preference and technique – you or the people you work with may have other opinions or techniques.   And that’s ok – it’s part of developing the art of providing anesthesia which is something you can do once you have a solid foundation of the science of anesthesia.  Michael and I both edited and reviewed our notes and I edited the content again in post-production.  However, as with any podcast or blog post, you should take what you learn here and cross reference it with published, peer-reviewed literature.  Your clinical practice and your decision making is your responsibility.  It can be super dangerous to just take something you hear in a podcast or read on a blog and immediately implement it in your practice without first doing your own due diligence by making sure you have both accurate information and a good understanding of how to integrate that into best practice.  Additionally, some of the common ways anesthesia providers use medications perioperatively are not FDA approved or are considered off-label.  We try to point those out in this series but again, your practice is your responsibility.  References Assante, J., Collins, S., & Hewer, I. (2015).
September 16, 2019
The Top Drawer Run Down covers the most common medications found in the top drawer of an anesthesia cart. Developing a mastery of these medications lays the foundation to a safe and effective anesthesia practice. This podcast is a start – or maybe a refresher – to developing that mastery. Here’s the medications we will cover in this series: Part 1 * Propofol* Etomidate* Ketamine* Lidocaine* Fentanyl * Morphine* Hydromorphone* Remifentanil* Sufentanil* Alfentanil* Succinylcholine* Rocuronium* Vecuronium* Cisatracurium Part 2 * Atropine* Glycopyrrolate * Neostigmine* Sugammadex * Metoprolol* Labetalol* Esmolol* Hydralizine* Phenylephrine* Ephedrine* Epinephrine* Calcium Chloride Part 3 * Heparin* Naloxone* Albuterol* Dexamethasone* Famotidine* Ondansetron* Haloperidol* Metoclopramide* Ketorolac* Oxytocin* Methylergonovine* Carboprost Michael Mielniczek, MSN, CRNA bio: Michael graduated from the University of Scranton with a Master’s in Nursing in December 2018. He currently practices anesthesia as a CRNA in Austin, Texas. He has an interest in pharmacology related to anesthesia and enjoys helping others understand this fascinating topic. Succinylcholine was the focus of Michael’s graduate research and he’s presented on the medication at both state CRNA conferences and national AANA Annual Congress. You may remember Michael from his previous contribution to From the Head of the Bed when he and I recorded a deep dive on succinylcholine back in March of 2018 (episode 39). Disclaimer Michael and I sourced our information from the leading anesthesia textbooks including Miller, Katzung, Oullette and Naglehout, as well as cross referencing with published journal articles and Up to Date.  That means that we’re bringing you the core, basic information about these medications.  It does NOT mean that everything we say is flawless and completely accurate.   Some of what we say may actually be a matter of opinion, personal preference and technique – you or the people you work with may have other opinions or techniques.   And that’s ok – it’s part of developing the art of providing anesthesia which is something you can do once you have a solid foundation of the science of anesthesia.  Michael and I both edited and reviewed our notes and I edited the content again in post-production.  However, as with any podcast or blog post, you should take what you learn here and cross reference it with published, peer-reviewed literature.  Your clinical practice and your decision making is your responsibility.  It can be super dangerous to just take something you hear in a podcast or read on a blog and immediately implement it in your practice without first doing your own due diligence by making sure you have both accurate information and a good understanding of how to integrate that into best practice.  Additionally, some of the common ways anesthesia providers use medications perioperatively are not FDA approved or are considered off-label.  We try to point those out in this series but again, your practice is your responsibility.  References Brull, S. J., & Kopman, A. F. (2017). Current Status of Neuromuscular Reversal and Monitoring Challenges and Opportunities.
September 6, 2019
The Top Drawer Run Down covers the most common medications found in the top drawer of an anesthesia cart. Developing a mastery of these medications lays the foundation to a safe and effective anesthesia practice. This podcast is a start – or maybe a refresher – to developing that mastery. Here’s the medications we will cover in this series: Part 1 * Propofol* Etomidate* Ketamine* Lidocaine* Fentanyl * Morphine* Hydromorphone* Remifentanil* Sufentanil* Alfentanil* Succinylcholine* Rocuronium* Vecuronium* Cisatracurium Part 2 * Atropine* Glycopyrrolate * Neostigmine* Sugammadex * Metoprolol* Labetalol* Esmolol* Hydralizine* Phenylephrine* Ephedrine* Epinephrine* Calcium Chloride Part 3 * Heparin* Naloxone* Albuterol* Dexamethasone* Famotidine* Ondansetron* Haloperidol* Metoclopramide* Ketorolac* Oxytocin* Methylergonovine* Carboprost Michael Mielniczek, MSN, CRNA bio: Michael graduated from the University of Scranton with a Master’s in Nursing in December 2018. He currently practices anesthesia as a CRNA in Austin, Texas. He has an interest in pharmacology related to anesthesia and enjoys helping others understand this fascinating topic.  Succinylcholine was the focus of Michael’s graduate research and he’s presented on the medication at both state CRNA conferences and national AANA Annual Congress. You may remember Michael from his previous contribution to From the Head of the Bed when he and I recorded a deep dive on succinylcholine back in March of 2018 (episode 39). Michael Mielniczek, MSN, CRNA Disclaimer Michael and I sourced our information from the leading anesthesia textbooks including Miller, Katzung, Oullette and Naglehout, as well as cross referencing with published journal articles and Up to Date. That means that we’re bringing you the core, basic information about these medications.  It does NOT mean that everything we say is flawless and completely accurate.   Some of what we say may actually be a matter of opinion, personal preference and technique – you or the people you work with may have other opinions or techniques.   And that’s ok – it’s part of developing the art of providing anesthesia which is something you can do once you have a solid foundation of the science of anesthesia.  Michael and I both edited and reviewed our notes and I edited the content again in post-production.  However, as with any podcast or blog post, you should take what you learn here and cross reference it with published, peer-reviewed literature.  Your clinical practice and your decision making is your responsibility.  It can be super dangerous to just take something you hear in a podcast or read on a blog and immediately implement it in your practice without first doing your own due diligence by making sure you have both accurate information and a good understanding of how to integrate that into best practice.  Additionally, some of the common ways anesthesia providers use medications perioperatively are not FDA approved or are considered off-label.  We try to point those out in this series but again, your practice is your responsibility.  References Çoruh, B., Tonelli, M. R., & Park, D. R. (2013).
July 16, 2019
This is a distillation of 10 key tips to help folks learning airway management to improve their skills. It’s also a framework for experienced providers to approach airway management from. This show gets straight to the point: 10 tips for airway management in 10 minutes. 10 Tips for Airway Management 1. Develop a growth mindset and practice deliberately 2. Do a good airway assessment 3. Develop and follow a plan 4. Control your environment 5. Position the patient and yourself for success 6. Preoxygenate adequately 7. Communicate effectively 8. Choose meds appropriately and let them work 9. Take your time with laryngoscopy 10. Recognize when you need to change your plan and do so deliberately Chong, J. (2016). Airway management in obese patients.  EMNote.  Retrieved from http://www.emnote.org/emnotes/airway-management-in-obese-patients This is my personal ramp preference – a stack of blankets wrapped in one blanket (which helps with removing the ramp after intubation) and either a pillow or foam shay on top. Photo by Jon Lowrance. Resources… delve in, read more: Achar, S. K., Pai, A. J., & Shenoy, U. K. (2014). Apneic oxygenation during simulated prolonged difficult laryngoscopy: comparison of nasal prongs versus nasopharyngeal catheter: a prospective randomized controlled study. Anesthesia, essays and researches, 8(1), 63. Booth, A. W. G., Vidhani, K., Lee, P. K., & Thomsett, C. M. (2017). SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study. BJA: British Journal of Anaesthesia, 118(3), 444-451 Caputo, N., Azan, B., Domingues, R., Donner, L., Fenig, M., Fields, D., … & McCarty, M. (2017). Emergency Department use of Apneic Oxygenation versus usual care during rapid sequence intubation: A randomized controlled trial (The ENDAO Trial). Academic Emergency Medicine, 24(11), 1387-1394. Chong, J. (2016).  Airway management in obese patients.  EMNote.  Retrieved from http://www.emnote.org/emnotes/airway-management-in-obese-patients Dearani, J. A., Gold, M., Leibovich, B. C., Ericsson, K. A., Khabbaz, K. R., Foley, T. A., … & Daly, R. C. (2017). The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection. The Journal of thoracic and cardiovascular surgery, 154(4), 1329-1336. Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939 Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt. Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81. e Silva, L. O. J., Cabrera, D., Barrionuevo, P., Johnson, R. L., Erwin, P. J., Murad, M. H., & Bellolio, M. F. (2017). Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis. Annals of emergency medicine, 70(4), 483-494.  Heard, A., Toner, A. J., Evans, J. R., Palacios,
April 17, 2019
In this episode, Skyler provides a thorough overview of local anesthetics including relevant anatomy and physiology (i.e. nerve fibers, sodium channels, pKa, etc), types of local anesthetics and factors that effect onset, potency, duration of action and absorption. We touch on methemoglobinemia, Local Anesthetic Systemic Toxicity (LAST) and common dosing and max dosing for local anesthetics. This is a great run down for anyone wanting to brush up on local anesthetics! At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a Level 1 Trauma Center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. She is expected to graduate in May 2020. References Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education. Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.
April 17, 2019
In this episode, Ashley walks us through an overview of the most common IV anesthesia induction agents. We cover propofol, ketamine, etomidate, barbiturates (e.g. methohexital), dexmedetomidine and benzodiazepines (e.g. midazolam). A run down of the mechanism of action, dosing, onset, metabolism and physiologic effects are provided. At the time of this recording, Ashley Scheil was a second-year SRNA at Marian University in Indianapolis, IN. She earned her BSN from Purdue University in 2012. Ashley worked as a critical care Registered Nurse in the surgical ICU at the Roudebush VA Medical Center in Indianapolis for 6 years before going back to anesthesia school. She is expected to graduate in May of 2020 with her DNP degree. References Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education. Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier.  Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.
April 17, 2019
In this episode, Skyler walks us through the pharmacodynamics of volatile anesthetics. We talk extensively about the concepts related to minimum alveolar concentration (MAC), the mechanism of action of volatile anesthetics and the physiologic response to volatiles. You don’t want to miss this excellent overview of core anesthesia concepts! At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a Level 1 Trauma Center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. She is expected to graduate in May 2020. References Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education. Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.
April 17, 2019
In this episode, Skyler gives a succinct run down on the pharmacokinetics of volatile anesthetics. We talk about uptake, distribution, elimination and metabolism and unpack concepts such as blood gas solubility, oil gas solubility, Fa/Fi curves and more. You don’t want to miss this excellent overview of core anesthesia concepts! At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a Level 1 Trauma Center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. She is expected to graduate in May 2020. References Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education. Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier.  Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences
April 17, 2019
In this episode, Ashley provides a detailed overview of the anesthesia machine, its components and key tips for using and troubleshooting it. If you want to know about or review the anesthesia machine… this is your podcast! At the time of this recording, Ashley Scheil was a second-year SRNA at Marian University in Indianapolis, IN. She earned her BSN from Purdue University in 2012. Ashley worked as a critical care Registered Nurse in the surgical ICU at the Roudebush VA Medical Center in Indianapolis for 6 years before going back to anesthesia school. She is expected to graduate in May of 2020 with her DNP degree. E – Cylinder Calculation Amount of oxygen in cylinder in liters divided by liters of flow Ex:       660 liters / 3 lpm = 220 minutes of oxygen              330 liters / 10 lpm = 33 minutes of oxygen References Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education. Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier.  Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.
April 17, 2019
In this episode, Ashley and I talk through how to set up an operating room anesthesia workstation, perform preoperative patient assessment and progress through an IV induction and intubation. This is a great podcast to help SRNAs and other anesthesia learners to get their clinical flow down! At the time of this recording, Ashley Scheil was a second-year SRNA at Marian University in Indianapolis, IN. She earned her BSN from Purdue University in 2012. Ashley worked as a critical care Registered Nurse in the surgical ICU at the Roudebush VA Medical Center in Indianapolis for 6 years before going back to anesthesia school. She is expected to graduate in May of 2020 with her DNP degree. References Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education. Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.
April 6, 2019
I had the distinct pleasure to talk with John Preston, DNSc, CRNA, APN and Lisa Kamen, CAE of the National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA) on the Continued Professional Certification (CPC) Program. If you want to know what’s up with the CPC Program, you’ve landed on the right podcast. We walk through a comprehensive overview of the program from what’s required in each 4-year cycle, a run down on Class A & B credits, Core Modules, the 2-year check-in requirements and, of course, an overview of the CPC Assessment or examination process. Additionally, we talk about the significance of the CPC Program from an continuing education standpoint and how it stacks up to what other professionals are doing and we wrap up the show with a conversation on the challenges and opportunities CRNAs will face in the coming years. John Preston, DNSc, CRNA, APN is the Chief Credentialing Officer for the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA). Dr. Preston has been active in nurse anesthesia accreditation, education and regulation for over 20 years.  His previous career accomplishments include nurse anesthesia program administrator, Chair of the Council on Accreditation and AANA Senior Director for Education and Professional Development. He has been a registered nurse for 31-years and a Certified Registered Nurse Anesthetist since 1994.   Lisa Kamen, CAE is the Senior Director of Communications, Publications and Governance with the NBCRNA and has been with the NBCRNA since 2015. Lisa earned the Certified Association Executive designation in 2018. The CAE credential is the marker of a committed association professional who has demonstrated the wide range of knowledge essential to manage an association in today’s challenging environment. She has more than 20 years of experience in the health care communications field, having worked with numerous health care non-profit organizations and associations. Resources: NBCRNA CPC Program website. This is where you want to for further information on the CPC Program at large. NBCRNA CPC Program Calculator – this will walk you through the key CPC Program dates tailored to where you are in your specific recertification cycle. Upload Class B credits with AANA here. This is the site, if you’re a member of the American Association of Nurse Anesthetists, that you can upload class be credits. Click “Class B Submissions” on the top banner and follow the instructions. NBCRNA’S CPC Program Timeline. (2018). Retrieved from: https://www.nbcrna.com/continued-certification
March 3, 2019
In this episode, we explore opioid free anesthesia with Tom Baribeault, MSN, CRNA and Jayme Reuter, MS, CRNA. Tom is the founder of the Society for Opioid Free Anesthesia and Jayme is the founder of Cornerstone Anesthesia Conferences. The three of us came together in Scottsdale, Arizona at one of Cornerstone’s continuing education conferences for CRNAs. We discuss the progression to opioid free anesthesia (OFA) in our field, where OFA fits into enhanced recovery programs and the specific techniques of how to provide a comfortable, opioid-free perioperative experience for our patients. Click the following link to find out more about the Society for Opioid Free Anesthesia, including a resource-filled members-only section of their website which includes overviews of pharmacological alternatives to opioids and specific opioid-free anesthetic plans. You can also explore all of Cornerstone Anesthesia Conference’s offerings. We will be in San Antonio, Sonoma, Huston and New Orleans in the coming months… come check us out! Tom Baribeault, MSN, CRNA is the Chief CRNA at Lexington Surgery Center in Lexington, Kentucky. He completed his anesthesia training at Case Western Reserve University. Tom has a passion for teaching anesthesia providers and others on opioid-free anesthesia, enhanced recovery after surgery, ultrasound guided regional anesthesia and point of care ultrasound. He is the president and founder of the Society for Opioid Free Anesthesia and is a member of the American Association of Nurse Anesthetists and the Kentucky Association of Nurse Anesthetists. Jayme Reuter, MS, CRNA is the Program Director and founder of Cornerstone Anesthesia Conferences. She completed her anesthesia training at Baylor College of Medicine and practices at Houston Methodist Hospital, which is part of Texas Medical Center. She created Cornerstone Anesthesia Conferences in 2017 with a mission to be the foundation for excellence in continuing anesthesia education.
February 2, 2019
I had the pleasure of speaking with Major April Ritter, DNAP, CRNA, recently on the topic of operating room fires… which is a bit of a hot topic in the perioperative world. Dr Ritter completed her Masters of Nursing Science (MSN) and Doctorate of Nurse Anesthesia Practice at Virginia Commonwealth University. Dr Ritter is also a Major in the United States Army Reserves. 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 and returning to school for her master’s and doctorate degrees in anesthesia. She was recently involved in an operating room procedure in which there was a fire. We discuss the case at length and then dive into the background on OR and airway fires including contributing factors, prevention, crisis management and the importance of critical incident debriefing. You don’t want to miss this red hot podcast… hopefully the lessons here will smolder in your memory moving forward and help you turn up the heat on your fire prevention practices! Resources: Anesthesia Patient Safety Foundation Fire Safety Video APSF Fire Safety Video Contributes to 44% Decrease in Intraoperative Fires Since 2011 Anesthesia e-Nonymous – Virginia Commonwealth University
February 2, 2019
Hey folks! This podcast is about recharging. It’s a talk that touches on provider wellness and our need to find time on a weekly basis to pull back and take care of ourselves – to recharge! Below you’ll see the Crisis Text Line phone number: 741-741. This is the number you text if you or someone you know is having a crisis, particularly involving suicidal ideation, depression and/or hopelessness. Below that is an image outlining the National Wellness Institute’s Six Dimensions of Wellness. I talk more about both of these and so much more in the podcast – check it out! In the podcast I reference facts from the following articles: * Tarantur, N., Deshur, M. (2018). Anesthesia professional burnout – a clear and present danger.  APSF Newsletter. 33(2), 43-44.* Chipas, A., & McKenna, D. (2011). Stress and burnout in nurse anesthesia. AANA journal, 79(2). * Chipas, A, Cordrey, D., Floyd D., Grubbs, L., Miller S., & Tyre B. (2012). Stress: perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. AANA journal, 80(4), S49. * De Oliveira, G. S., Chang, R., Fitzgerald, P. C., Almeida, M. D., Castro-Alves, L. S., Ahmad, S., & McCarthy, R. J. (2013). The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesthesia & Analgesia, 117(1), 182-193.  * Raj, K. S. (2016). Well-being in residency: a systematic review. Journal of graduate medical education, 8(5), 674-684.  * Crisis Text Line image.  (n.d.)  Copyright 2013-2018 Crisis Text Line.  Retrieved 26 November 2018 from https://www.crisistextline.org.  Screenshot by author* Hettler, B. (1976). Six dimensions of wellness model. National Wellness Institute. Retrieved from https://cdn.ymaws.com/www.nationalwellness.org/resource/resmgr/tools/SixDimensionsFactSheet_Tool.pdf.  Screenshot by author.* Dweck, C. S. (2008). Mindset: The new psychology of success. Random House Digital, Inc..  Retreived from https://www.penguinrandomhouse.com/books/44330/mindset-by-carol-s-dweck-phd/9780345472328/. * Grant, A.  (2018, December 8).  What straight-A students get wrong.  The New York Times.  Retrieved from https://www.nytimes.com/2018/12/08/opinion/college-gpa-career-success.html
March 25, 2018
In this episode, I had the privilege of chatting with Michael Mielniczek, BSN, SRNA on an overview of succinylcholine. At the time of this recording, Michael was a second year Student Registered Nurse Anesthetist at the University of Scranton and a student representative for the AANA Foundation.  His background includes experience as a critical care Registered Nurse in Austin and achieving nursing certifications in critical care (CCRN), cardiac medicine (CMC) and cardiac surgery (CSC).   As part of his graduate studies, Michael completed an in-depth project regarding the history, latest research and controversies on succinylcholine titled “Succinylcholine:  From Discovery to Current Evidence for Everyday Practice,” which is also the title of his podium presentation at the 2018 national AANA Nurse Anesthetists Annual Congress in Boston. Michael contacted me with a desire to share what he’s learned on succinylcholine with our podcast listeners and I couldn’t be more pleased to bring you this episode. In the episode, we cover an in-depth overview of succinylcholine pharmacology, dosing, considerations and controversies. While our conversation is strictly based on published anesthesia textbooks and published, peer-reviewed journal articles, we both strongly encourage you to cross-reference any and all information, especially on dosing, with published resources. The resources we pulled from for this conversation are below: Alvarellos, M. L., McDonagh, E. M., Patel, S., McLeod, H. L., Altman, R. B., & Klein, T. E. (2015). PharmGKB summary: succinylcholine pathway, pharmacokinetics/pharmacodynamics. Pharmacogenetics and genomics, 25(12), 622. Barash, P. G. (Ed.). (2009). Clinical anesthesia. Lippincott Williams & Wilkins. Fukano, N., Suzuki, T., Ishikawa, K., Mizutani, H., Saeki, S., & Ogawa, S. (2011). A randomized trial to identify optimal precurarizing dose of rocuronium to avoid precurarization-induced neuromuscular block. Journal of anesthesia, 25(2), 200-204. Lee, C. (2003). Conformation, action, and mechanism of action of neuromuscular blocking muscle relaxants. Pharmacology & therapeutics, 98(2), 143-169. Nagelhout, J. J., & Plaus, K. L. (2014). Nurse anesthesia. Elsevier Health Sciences. Miller, R. D. (2015). Miller’s anesthesia (8th ed.). Philadelphia, PA: Churchill Livingstone/Elsevier. Schreiber, J. U., Lysakowski, C., Fuchs-Buder, T., & Tramer, M. R. (2005). Prevention of Succinylcholine-induced Fasciculation and MyalgiaA Meta-analysis of Randomized Trials. Anesthesiology: The Journal of the American Society of Anesthesiologists, 103(4), 877-884. Tran, D. T., Newton, E. K., Mount, V. A., Lee, J. S., Wells, G. A., & Perry, J. J. (2015). Rocuronium versus succinylcholine for rapid sequence induction intubation. The Cochrane Library.
November 20, 2017
Tim Fitzgerald, MD is a surgical oncologist and Director of Surgical Oncology at Maine Medical Center and MaineHealth. He is an Associate Professor of Surgery at Tufts University School of Medicine and specializes in complex gastrointestinal surgery.  Dr Fitzgerald has published and lectured extensively on enhanced recovery programs for the perioperative environment.  His implementation of an enhanced recovery program for complex gastrointestinal surgical patients at a tertiary medical center in North Carolina resulted in significant reduction in length of stay, decreased mortality and decreased cost. Dr Fitzgerald joined me to record a three-part series on enhanced recovery programs (colloquially referred to as “ERAS” programs).  In part 1, we discuss the realm of quality in healthcare and why enhanced recovery programs matter.  In part 2, we take a deep dive into the details of enhanced recovery programs from the pre-hospital phase through the post-operative phase of care.  In part 3, we discuss the concept of frailty and optimizing patient care in the perioperative surgical home. The American Association of Nurse Anesthetists (AANA) offers a public website with links to numerous consensus guidelines and resources related to implementing enhanced recovery programs. Sources: * Timothy L., F., Catalina, M., Nicholas J., K., Nasreen A., V., Kimberly V., E., & Emmanuel E., Z. (2016). Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter. Surgery Research And Practice, Vol 2016 (2016), doi:10.1155/2016/6830260 * Mosquera, C., Koutlas, N., Fitzgerald, T.  (2016)  A single surgeon’s experienced with enhanced recovery after surgery: an army of one.  The American Surgeon. 82 (7), 594-601. * AANA. (2017).  Enhanced recovery after surgery: considerations for pathway development and implementation. American Association of Nurse Anesthetists. Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/enhanced-recovery-after-surgery.pdf?sfvrsn=6d184ab1_6
November 20, 2017
Tim Fitzgerald, MD is a surgical oncologist and Director of Surgical Oncology at Maine Medical Center and MaineHealth. He is an Associate Professor of Surgery at Tufts University School of Medicine and specializes in complex gastrointestinal surgery.  Dr Fitzgerald has published and lectured extensively on enhanced recovery programs for the perioperative environment.  His implementation of an enhanced recovery program for complex gastrointestinal surgical patients at a tertiary medical center in North Carolina resulted in significant reduction in length of stay, decreased mortality and decreased cost. Dr Fitzgerald joined me to record a three-part series on enhanced recovery programs (colloquially referred to as “ERAS” programs).  In part 1, we discuss the realm of quality in healthcare and why enhanced recovery programs matter.  In part 2, we take a deep dive into the details of enhanced recovery programs from the pre-hospital phase through the post-operative phase of care.  In part 3, we discuss the concept of frailty and optimizing patient care in the perioperative surgical home. The American Association of Nurse Anesthetists (AANA) offers a public website with links to numerous consensus guidelines and resources related to implementing enhanced recovery programs. Sources: * Timothy L., F., Catalina, M., Nicholas J., K., Nasreen A., V., Kimberly V., E., & Emmanuel E., Z. (2016). Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter. Surgery Research And Practice, Vol 2016 (2016), doi:10.1155/2016/6830260 * Mosquera, C., Koutlas, N., Fitzgerald, T.  (2016)  A single surgeon’s experienced with enhanced recovery after surgery: an army of one.  The American Surgeon. 82 (7), 594-601. * AANA. (2017).  Enhanced recovery after surgery: considerations for pathway development and implementation. American Association of Nurse Anesthetists. Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/enhanced-recovery-after-surgery.pdf?sfvrsn=6d184ab1_6
November 20, 2017
Tim Fitzgerald, MD is a surgical oncologist and Director of Surgical Oncology at Maine Medical Center and MaineHealth. He is an Associate Professor of Surgery at Tufts University School of Medicine and specializes in complex gastrointestinal surgery.  Dr Fitzgerald has published and lectured extensively on enhanced recovery programs for the perioperative environment.  His implementation of an enhanced recovery program for complex gastrointestinal surgical patients at a tertiary medical center in North Carolina resulted in significant reduction in length of stay, decreased mortality and decreased cost. Dr Fitzgerald joined me to record a three-part series on enhanced recovery programs (colloquially referred to as “ERAS” programs).  In part 1, we discuss the realm of quality in healthcare and why enhanced recovery programs matter.  In part 2, we take a deep dive into the details of enhanced recovery programs from the pre-hospital phase through the post-operative phase of care.  In part 3, we discuss the concept of frailty and optimizing patient care in the perioperative surgical home. The American Association of Nurse Anesthetists (AANA) offers a public website with links to numerous consensus guidelines and resources related to implementing enhanced recovery programs. Sources: * Timothy L., F., Catalina, M., Nicholas J., K., Nasreen A., V., Kimberly V., E., & Emmanuel E., Z. (2016). Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter. Surgery Research And Practice, Vol 2016 (2016), doi:10.1155/2016/6830260 * Mosquera, C., Koutlas, N., Fitzgerald, T.  (2016)  A single surgeon’s experienced with enhanced recovery after surgery: an army of one.  The American Surgeon. 82 (7), 594-601. * AANA. (2017).  Enhanced recovery after surgery: considerations for pathway development and implementation. American Association of Nurse Anesthetists. Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/enhanced-recovery-after-surgery.pdf?sfvrsn=6d184ab1_6
August 25, 2017
The September 2017 AANA News Bulletin contains an article I wrote titled:  SRNAs – Key Tips for Transitioning to Practice. The article builds on podcast #25 – Transitioning to Practice that I put out back in February 2016.  In the article I discuss tips for the last six months of anesthesia school including tips for mastering boards, the transition out of school and the first six months of practice. This podcast pairs with the AANA News Bulletin article providing additional insights and stories to help SRNAs and new grad CRNAs make the transition smooth and begin to set goals for the next season of life. Below are some references made in the podcast: Dweck, C. S. (2006). Mindset: The new psychology of success. Random House Incorporated. Carol Dweck TEDTalk:  The power of believing you can improve Death, Sex & Monday podcast on student loans NOLS Wilderness Medicine for the Professional Practitioner Cornerstone Anesthesia Conferences NOLS Expedition Behavior blog post Heuer, A., Kossick, B. M. A., & Riley, C. J. (2017). Update on Guidelines for Perioperative Antibiotic Selection and Administration From the Surgical Care Improvement Project (SCIP) and American Society of Health-System Pharmacists. AANA Journal, 85(4), 293.
August 15, 2017
I caught up with Christine Hein, MD recently to talk about healthcare provider wellness. Dr Hein is an emergency medicine physician and Director of the Provider Well-being and Peer Support program at Maine Medical Center in Portland, Maine. I was also very honored to have a special guest on this episode:  Ms Abby Irish, Dr Hein’s daughter. Abby is currently in 8th grade and recently completed a surgery summer camp in Boston. She has a strong interest in becoming a physician and sat in to both listen and contribute to our conversation on provider wellness.  I’m so thankful for her participation and unique views of both her mom’s career and medicine at large! Christine Hein, MD Bio: Dr Hein completed medical school at Dartmouth in 2001 followed by her residency in emergency medicine at Maine Medical Center where she was Chief Resident in her final year.  She currently serves as the Associate Medical Director for the Department of Emergency Medicine and the Director of Provider Well-being and Peer Support at Maine Medical Center as well as the Director of Emergency Medicine for MaineHealth.  She is an Associate Professor of Emergency Medicine at Tufts University School of Medicine and is well-respected as a medical educator, receiving in 2009 the American College of Emergency Physicians National Teacher of the Year award.  Her research interests include burnout, resiliency, critical care and women’s issues in medicine.  Outside of work, Dr Hein is married, has five children and is an avid marathoner, completing over 23 marathons including posting highly competitive times in the Boston Marathon. Quotes: “Three-hundred to 400 physicians each year in the United States commit suicide… essentially two medical school classes of physicians each year.”  Christine Hein, MD “I think that it has professionally been probably the most satisfying experience of my career – to be involved in [Provider Wellness].”  Christine Hein, MD “[Resilience is] the capability of a strained body to recover its size and shape after deformation caused especially by compressive forces.”  Christine Hein, MD Resources: AANA Health & Wellness and Peer Assistance Website Attending:  medicine, mindfulness and humanity Ronald Epstein, MD TEDTalk:  Everything you think you know about addiction is wrong by Johann Hari Epstein, R. M., & Krasner, M. S. (2013). Physician resilience: what it means, why it matters, and how to promote it. Academic Medicine, 88(3), 301-303. Raj, K. S. (2016). Well-being in residency: a systematic review. Journal of graduate medical education, 8(5), 674-684. Swensen, S. J., & Shanafelt, T. (2017). An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice. The Joint Commission Journal on Quality and Patient Safety, 43(6), 308-313.  
July 18, 2017
This is a quick overview of some continuing education opportunities coming up.  I’ll be co-instructing a NOLS Wilderness Medicine course with my good friend Sara Nelson, MD this October 20-22, 2017 near Flagstaff, Maine.  I’ll also help teach an anesthesia continuing education conference for CRNAs with Cornerstone Anesthesia Conferences from February 26 – March 1, 2018 in Scottsdale, Arizona. NOLS Wilderness Medicine course overview: I’ve taught for NOLS Wilderness Medicine since 2007 and the course Dr Nelson and I are offering this fall is a Wilderness Medicine for the Professional Practitioner course.  This course is open to the general healthcare community and teaches clinicians how apply existing medical knowledge in a new way to manage a patient in a wilderness, remote or disaster setting.  This course is hands-on, fast-paced and super fun!  We’re offering this course at a unique destination location:  the Flagstaff Hut of the Maine Huts and Trails network.  This hut is 1.8 miles from the nearest trail head and is a bit more than a “hut.”  Think lakeside beautiful log cabin with vaulted ceilings, wood stoves, leather couches and fully staffed commercial kitchen.  The huts run completely off the grid yet have heated bunk rooms, hot showers and full electricity.  All meals and lodging are included in course fees.  16 hours of AMA PRA Category 1 CME is included.  Check the links below for more details. NOLS Wilderness Medicine for the Professional Practitioner NOLS Wilderness Medicine continuing education information. Cornerstone Anesthesia Conferences overview: I’m so excited to contribute to Cornerstone Anesthesia Conferences’ February/March 2018 Scottsdale, AZ conference!  The “Anesthesia Update in Desert Oasis” is going to be a fantastic opportunity for CRNAs to earn 20 CE credits through the American Association for Nurse Anesthetists (AANA).  I’m in the line up to teach 5 topics at this conference: 1.  Ketamine, 2.  Neuromuscular Blockade and Reversal, 3.  Updates in Airway Management, 4.  Leadership in Emergencies and 5.  Enhanced Recovery After Surgery (ERAS): Updates.  It’s going to be EPIC! The conference will be hosted at the Double Tree Resort by Hilton Hotel Paradise Valley.  You’ll receive 20 Class A CE credits, 6 pharmacology credits and a full breakfast buffet each morning as part of the conference.  All of the lectures are based on CPC Core Modules. From Cornerstone Anesthesia Conferences’ website: Cornerstone Anesthesia Conferences is based in Houston, Texas, which is home to the largest medical center in the United States and many world-renowned medical complexes. Founded in 2016 by three lifelong friends, our mission is to serve as the foundation for excellence in continuing education services. Cornerstone Anesthesia Conferences focuses on offering the most up-to- date, evidence-based information with lectures pertaining to the Core Modules of the CPC Requirements. Our topics are hand-picked to correspond with all of the four Core Modules. To that end, we offer world class speakers and cutting edge topics in exciting, fun-filled locations with opportunities for networking, meeting other CRNAs, and relaxing while learning. Check out one of our CRNA seminars today!
July 6, 2017
In this podcast, I talk with Chuck Biddle, PhD, CRNA about iatrogenic infections related to anesthesia workstation behaviors.  This continues to be a focal point of Dr Biddle’s research on patient safety and is a topic that concerns every anesthesia provider everywhere.  Anesthesia providers have the potential to harm patients via the spread of infectious organisms as part of routine patient care.  Dr Biddle discusses challenges and possible solutions for reducing patient harm related to anesthesia provider practices and the anesthesia workstation.  This topic and related research has the potential to change practice and advance the care that anesthesia practitioners provide worldwide. Dr Biddle is a professor of Nurse Anesthesia at Virginia Commonwealth University (VCU) and provides anesthesia services as a CRNA at VCU Medical Center.  He oversees the research efforts of the Department of Nurse Anesthesia at VCU and has served continuously as the Editor-in-Chief of the AANA Journal for over 25 years.  Dr Biddle’s anesthesia education and Master’s degree were earned at Old Dominion University and his PhD in epidemiology is from the University of Missouri. Highlights: “I think the most important thing that the listener can do, that we can do as practitioners, is to talk about it… because there are people out there far smarter than I with greater perspective – novel perspective – that will come up with solutions for this problem that we’re facing.” Chuck Biddle, PhD, CRNA “There will be a new generation of anesthesia providers and thinkers and engineers and nurses and doctors etcetera that will find solutions to these problems.”  Chuck Biddle, PhD, CRNA Resources: Biddle, C., & Shah, J. (2012). Quantification of anesthesia providers’ hand hygiene in a busy metropolitan operating room: What would Semmelweis think? American Journal of Infection Control, 40, 756-759. doi:10.1016/j.ajic.2011.10.008 Biddle, C. (2009). Semmelweis Revisited: Hand Hygiene and Nosocomial Disease Transmission in the Anesthesia Workstation. AANA Journal, 77(3), 229-237. Munoz-Price, L. S., & Weinstein, R. A. (2015). Fecal patina in the anesthesia work area. Anesthesia And Analgesia, 120(4), 703-705. doi:10.1213/ANE.0000000000000542
June 6, 2017
In this podcast, I chat with Chuck Biddle, PhD, CRNA about his and other research on at-home cardiorespiratory events following ambulatory surgery.  We discuss risk factors, screening tools and patient education that is designed to enhance patient safety and decrease postoperative negative outcomes following ambulatory surgery. Dr Biddle is a professor of Nurse Anesthesia at Virginia Commonwealth University (VCU) and provides anesthesia services as a CRNA at VCU Medical Center.  He oversees the research efforts of the Department of Nurse Anesthesia at VCU and has served continuously as the Editor-in-Chief of the AANA Journal for over 25 years.  Dr Biddle’s anesthesia education and Master’s degree were earned at Old Dominion University and his PhD in epidemiology is from the University of Missouri. “The first step in fixing a problem is identifying the problem.”  Jonathan Benumof, MD “We are only now… illuminating terrain that previously has been quite darkened… this idea [of] what happens to patients in their homes after anesthesia.  We’re beginning to look systematically at this and I think it’s long overdue.”  Chuck Biddle, PhD, CRNA Resources: Benumof, J. L. (2016). Mismanagement of obstructive sleep apnea may result in finding these patients dead in bed. Canadian Journal of Anesthesia/Journal canadien d’anesthésie, 63(1), 3-7. Biddle, C., Elam, C., Lahaye, L., Kerr, G., Chubb, L., & Verhulst, B. (2017). Predictors of At-Home Arterial Oxygen Desaturation Events in Ambulatory Surgical Patients. Journal of Patient Safety. Hill, M. V., Stucke, R. S., McMahon, M. L., Beeman, J. L., & Barth Jr, R. J. (2017). An Educational Intervention Decreases Opioid Prescribing After General Surgical Operations. Annals of Surgery. STOP-BANG Obstructive Sleep Apnea Questionnaire Washington Post article on Barth’s study AANA Journal homepage Virginia Commonwealth University Nurse Anesthesia Biddle, C. (2013). Evidence trumps belief: Nurse anesthetists and evidence-based decision making.  
May 2, 2017
In 2014, Mason McDowell, DNAP, CRNA quit his job, sold most of what he owned and moved with his wife and two young daughters to Chad, Africa for a long-term commitment to provide anesthesia and education.  Here is a glimpse of their story. Part 1 overviews Dr McDowell’s experience and challenges providing anesthesia and living in Chad. In Part 2, Dr McDowell offers advice for CRNAs/SRNAs who are looking to travel internationally to provide anesthesia in developing nations. The McDowell family’s time in Chad was interrupted abruptly by a deteriorating political situation making it unsafe for them to stay.  They lived in Bere, Chad for nearly two years before being forced to leave and return to the United States.  Since that time, Dr McDowell has traveled to Nepal and Sierra Leone to provide short term anesthesia services.  In this podcast I talk with him about the challenges of providing anesthesia in underdeveloped settings.  From the bugs at night in the desert heat to draw-over vaporizers and the heart wrenching stories of not having enough resources to provide care, Dr McDowell conveys what it was like for his family to live and work in Chad and what we can do as SRNAs, CRNAs and anesthesia providers to help serve underdeveloped nations. This is really an amazing story that I’m honored to share.  You can read more about Dr McDowell’s time in Chad at his blog: Why We Should Go.  Dig deep, read the stories.  They’re amazing. http://whyweshouldgo.blogspot.com Dr Mason McDowell lives in Western North Carolina and serves as faculty with Western Carolina University’s (WCU) Graduate Nurse Anesthesia Program.  Before moving to Chad, he served as the Assistant Director of the Graduate Nurse Anesthesia Program at WCU.  He is the co-author of the chapter on Hepatobillary and Gastrointestinal Disturbances and Anesthesia in Nagelhout’s Nurse Anesthesia. Resources: Unites States Department of State page on Chad: https://travel.state.gov/content/passports/en/country/chad.html Corbett, S., Fikkert, B.  (2012) When helping hurts: how to alleviate poverty without hurting the poor… and yourself.  Chicago, IL: Moody Publishers.
May 2, 2017
In 2014, Mason McDowell, DNAP, CRNA quit his job, sold most of what he owned and moved with his wife and two young daughters to Chad, Africa for a long-term commitment to provide anesthesia and education.  Here is a glimpse of their story. Part 1 overviews Dr McDowell’s experience and challenges providing anesthesia and living in Chad. In Part 2, Dr McDowell offers advice for CRNAs/SRNAs who are looking to travel internationally to provide anesthesia in developing nations. The McDowell family’s time in Chad was interrupted abruptly by a deteriorating political situation making it unsafe for them to stay.  They lived in Bere, Chad for nearly two years before being forced to leave and return to the United States.  Since that time, Dr McDowell has traveled to Nepal and Sierra Leone to provide short term anesthesia services.  In this podcast I talk with him about the challenges of providing anesthesia in underdeveloped settings.  From the bugs at night in the desert heat to draw-over vaporizers and the heart wrenching stories of not having enough resources to provide care, Dr McDowell conveys what it was like for his family to live and work in Chad and what we can do as SRNAs, CRNAs and anesthesia providers to help serve underdeveloped nations. This is really an amazing story that I’m honored to share.  You can read more about Dr McDowell’s time in Chad at his blog, Why We Should Go.  Dig deep, read the stories.  They’re amazing. http://whyweshouldgo.blogspot.com Dr Mason McDowell lives in Western North Carolina and serves as faculty with Western Carolina University’s (WCU) Graduate Nurse Anesthesia Program.  Before moving to Chad, he served as the Assistant Director of the Graduate Nurse Anesthesia Program at WCU.  He is the co-author of the chapter on Hepatobillary and Gastrointestinal Disturbances and Anesthesia in Nagelhout’s Nurse Anesthesia. Resources: Unites States Department of State page on Chad: https://travel.state.gov/content/passports/en/country/chad.html Corbett, S., Fikkert, B.  (2012) When helping hurts: how to alleviate poverty without hurting the poor… and yourself.  Chicago, IL: Moody Publishers.  
February 28, 2017
I talk with Denham Ward, MD, PhD on the topic of expertise in anesthesia.  Dr Ward is currently the director of the Academy at Maine Medical Center Institute for Teaching Excellence and a Professor of Anesthesiology at Tufts University School of Medicine.  He is Emeritus Professor and Chair of Anesthesiology and Emeritus Professor of Biomedical Engineering at the University of Rochester. This podcast focuses on the idea of developing and maintaining expertise over a career in anesthesia.  Highlights range from defining expertise, specialization in anesthesia, types of problem solving and clinical decision making and how to teach and coach the development of expertise in trainees as well as experienced clinicians. “The difference between medicine and music is… musicians practice, practice, practice and then they go to Carnegie Hall for one evening…  We’re essentially at Carnegie Hall every day.”  Denham Ward, MD, PhD References: Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939 Gawande, A. (2011). Personal best. The New Yorker, (30). 44.  Retrieved from http://www.newyorker.com/magazine/2011/10/03/personal-best. Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux. Moulton, C. E., Regehr, G., Mylopoulos, M., & MacRae, H. M. (2007). Slowing down when you should: a new model of expert judgment. Academic Medicine: Journal Of The Association Of American Medical Colleges, 82(10 Suppl), S109-S116.  
February 28, 2017
Jon provides a quick update on the publication of the article “Social media in nurse anesthesia – a model for a reproducible podcast” published in the February 2017 edition of the AANA Journal.  This article provides the literature review associated with and production overview of the creation of “From the Head of the Bed… a podcast for the anesthesia community.”  The article was authored by the founders of From the Head of the Bed:  Kristin Andrejco, Jon Lowrance, Brad Morgan, Cassidy Padgett and by Shawn Collins. References: Andrejco, K. (2017). Social Media in Nurse Anesthesia: A Model of a Reproducible Educational Podcast. AANA Journal, 85(1), 10-16. Biddle, C. (2017). Increasing the Online Presence of the AANA Journal. AANA Journal, 85(1), 6-7.  
July 16, 2016
In this show I talk about hardship in anesthesia school. Yep. It is for you, actually.  It’s for you if you’re struggling.  Or even if you’re not – cause your classmate or colleague might be. This podcast is about the hardships we face in anesthesia school and how we can find help, cope and pull through to a brighter future.  It’s about knowing you’re not alone.  It’s about learning how to deal with the pain and the challenges and how to find help. To develop this show, I asked for help from my friends, colleagues and from the anesthesia social media world.  Many of you replied with your stories and advice.  I pulled together what I’ve heard and a little of what I went through personally and put it here, for you, for each of us. I want you to know this: If you’re struggling with suicidal ideation or drug abuse there is help available. You are important.  You are not alone.  Your life is important and people care about you. Please seek help and support.  Please tell someone what you’re facing.   Please call one of the numbers below and reach out to a friend, family member or colleague. Help is available.  You are not alone.  People care about you. American Foundation for Suicide Prevention Hotline 1-800-273-8255 National Suicide Prevention Lifeline   1-800-273-8255   AANA Peer Assistance Hotline 1-800-654-5167 National Helpline 1-800-662-4357 Anesthetists in Recovery Overview of Anesthetists in Recovery (AIR) and Partners of Anesthetists in Recovery (PAIR): Bertrand, Anita.  (2013).  Saving Lives: AIR/PAIR.  AANA NewsBulletin.  Retrieved from: http://www.aana.com/resources2/health-wellness/Documents/nb_pan_0513.pdf  
February 1, 2016
This episode covers advice for the last six months of anesthesia school, transitioning out of school and into the first six months of your CRNA practice! The year encompassing your last six months of anesthesia school through your first six months of practice is a big one!  There’s such a learning curve you will encounter from studying for boards to landing your first anesthesia job through your first several months of practice.  It’s an amazing time and well worth all the hard work and effort! Check out the podcast and please feel free to offer your own insights/advice in the comments section. Topics covered: * Wrapping up anesthesia school:  your project/thesis, landing a job and tips for boards * Transitioning out of school – it goes by fast! * The first six months of practice:  tips for your practice, your ability to influence others and finances! I mentioned this article in the podcast: Assante, J., Collins, S., & Hewer, I. (2015). Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review. AANA Journal, 83(4), 281-288.
January 26, 2016
Cherie Burke, DNP, CRNA discusses the concept of positive deviance in healthcare.  Highlights include how to effect change as healthcare providers and the power of focusing quality improvement proactively on what goes right in an organization verses reacting to errors and negative outcomes.  Dr Burke is a practicing CRNA with nearly 30 years of clinical and teaching experience.  She holds a Doctorate of Nursing Practice from LaSalle University with her doctoral research focusing on patient safety. Topics Discussed: * Positive deviance as a methodology of outcome analysis * Positive deviance as a professional behavior of healthcare providers * How to harness the power of positive deviance in anesthesia practice and education * The limitations and risks of positive deviance as a research tool and professional practice   Highlights: “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 patient’s care, our patient’s outcome.”  Dr Cherie Burke “We have to really encourage innovation.  We’re at a tipping point in healthcare.  We’re going to have to do major, major innovation to be successful and to survive in the healthcare arena…  Nurse anesthetists are going to have to be creative.  We’re going to have to figure out how can we continue doing high quality care with excellent outcomes, safety [and] efficiency.”  Dr Cherie Burke   Resources:  Bradley, E. H., Curry, L. A., Ramanadhan, S., Rowe, L., Nembhard, I. M., & Krumholz, H. M. (2009). Research in action: using positive deviance to improve quality of health care. Implementation Science, 41-11. doi:10.1186/1748-5908-4-25\ Ford, K. (2013). Survey of Syringe and Needle Safety Among Student Registered Nurse Anesthetists: Are We Making Any Progress?. AANA Journal, 81(1), 37-42. Gary, J. C. (2013). Exploring the concept and use of positive deviance in nursing. The American Journal Of Nursing, 113(8), 26. doi:10.1097/01.NAJ.0000432960.95762.5f Lawton R., Taylor, N., Clay-Williams, R., & Braithwaite, J. (2014). Positive deviance: a different approach to achieving patient safety.  BMJ, 0:1–4. doi:10.1136/bmjqs-2014-003115 Prielipp, R. C., Magro, M., Morell, R. C., & Brull, S. J. (2010). THE OPEN MIND. The Normalization of Deviance: Do We (Un)Knowingly Accept Doing the Wrong Thing?. AANA Journal, 78(4), 284-287. doi:10.1213/ANE.0b013e3181d5adc5 Rosenberg, T. (2013, February 27).  When deviants do good.  The New York Times, Retrieved from http://opinionator.blogs.nytimes.com/2013/02/27/when-deviants-do-good/?_r=0
December 21, 2015
I sat down with Jon Bradstreet, MSN, CRNA to chat about how SRNAs and CRNAs can prepare for the job market.  Jon Bradstreet, MSN, CRNA is the Chief CRNA and Director of CRNA Services of Maine’s largest CRNA group and only level one trauma center, Maine Medical Center, in Portland, Maine.  In this episode we cover everything from Curriculum Vitae’s (CVs) to tips for interviews and the job hunt.  If you’re an SRNA wrapping up your anesthesia training or a CRNA considering a job move – check it out! Key topics: * CV Preparation – what works and what’s fluff on your CV * When to and how to contact prospective employers * Tips for interviews including: * What chief CRNAs are looking for in your interview * Questions you should be asking in your interview * Things to consider doing and avoid doing in an interview * When to follow up on an interview * Tips for promoting yourself as a CRNA * Advice for how to prioritize important aspects of jobs including location, practice type, group culture, compensation packages and more * Advice for CRNA couples who are in the job hunt together Parting words from Jon Bradstreet, MSN, CRNA: “Have fun… we have a great profession and we have a great lifestyle.  We’re very lucky to do what we do for a living.  Always keep that in mind – how fortunate we are in this profession.  And then finally I think I would say listen to your gut.  It’s taken you very far in life already… don’t repress what it’s telling you as you’re in that interview.” Links: Maine Medical Center
October 9, 2015
Jon caught up with Dr Juan Quintana, president of the American Association of Nurse Anesthetists, and Kristie Hoch, president of the Maine Association of Nurse Anesthetists, to chat about the value of being a member of the American Association of Nurse Anesthetists (AANA).  Membership in the AANA is open to Certified Registered Nurse Anesthetists (CRNAs) and Student Registered Nurse Anesthetists (SRNAs). Dr Juan Quintana, CRNA, DNP, MHS, leads a CRNA-only anesthesia practice in Texas and well as an anesthesia billing firm.  His expertise lies in the areas of anesthesia practice models, economics, billing and reimbursement.  According to his website, “Dr Quintana became the first CRNA to serve on the Medicare Evidence Development and Coverage Advisory Council (MEDCAC), an independent body that provides the Medicare agency guidance and expert advice on the science and technology affecting healthcare delivery.”  He currently is serving as the president of the American Association of Nurse Anesthetists. Kristie Hoch, APRN, CRNA, MSN, works in CRNA-only settings and Anesthesia Care Team practices in Maine.  She serves as the chairwoman of a group of CRNA chiefs in her organization in addition to serving as the CRNA recruiter for her company.  Kristie recently served on the Program Committee for the AANA, which is the committee that plans the Association’s Annual Congress and is currently on the AANA’s Communications Committee.  She is wrapping up her term as president of the Maine Association of Nurse Anesthetists where she has been very active in promoting CRNA services across the state.  During her term as president, MeANA was awarded the Best Public Relations Effort by Small State Association honor from the AANA. Highlights: “The future for CRNA’s is brilliant; absolutely brilliant.  Everything is designed right now to move CRNA practice into the forefront…  If you’re in CRNA practice, if you’re a student thinking about going into CRNA practice, you’ve made an excellent choice.”  Juan Quintana “There’s not a question in terms of the anesthesia that I provide because it’s always going to be what I would give my mom.  So it’s going to be the absolute best.”  Juan Quintana “The AANA supports your right to practice.  Over forty-four thousand CRNAs across the country have a much stronger voice than you alone would have.”  Kristie Hoch Resources: American Association of Nurse Anesthetists Maine Association of Nurse Anesthetists The Future of Anesthesia Care Today
September 19, 2015
Dr Shawn Collins, DNP, PhD, CRNA discusses his research on Emotional Intelligence of Student Registered Nurse Anesthetists (SRNAs).  Highlights include the relevance of emotional intelligence to the practice of anesthesia, models of emotional intelligence and ways that emotional intelligence can be developed as a skill. Dr Shawn Collins currently serves as the Director of the Graduate Nurse Anesthesia Program and the Interim Associate Dean of the College of Health and Human Sciences at Western Carolina University (WCU).  Dr Collins completed his anesthesia training at the Erlanger Medical Center at the University of Tennessee – Chattanooga and went on to obtain his Doctorate of Nursing Practice from Rush University before obtaining his PhD in Leadership from Andrews University.  He maintains his clinical practice at several CRNA-only clinical sites in both North Carolina and Iowa.  At WCU, he was integral in the development of the WCU Doctor of Nursing Practice Program and served as its first director.  He is currently developing WCU’s DNP program for entry-level education for CRNAs. Podcast highlights: * Overview of Dr Collins’ article:  Emotional Intelligence as a Noncognitive Factor in Student Registered Nurse Anesthetists * Discuss models and theories of emotional intelligence * Discuss the significance of emotional intelligence in the practice of anesthesia for SRNAs & CRNAs * Discuss how emotional intelligence is a skill that can be developed * Discuss the positive correlation of emotional intelligence to scores on the NBCRNA’s National Certification Exam Resources: Collins S. Emotional Intelligence as a Noncognitive Factor in Student Registered Nurse Anesthetists. AANA Journal [serial online]. December 2013;81(6):465-472. Available from: Academic Search Complete, Ipswich, MA. Accessed September 19, 2015. Collins S, Andrejco K. A longitudinal study of emotional intelligence in graduate nurse anesthesia students. Asia Pac J Oncol Nurs [serial online] 2015 [cited 2015 Sep 19];2:56-62. Available from: http://www.apjon.org/text.asp?2015/2/2/56/157566 (We’d like to highlight that podcast producer, Kristin Andrejco, was a co-author, along with Dr Collins, of the above study published in the Asia Pacific Journal of Oncology Nursing.)
August 6, 2015
Jon talks with Dr Shawn Collins, DNP, PhD, CRNA about the transition of CRNA education from a Master’s of Science in Nursing (MSN) to a Doctor of Nursing Practice (DNP).  We discuss the history, rationale and implications of the change and compare various doctoral degrees CRNAs may obtain such as DNP, DNAP, PhD and EdD. Dr Shawn Collins currently serves as the Director of the Graduate Nurse Anesthesia Program and the Interim Associate Dean of the College of Health and Human Sciences at Western Carolina University (WCU).  Dr Collins completed his anesthesia training at the Erlanger Medical Center at the University of Tennessee – Chattanooga and went on to obtain his Doctorate of Nursing Practice from Rush University before obtaining his PhD in Leadership from Andrews University.  He maintains his clinical practice at several CRNA-only clinical sites in both North Carolina and Iowa.  At WCU, he was integral in the development of the WCU Doctor of Nursing Practice Program and served as its first director.  He is currently developing WCU’s DNP program for entry-level education for CRNAs. Please see the links below for a detailed history on Doctor of Nursing Practice degrees and the process of CRNA training moving from MSN preparation to a DNP. Sources: 2014 Trial Standards for Accreditation of Nurse Anesthesia Programs: Practice Doctorate. Published by the Council on Accreditation of Nurse Anesthesia Educational Programs, Park Ridge, Illinois. Revised on 5/30/14. Hawkins, R., & Nezat, G. (2009). Doctoral Education: Which Degree to Pursue?. AANA Journal, 77(2), 92-96.
July 18, 2015
Jon caught up with Caleb Rogovin, MS, CRNA, CCRN, CEN to talk trauma anesthesia.  Pharmacology, massive transfusion protocols, fluid management, room set up, team communication and personal coping are all covered in this episode.   Caleb Rogovin, MS, CRNA, CCRN, CEN has an extensive background in trauma critical care and anesthesia.  Caleb worked for years in emergency medicine and critical care, earning a Master’s degree in Trauma Critical Care before returning to school to become a CRNA.  He has served as a trauma critical care educator and administration as well as a faculty member of nurse anesthesia programs.  Caleb currently works as part of the anesthesia team at Temple University Hospital in Philadelphia, Pennsylvania. Topics Covered: * Approach to trauma:  room set up & team psychology * Pharmacology:  induction sequence and hemostasis * Massive transfusion protocols and fluid resuscitation * Communication in the OR:  perhaps your best tool in trauma resuscitation   A couple of highlights: “You don’t judge them.  You just take care of them.”  – Caleb describing his approach to trauma patients. “You don’t need lactated ringers or normal saline… what is falling out of your body is blood.”  – Caleb explaining fluid resuscitation in massive transfusion protocols.   Links & Resources: The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study: Comparative Effectiveness of a Time-varying Treatment with Competing Risks Cook County Hospital’s Blood Bank Page – the world’s first blood bank. A bit about Caleb from the AANA.
April 21, 2015
Jeremy Stanley, CFP, President and founder of CRNA Financial Planning-an AANA Member Advantage partner , joins the podcast to discuss the intricacies of freelancing. Jeremy has over 18 years of experience helping nurse anesthetists pursue financial success and is a sought after speaker and author of “The Wealthy CRNA.” Topics Include: * Advantages/Disadvantages * options to structure your business * incorporation * how to find freelance opportunities * retirement saving options are all discussed. Highlights: * Advantages: potentially higher hourly rate, scheduling flexibility, potential to save more for retirement, potential business expenses and possible tax deductions, more control over your practice * Disadvantages: must find own work opportunities (or have someone else do it for you), running your own business, cost considerations (incorporation filing fees, legal setup fees, professional insurances, current benefits * Differences in how you are paid (W2 vs. 1099): Payroll Tax, W2 deductions, Alternative Minimum Tax, 1099 Deductions * Various business structures: Sole Proprietorship, S-corporations, and LLC’s * Incorporation * Finding freelance work opportunities: anesthesia placement service, seek out and apply on job posting sites, develop relationships with facilities, groups, or individual surgeons, LinkedIn, contact CRNA Financial Planning * Retirement saving options: SEP IRAs vs SOLO 401k
March 23, 2015
Mark A. Kossick, DNSc, CRNA, APN, professor at Western Carolina University, discusses the cardinal elements and evidence based recommendations for EKG lead selection during anesthesia. Dr. Kossick is a tenured professor at Western Carolina University, the author of a textbook and handbook on electrocardiography, and serves as an AANA Journal reviewer. Dr Kossick provided specific and detailed show notes to this podcast that can be found here: Shownotes Mark Kossick Bio
March 10, 2015
Jon, Kristin, Brad & Cass sit down to talk about communicating with preceptors.  This talk will be helpful for SRNAs who are hitting the clinical environment for the first time.  This podcast was recorded during our anesthesia training and hopefully will give new SRNAs a student’s perspective on communicating with preceptors. Topics discussed: * Importance of communication skills in the perioperative environment * How to prepare for clinicals * Tips for making pre-clinical phone calls to preceptors * The use of cell phones/electronic devices in the OR * Common questions preceptors ask students * Transitioning from day one of clinical to being a senior anesthesia student * Importance of being teachable, flexible, humble and thankful   By the way, the max dose of methylene blue is… 7-8 mg/kg. “Methylene blue 1 to 2 mg/kg over 5 minutes (maximum dose, 7-8 mg/kg) reverses methemoglobinemia, but the patient should be monitored for the reoccurrence of symptoms” (Ouellette, 2011, p. 126). And if you’re looking for the “smooth and in” video Cass eluded to, here it is.  To be honest, it’s pretty cheesy.  We were shown this video in the first weeks of anesthesia school and told that our goal was to be “smooth and in.”   References Ouellette, R. G., & Joyce, J. A. (2011). Pharmacology for nurse anesthesiology. Sudbury, MA: Jones & Bartlett Learning.
March 1, 2015
Kristin talks with Eric Carlson, MSN, CRNA who shares a gripping personal tale of managing an unexpected difficult airway during an emergency Cesarean section.  Eric found himself in a “cannot intubate/cannot ventilate” situation which evolved into performing a cricothyrotomy followed by a surgical airway.  Eric’s vulnerability, humility and professionalism in bringing this story forward is astounding.  Don’t miss his account of what happened and the personal and professional ramifications of those involved in this difficult situation. Eric Carlson, MSN, CRNA has been a practicing CRNA for over 30 years.  He did his anesthesia training at the University of George Washington and was recruited into the Air Force to continue his anesthesia training.  He worked as a CRNA for the Air Force at Keesler Air Force base in Biloxi, Mississippi and then pursued employment at All Care Clinical Associates in Asheville, NC, where he currently works. Topics Discussed: * Personal case study of a difficult airway during an emergent C-section * Decision making in emergencies * Communication strategies in emergencies * Challenges faced during this particular case * Legal ramifications * Algorithms for airway management * Benefits to advanced airway training   Update, June 2015: This interview was posted by the North Carolina Association of Nurse Anesthetists in an email on 15 May 2015 to members titled “Spotlight on CRNAs” where a North Carolina CRNA is introduced at greater depth to the membership.  Of note, Eric was interviewed by Dustin Degman, CRNA, who has also contributed to our podcast in the Combat Trauma Anesthesia series.  In the interview, Dustin talks with Eric about his experience with the difficult airway case that he speaks to in the show featured on this page.  This interview is posted with the permission of the NCANA.   Eric Carlson, CRNA Interviewed by Dustin Degman, CRNA You were recently on the pod cast “From the Head of the Bed” where you explained a case that, I guess you could say, changed the way you practice today. You got to give your history, the beginning of the scenario, and there was a moment that you said “I had a difficult airway case”. I must tell you that I was completely locked-in at that moment. Nothing was going to distract me from listening to the next 25 minutes. What I want to ask is, what about that event changed you most, either as a person or in practice? This is a challenging question to answer. I am sure the event changed me both as a person and a CRNA practitioner. At the time of the event, I was very early in my career and riding high in self confidence. The event changed my level of confidence and reinforced the significance of the risks we take as CRNAs performing our job every day. I had to actively work on rebuilding my confidence over the ensuing months, slowly, I was able to regain some of the loss, but for better or for worse, I probably did not get back to the level I had been. In the long run, I think it made me a better CRNA because I realized that bad things can occur in our line of work at any time and you always need to have a back-up plan in mind. Be prepared for the unexpected. As a person, the event may have made me a more humble individual and helped me realize that we are all susceptible to very challenging occurrences in our profession. People, who know you, know that you are a wonderful provider. Your patients, colleagues, and the students really look up to you. Is there something you would like to share about being a great mentor? I appreciate the feedback and compliment. I consider myself very fortunate to have made the decision to become a CRNA more than 30 years ago. We all have many forks in the road when we have to make a choice t...
February 25, 2015
Jon and Ian discuss the history and economics of anesthesia delivery models.  Ian overviews the various types of anesthesia care models, some of the historical context for the development of those models and explains how anesthesia providers can optimize the delivery of anesthesia care in terms of billing, efficiency and quality outcomes.  We also discuss some of the challenges facing researchers in terms of gathering and interpreting “big data” on quality outcomes related to anesthesia care.  If you’re interested in the behind-the-scenes story on anesthesia care in the United States, this podcast is a good place to start! Ian Hewer, MSN, MA, CRNA is an Assistant Professor and the Assistant Director of the Graduate Nurse Anesthesia Program at Western Carolina University.  He is a Fellow of the American Association of Nurse Anesthetists’ Journal Writing Fellowship Program and has published articles in the AANA Journal, the International Journal of Nursing Research and the Social Science Journal.  Ian is currently pursuing his PhD at the University of North Carolina – Charlotte in Health Services Research with research focusing on the economics and outcomes of various anesthesia care delivery models. Topics discussed: * Types of anesthesia care models in the United States * Types of specific billing modalities for anesthesia services and the implications for anesthesia care models * The difference between medical direction and medical supervision and defining these terms in relation to billing & reimbursement verses standards of care of anesthesia providers * What “opt-out” means in terms of reimbursement and CRNA practice autonomy * Historical economic and political evolution & context of anesthesia care * The challenge of gathering & interpreting anesthesia quality data * Current trends in anesthesia quality research * Ideas on structuring anesthesia care models for success in a future where healthcare must become more efficient and cost-effective while maintaining safety and high quality * Suggestions for anesthesia providers in educating themselves on trends in healthcare economics * Thoughts on CRNAs becoming doctorally prepared clinicians and how this evolution will influence anesthesia in the United States Background information: Kane & Smith’s 2004 article titled An American tale – professional conflicts in anaesthesia in the United States: implications for the United Kingdom, published in the 2004, vol 59 edition of Anaesthesia, provides a particularly in-depth review of the development of anesthesia in the United States.  The types of anesthesia providers and models of practice are reviewed along with many of the key dates, legislation and publications that have influenced the anesthesia field in the United States over the last 100 years.  Professor Hewer touches on many of these dates and developments and we encourage listeners to reference Kane (2004) for more detail. Chronology of important dates in US anaesthesia (quoted from Kane, 2004) 1846  First anaesthetic administered 1847  American Society of Anaesthesiologists formed 1909  First formal Nurse Anaesthetist training program 1931  American Association of Nurse Anaesthetists formed 1932  Anaesthesia recognised as a medical Specialty by the American Medical Association 1960s  Johnson administration healthcare reforms 1966  Medicare program allows anaesthesiologists to bill them directly for overseeing hospital-employed CRNAs as well as personally administered anaesthetics. Graduate Medical Education program 1980  Forrest study published 1981  Bechtoldt study published
February 21, 2015
If you’re planning on becoming a CRNA or even if you’re currently in CRNA school, this talk is for you!  Jon talks with Mason McDowell, DNAP, CRNA and Kara Michalov, MSN, CRNA about success strategies for nurse anesthesia school. Topics covered: * Advice for how to be successful in grad school. * Thoughts on figuring out your study plan, budgeting time and preparing for exams. * Whether or not to work during school. * Tips for starting clinical as a SRNA. * Advice for how to pick yourself up again after hard days. * Tips for approaching projects and/or thesis’s * Advice for preparing for boards.   Mason McDowell, DNAP, CRNA is an Associate Professor and former Assistant Director of the Nurse Anesthesia Program at Western Carolina University.   His Doctorate of Nurse Anesthesia Practice (DNAP) from Texas Wesleyan University included research focused on perioperative patient management and cardiac risk assessment. He is the author of the Hepatobiliary and Gastrointestinal Disturbances and Anesthesia chapter in Nagelhout’s Nurse Anesthesia 5th Edition.  He is currently serving as an anesthesia educator and clinician in Bere, Chad, along with his wife and two daughters. You can read about his ongoing experiences there at http://www.whyweshouldgo.blogspot.com. If you want to know what it’s like to practice anesthesia (and care for the whole patient, family & community) in remote and challenging environments, you owe it to yourself to check out Mason’s stories!   Kara Michalov, MSN, CRNA is a CRNA with AllCare Clinical Associates in Asheville, North Carolina. She is one of the authors of Intravenous Acetaminophen and Intravenous Ketorolac for Management of Pediatric Surgical Pain: A Literature Review, which was published in the February 2014 edition of the AANA Journal (Vol. 82, No.1).
February 21, 2015
If you’re a critical care nurse and you’re thinking about applying for anesthesia school, this show is for you!  Jon talks with Mason McDowell, DNAP, CRNA & Kara Michalov, MSN, CRNA about how best to prepare for getting into nurse anesthesia school. Topics Covered: – advice for how to prepare for nurse anesthesia school – advice for students with families, significant others & pets – what to study (or not) ahead of time – how to prepare for the Big Interview to get into school Mason McDowell, DNAP, CRNA is an Associate Professor and former Assistant Director of the Nurse Anesthesia Program at Western Carolina University.   His Doctorate of Nurse Anesthesia Practice (DNAP) from Texas Wesleyan University included research focused on perioperative patient management and cardiac risk assessment.  He is the co-author of the Hepatobiliary and Gastrointestinal Disturbances and Anesthesia chapter in Nagelhout’s Nurse Anesthesia 5th Edition.  He is currently serving as an anesthesia educator and clinician in Bere, Chad, along with his wife and two daughters. You can read about his ongoing experiences there at http://www.whyweshouldgo.blogspot.com. If you want to know what it’s like to practice anesthesia (and care for the whole patient, family & community) in remote and challenging environments, you owe it to yourself to check out Mason’s stories!   Kara Michalov, MSN, CRNA is a CRNA with AllCare Clinical Associates in Asheville, North Carolina. She is one of the authors of Intravenous Acetaminophen and Intravenous Ketorolac for Management of Pediatric Surgical Pain: A Literature Review, which was published in the February 2014 edition of the AANA Journal (Vol. 82, No.1).
February 15, 2015
Part 3: Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA.  Dustin and Jon wrap up their conversation with an overview of how people can get involved as CRNAs in the military and how we can support our troops. Dustin Degman, MSN, CRNA is an Associate Professor of Anesthesia at Western Carolina University works with AllCare Clinical Associates in Asheville, North Carolina as a CRNA.  He served Active Duty with the United States Air Force from 1998-2002 as a critical care nurse.  In 2010, he joined the Army Reserves as a CRNA.  Dustin was deployed in November 2012 to Forward Operating Base (FOB) Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team which provided damage control resuscitation to injured soldiers.  He has a special interest in trauma anesthesia and has served on trauma call teams in civilian centers as well as in his military service.  Many thanks to Dustin and the brave men and women who have served and serve in and with the United States Armed Services! Combat Trauma Anesthesia Part 1:  Key differences and challenges facing CRNAs serving in Forward Surgical Teams (FSTs) and managing combat trauma patients Part 2:  Damage Control Resuscitation principles and particulars Part 3:  Getting involved as a military CRNA and supporting our troops Highlights: “…remember why you joined… For me it was to be able to have the honor in taking care of an injured soldier who is doing the upmost thing to take care of us as Americans.”  Dustin Degman, MSN, CRNA “If you see a guy in uniform, approach him… thank him… ask him what he does. People are very proud to say what they do for this country.”  Dustin Degman, MSN, CRNA   Resources: United Service Organizations Our Mission: The USO lifts the spirits of America’s troops and their families. Millions of times each year at hundreds of locations around the world, the USO lifts the spirits of America’s troops and their families.  A nonprofit, congressionally chartered, private organization, the USO relies on the generosity of individuals, organizations and corporations to support its activities. The USO is not part of the U.S. government, but is recognized by the Department of Defense, Congress and President of the United States, who serves as Honorary Chairman of the USO. (from http://www.uso.org/the-organization.aspx)   The United States Army Graduate Program in Anesthesia Nursing Mission Statement:  The US Army Graduate Program in Anesthesia Nursing (USAGPAN) supports the AMEDDC&S mission by producing clinicians educated in the complexity of practice at the doctoral level and competent in the unique skills of anesthesia nursing. The graduate nurse anesthetist is prepared to function as a leader advocating for quality patient care in times of peace, and when necessary, in times of war, civil disorder, natural disaster or humanitarian missions. (from http://www.usagpan.org) Here’s a great video overviewing military CRNAs that was produced by SRNAs with USAGPAN:  CRNA: Combat Ready Nurse Anesthetists – USAGPAN student video project.    Uniformed Services University of the Health Sciences Nurse Anesthetist Program Philosophy: The Nurse Anesthesia Program is dedicated to the graduate education of nurse anesthetists in the uniformed services. The uniformed services require that graduates independently provide quality anesthesia care in diverse settings throughout the world. The rigorous curriculum is designed to integrate scientific principles with anesthesia theory and practice, stressing unique aspects of the federal health care system.
February 15, 2015
Part 2: Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA.  Dustin discusses the specifics of Damage Control Resuscitation that he utilized as the sole anesthesia provider at Forward Operating Base (FOB) Orgun-E in Afghanistan. Dustin Degman, MSN, CRNA is an Associate Professor of Anesthesia at Western Carolina University works with AllCare Clinical Associates in Asheville, North Carolina as a CRNA.  He served Active Duty with the United States Air Force from 1998-2002 as a critical care nurse.  In 2010, he joined the Army Reserves as a CRNA.  Dustin was deployed in November 2012 to Forward Operating Base (FOB) Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team which provided damage control resuscitation to injured soldiers.  He has a special interest in trauma anesthesia and has served on trauma call teams in civilian centers as well as in his military service.  Many thanks to Dustin and the brave men and women who have served and serve in and with the United States Armed Services! Combat Trauma Anesthesia Part 1:  Key differences and challenges facing CRNAs serving in Forward Surgical Teams (FSTs) and managing combat trauma patients Part 2:  Damage Control Resuscitation principles and particulars Part 3:  Getting involved as a military CRNA and support our troops Topics Discussed: * What constitutes the “front lines.”  You’ve got to hear Degman humbly give credit to those who, in his opinion, really served on the front lines (first two minutes of the show…). * Assessment priorities for CRNAs including physical exams “from the neck up” (i.e. ruptured tympanic membranes may indicate proximity to explosions) * Induction sequence & airway management * Use of tourniquets * Techniques to support clot formation * fluid, blood product, pharmacological and hemodynamic management * Surgical goals of damage control resuscitation   Highlights: * Blood product management * 1:1 transfusion protocol was frequently used for hemorrhagic shock patients.  Dustin did not have platelets available so one fresh frozen plasma (FFP) unit was given with every packed red blood cell (PRBC) unit. * Very limited crystalloid replacement * Walking Donor Protocol – use of direct, typed whole blood administration from uninjured soldiers to hemorrhagic shock patients.  Benefits:  the blood’s got all the products (red cells, plasma, platelets, cry0, factor 7) and it’s warm. * Colloid resuscitation end points: * 80-90 systolic blood pressure * goal for INR less than 1.5 * base excess greater that -4 * hemoglobin & pH monitoring * surgical hemostasis * Pharmacological management * Induction drugs * Overview of antibiotics * Use of ketamine with head trauma patients* * transexamic acid (TXA) and Factor 7 commonly administered * Vascular access * Goal was bilateral 16g peripheral IVs * Central lines uncommon but were typically used with 3% sodium chloride, especially once the patient was bundled or “burrito wrapped” for the flights out of the FOB to more definitive care. * Arterial lines were commonly placed * Tourniquet use * very common * hemostatic agents/products (e.g. chitosan) were not commonly used * Resuscitation end points * Dustin discusses a case from his civilian trauma experience that was similar to one he experienced in Afghanistan in which ultrasound was used to evaluate cardiac wall motion (specifically, the lack there of) in a hemorrhagic shock patient in order to make the decision to not attempt surgical resus...
February 15, 2015
Part 1: Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA. In this interview, Jon sits down with Dustin Degman to discuss his role as a CRNA working at Forward Operating Base (FOB) Orgun-E in Afghanistan. Dustin Degman, MSN, CRNA is an Associate Professor of Anesthesia at Western Carolina University works with AllCare Clinical Associates in Asheville, North Carolina as a CRNA.  He served Active Duty with the United States Air Force from 1998-2002 as a critical care nurse.  In 2010, he joined the Army Reserves as a CRNA.  Dustin was deployed in November 2012 to Forward Operating Base (FOB) Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team which provided damage control resuscitation to injured soldiers.  He has a special interest in trauma anesthesia and has served on trauma call teams in civilian centers as well as in his military service.  Many thanks to Dustin and the brave men and women who have served and serve in and with the United States Armed Services! Combat Trauma Anesthesia Part 1:  Key differences and challenges facing CRNAs serving in Forward Surgical Teams (FSTs) and managing combat trauma patients Part 2:  Damage Control Resuscitation principles and particulars Part 3:  Getting involved as a military CRNA and support our troops Points discussed: * Basic overview of where Dustin was & his Forward Surgical Team (FST) set up * Overview of the types of patients and types of cases Dustin saw * Differences in patient care priorities and perioperative flow in a FST from civilian trauma centers:  triage, assessment, surgical & anesthesia goals and more. * FST team members and dynamics
February 15, 2015
In this episode, Kristin and Sandry Gaillard, a CRNA who works independently at a critical access hospital in rural western North Carolina, sit down to discuss the business of anesthesia in terms of working as a 1099 employee verses a W2 employee. Topics Discussed Include: * Differences between 1099 and W2 work arrangments * Advantages/Disadvantages of 1099/W2 * Responsbilities of 1099 employment * Tips for starting 1099 employment * Types of coorporations * CRNA-only practice Shownotes: Difference between 1099 and W2 employee: – Based on 3 sets of criteria – whether there is behavior control, financial control and what the      relationship is between the parties involved – W2- specific requirements by the employer – job is directed to what, how, when, where you are going to do your job – Independent contractor – no requirements by employer – 1099 – you can have a 1099 as an independent contractor or work in a care team   Advantages to W2 – Don’t have to worry about business side of things (taxes)   Independent Contractor Advantages: – more control, flexibility, more money potentially, autonomy   Disadvantages of 1099: – stressful, deal with all business aspects   Responsibilities for 1099: – Liability insurance and health insurance – Responsible for employee portion of Social Security and Medicare – Disability insurance, Unemployment insurance – Money to plan for sick days – Determine money to put away for taxes/business/personal (**Good rule: at least 30% of what you bring home for taxes – don’t know what tax bracket you are going to be put into at the end of the year)   Tips for 1099: – Get a business attorney – someone who does small business – Do your research! – Do you plan to incorporate? Keep your business and personal separate so both are protected – Find an accountant for help managing taxes (who also does small business)   Types of Corporations: PC – Professional Corporation (available only to certain professions – you apply for this through the state that licenses you) S – Corp – Requires annual board meeting, documentation of minutes LLC – Limited Liability Corporation – similar to PC, less complex, less paperwork (combines the best features of your PC and S-corp) **Business attorney can help you make a good choice for you – You can do this yourself if you are business savvy! – Lots of info online   CRNA only practice: – Depending on size of practice could cover call, weekends, holidays – Responsible for pre-op medical reviews, review anesthetic plan, see if they need to be cleared for surgery by other health care provides – Post-op: follow ups, if they are going home – make sure they have appropriate instructions to go home; post-operative teaching, managing post-op phones, in house post-op visits, make sure patients are pleased with anesthetics – Critical access hospitals are able to reimbursed for medicare part A – CRNAs providing anesthesia services in a rural critical access hospital – A signature by a physician is required by federal government for reimbursement;  this signature does not mean that physicians are legally liable for anything that the anesthetists does – Independent practitioners are liable for whatever they do.  If a surgeon dictates how he/she wishes you to administer the anesthesia, he/she may be liable for those decisions.
February 9, 2015
In this interview, David Andrews, MHS, CRNA, sits down with Jon Lowrance to discuss the importance of CRNAs and SRNAs advocating for their profession through state and national associations. David is the current President of the Oregon Association of Nurse Anesthetists and Clinical Director for Outpatient Anesthesia Services and has been actively involved in leadership positions in state associations as well as the American Association of Nurse Anesthetists (AANA).  This interview was conducted during the Fall of 2014 in Tualatin, OR. Topics Discussed Include: * Rationales for participating in state and national associations. * The role state and national associations have had in protecting and advancing the field of nurse anesthesia. * Importance of contributions to political action committees (PACs) whether through time or financial commitments. * The role anesthesia program directors can have in helping SRNAs get involved in advocating for their profession. * Tips for talking with legislators. * Principles of leadership and volunteerism. Resources and links: Oregon Association for Nurse Anesthetists (OANA) https://www.oregon-crna.org American Association for Nurse Anesthetists (AANA) http://www.aana.com Outpatient Anesthesia Services (OASOR) http://www.oasor.com The Future of Anesthesia Care Today http://www.future-of-anesthesia-care-today.com Highlights: “…and the message we have [as CRNAs] is good – it’s quality of care, access to care and cost savings – that’s the side of the argument you want to be on.” David Andrews “Because of this challenge we face, we get this great opportunity to learn how to legislate and… how to lead. Our state organization and the national organization teach effective leadership… and that’s a great life lesson – that’s just a side benefit of becoming a CRNA.” David Andrews
February 9, 2015
In this episode Kristin and David Andrews, MHS, CRNA, President of the Oregon Association of Nurse Anesthetists and Clinical Director of Outpatient Anesthesia Services, sit down to discuss the challenges facing outpatient anesthesia providers. Information about Outpatient Anesthesia Services can be found at their website www.oasor.com. Shownotes: –  Challenges faced in operating outpatient surgical facilities include scheduling and flexibility in order to be a profitable company. –  Patient selection is a challenge.  The last thing you want to do is cancel a procedure on the day of surgery.  Make sure that a solid pre-anesthesia assessment is taken care of ahead of time. –  How do you assess risk?  There is a push to limit pre-operative testing because it does not necessaritly result in better outcomes.  Also, it costs more and can be a hassle for patients. –  There is financial pressure not to cancel cases.  How do we attenuate this – by trying to get as much patient information as possible before the actual surgery.  Train your office to get particular information depending on how patients present. –  Ultimately it boils down to the provider on that day to make the decision whether or not to proceed. –  There is a constant balance between rapid turnover and patient safetly.  Develop a quick, systematic efficient method of putting people to sleep and waking them up.  If you feel rushed, take a deep breath and slow down.  Every patient deserves the best care.  Ultimatley you are accountable for the care you give. –  Critical incidents are rare in the outpatient setting but the most common are airway related.  In order to deal with this properly you need preparation. –  Goals for the outpatient setting: Nausea free, quick wake up, prompt discharge within an hour, pain free and comfortable.  Regional anesthesia works great for this setting. –  Outpatient is a service industry.  CRNAs should be able to be flexible to accommadate surgeon preferences and needs within safe boundries. –  Anesthesia is the same regardless who is providing it; the way that CRNAs can really excell is by providing excellent service.
January 26, 2015
Sickle Cell Disease - Dr. Kuestner Sickle Cell Disease affects kids as well as adults. Problems related to sickle cell is seen more as people age. Scenario: A 7yr old boy presenting for a tonsil and adenoidectomy, for Obstructive Sleep Apnea. They have a history of sickle cell disease and a few crises’ but none in the past few months. Hemoglobin while taking hydroxyurea is 10. Question: Prior to receiving surgery all of the following are true except? A: He should have hematology consult preoperatively. B: He does not require a transfusion since his hemoglobin is 10. C: A hemoglobin electrophoresis should be obtained. D: Surgery should not be done in an ambulatory center. Answer: B Sickle Cell Disease is not just a simple erythrocyte deformation that makes cells that look like sickles. It involves hemolysis, anemia, microvascular occlusion and recurrent ischemic injury in all organ systems. If you think of it as just a blood problem you are missing what is really happening. It is the leading cause of morbidity and mortality among African-Americans. Acute complications of sickle cell disease that are relevant to pediatric anesthesia. Acute Splenic Sequestration this usually occurs in children age 5 months to 2 years. But may occur as late as the teenage years in children with sickle thalassemia. This results from the pooling of large quantities of blood in the spleen and leads to shock with profound anemia. Aplastic Crisis – Results with the normal brisk reticulocytosis that is associated with sickle cell disease is suppressed. So they are not forming red blood cells quickly enough. This happens when the have a viral infect with parvovirus b19. Hemolytic Crisis – Occurs in patients that have an abrupt increase in hemolytic stress, such as infection or medication induced. Many of the patients are also deficient in the enzyme glucose 6 phosphate dehydrogenase. Sepsis / Septic Shock are serious acute complications. They generally experience autoinfarction of the spleen in early childhood and they are rendered susceptible to encapsulated organism infections. Aseptic techniques and wound infection prophylaxis is critical. Vaso-Occlusive Crisis – Are episodes of painful ischemia, and tissue infarction that result from small vessel occlusion by sickle cells. Most types of the occlusive crises include: dactylitis, priapism in males, stroke, and acute chest syndrome. Chronic complications relevant to pediatric anesthesia. Can apply to pretty much all organ systems, decrease growth and maturation, increased nutritional requirements, retinopathy, stroke, cognitive dysfunction, cardiac dysfunction, elevated pulmonary vascular resistance, chronic lung injury, diminished renal tubular dysfunction, bone and joint destruction, leg ulcerations, splenic infarction. Mostly importantly to the perioperative management is the chronic changes to the cardiovascular, respiratory, and renal systems. The elevated pulmonary vascular resistance in childhood is a predictor of premature death. Treatment of the Crises include: Intravascular volume expansion. Transfusion of red blood cells. Treatment of the infection. Stopping the offending medications. Preop on children with Sickle cell. Most patients are now identified with newborn electrophoresis if they have sickle cell or not. Dehydration may predispose you to a vaso-occlusive crisis and acute chest syndromes. The most debated topic over the perioperative management of sickle cell patients is the prophylactic preoperative blood transfusion.
January 25, 2015
Matthew Kuestner, M.D., attending anesthesiologist at Kosair Children’s Hopsital, overviews hematopoiesis, fetal hemoglobin and physiologic anemia in pediatrics.  Dr Kuestner is a board certified pediatric anesthesiologist and a Diplomate of the American Board of Anesthesiology. Hematopoiesis, Fetal Hemoglobin & Physiologic Anemia in Pediatrics by Dr. Kuestner Hematopoiesis * Liver will produce fetal erythropoietin in the first 24 weeks of life. * In the last trimester of pregnancy the erythropenia will be coming from the kidney. * At 10-12 weeks 80% of hemoglobin is fetal hemoglobin or hemoglobin-F which decline to 0% by six months of age. * So a term baby has 20% of Adult or hemoglobin-A. * Hemoglobin-A is made up of 2 Alpha and 2 beta polypeptide chains. * Fetal hemoglobin behaves differently than adult hemoglobin. Fetal hemoglobin shifts from a P-50 of 19.4 on the first day of life to 30.3 at eleven months of age. * Normal adult P-50 is 27. * P-50 is the conventional measure of Hemoglobin’s affinity for oxygen. * Fetal oxygen hemoglobin dissociation curve will shifted to the Left of moms curve. * Fetal hemoglobin must have a greater affinity for oxygen than maternal hemoglobin to be accepted in the uterine villi and supply oxygen to the fetus. * Fetal hemoglobin’s greater affinity for oxygen is due to its low capacity to interact with (2,3 DPG). * The binding site for (2,3 DPG) is on the Beta chain. Which is absent in fetal hemoglobin. * Oxygen will still transfer from mother to fetus when hemoglobin-A is transfused in utero. So if you have to give a fetus a transfusion with adult hemoglobin the fetus will still get the oxygen they need. Normal Physiologic Shift in Hemoglobin Values * Normal Neonate hemoglobin is 17, mostly hemoglobin-F. * At 3-4months of age, in a full term newborn hemoglobin will drop to 10-11. Termed the normal physiologic anemia of infancy. * At age 2 hemoglobin should be around 12. * Slow increases to 13-14 by the age of 10. The normal physiologic anemia occurs because hemoglobin-F is transitioning to hemoglobin-A.  The drop in hemoglobin stimulates the erythropoietin to be produced by the kidney.   Premature babies do things differently.  They drop further and faster and the take longer to transition to adult hemoglobin. Difference in premature and healthy full term babies. * The anemia in healthy full term babies are symptomatic. * In premature babies it occurs earlier, persist longer and it causes them to be symptomatic. * In premature babies hemoglobin may drop to as low as 8 by the 4th week of age. * The anemic infant could have bradycardia, apnea, delayed growth, and poor weight gain. * The bradycardia, apnea, and hemodynamic changes are big concerns in anesthesia. In infants weighing less than 1kg often blood sampling and lab work exceeds or equals half of their blood volume.  So then they get transfused with adult hemoglobin-A.  Therefore, there is no stimulation of for the kidneys to  produce erythropoietin.  So the red cells don’t last very long and they become anemic again. For a NICU baby make sure blood is available for these kids before going back for surgery. New information says it’s better to start transfusing on the earlier side of things, so you don’t have to give the blood so quickly and at the same time you’re decreasing their risk of hyperkalemia. You do not want to wait until the baby has become tachycardia or bradycardia to start your intervention.
January 21, 2015
Adrea Kristofy, M.D., attending anesthesiologist at Kosair Children’s Hospital, discusses single lung ventilation in pediatrics.  Dr Kristofy is an Assistant Professor of Anesthesiology at the University of Louisville School of Medicine.  She is also a Diplomate of the American Board of Anesthesiology. Single Lung Ventilation In Pediatrics The goal is to answer 2 questions: * How do we determine the need for single lung ventilation? * How do we proceed once we have made that decision? Indications for Single Lung Ventilation. * Absolute Indications – Isolate on lungs because of Contamination, Infection, Bleeding, control of ventilation for bronchopleural fistula, large cyst, ect.. * Relative Indications – Surgical Exposure, thoracic aortic aneurysm, pneumonectomy, ect… Three Different techniques used to achieve single lung ventilation. * Simplest – Single tube right or left mainstem, right easier than left. * Balloon tip bronchial blocker such as uninvent tube. * Double lumen tubes. Downside with single lumen tube only. Inadequate seal, failure of lung to collapse, easier to get contamination from one side to the other. Balloon tip bronchial blockers. Can be placed on either side. Can be dislodged somewhat easily. Balloon low volume and high pressure. Can Not suction threw the bronchial blocker. Discrepancy between outer and inner lining of the tube and be problematic in small children Double Lumen Endotracheal Tubes Most common is the Carlens tube, carinal hook endotracheal tubes used in the past. Two tubes equal length, with two cuffs one tracheal cuff and one bronchial cuff. The size is measured in French not in millimeters. So a 26fr double lumen endotracheal tube has an outer diameter of 9.3mm. Advantages of Double lumen tubes You can provide positive pressure ventilation You can suction either the operative or the non-operative lung as needed The cuffs are high volume and low pressure One thing to remember with pediatrics and double lumen tubes is that a size 26fr corresponds with approximately at 5.5-6mm cuffed singled lumen endotracheal tube. So if your patient can tolerated that size single lumen tube then they can tolerate a double lumen tube. Physiologic concerns with single lung ventilation. If decrease in saturation occurs check: Is the tube dislodged, secretions. Most of the time desaturation occurs because of mismatch of ventilation and perfusion.  To help fix this add CPAP to non-dependent, non-ventilated lung or add PEEP to ventilated lung.  May have decrease TV and increase frequency to keep ventilation pressures the same. If desaturation continues talk with your surgeon to see if you can intermittently re-expand the operative lung. If still no increase in saturation then the surgeon may be able to put a temporary or possibly a permanent ligature on the pulmonary artery. If all else fails talk with the surgeon and go directly to re-expansion of both lungs then continue trouble shooting. Charts from Hammer et al. (Anesth Analg 1999)                                 Reference Hammer, G. B., Fitzmaurice, B. G., & Brodsky, J. B. (1999). Methods for Single-Lung Ventilation in Pediatric Patients. Anesthesia & Analgesia, 89(6), 1426 1410.1213/00000539-199912000-199900019.
January 15, 2015
Steven Auden, M.D., attending anesthesiologist at Kosair Children’s Hospital, discusses myths, mistakes and misconceptions in pediatric anesthesia.  Dr Auden is the Medical Director of Kosair Children’s Hospital Department of Anesthesiology and a Clinical Professor of Anesthesiology for the University of Louisville School of Medicine.  He is a board certified pediatric anesthesiologist and a Diplomate of the American Board of Anesthesiology and the American Board of Pediatrics. Myths, Mistakes & Misconceptions In Pediatric Anesthesia by Dr. Steve Auden Two Topics of Discussion: 1.  The Cricoid Ring. 2.  Cricoid Puncture. Questions. What is the narrowest point of the pediatric airway? Is Cricoid Pressure (Sellick Maneuver) needed in pediatrics? Should Atropine be given as a premedication in the pediatric population? What is the minimal dose of Atropine? Which is more potent Atropine or Glycopyrrolate? So To Recap: What’s the narrowest point in the pediatric airway? * The glottic opening just as in adults * Proven by Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg, 2009;108:1475-9 * Supported again in the May 2009 issue of Anesthesia and Analgesia by Motoyama – The Shape of the Pediatric Larynx: Cylindrical or funnel shaped. What’s to remember about Cricoid Pressure? * It is very difficult to do properly. * More Importantly. DO NOT inflate the stomach. * Pre-oxygenate very well * Do NOT attempt intubation until the pt is very deep. * Use a serial twitch monitor * It is NOT effective against forceful vomiting Should Atropine be used routinely as a premedication? * No! * Unless there is a known history of bradycardia or disease process that is prone to bradycardia. * Supported by Johr in the 1999 issue of Pediatric Anaesthesia – Is it time to question the routine use of anticholinergic agents in pediatric Glycopyrrolate versus Atropine which is more potent? * Given IV there is basically No Difference in Potency. * IM there is a difference. Why? * Glycopyrrolate is a quaternary ammonium – Big and does NOT cross the BBB. So no CNS Symptoms. (Lethargy, somnolence, Seizures) * Atropine is a Tertiary Amine – Smaller – DOES cross BBB. * In a Code situation maybe give 1 dose to follow protocol otherwise just go straight to Epi. Cricoid puncture can be done in pediatrics, but it should be done by trained and qualified personnel. Disclaimer The information provided can NOT necessarily be applied to CRNA board questions as the content of boards may have not been updated to reflect the results of the studies and information discussed.  However, hopefully this will help to improve your knowledge base and personal practice.   References: Cricoid Ring Dalal, P. G., Murray, D., Messner, A. H., Feng, A., McAllister, J., & Molter, D. (2009). Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg, 108(5), 1475-1479. doi: 10.1213/ane.0b013e31819d1d99 Lerman, J. (2009). On cricoid pressure: “may the force be with you”. Anesth Analg, 109(5), 1363-1366. doi: 10.1213/ANE.0b013e3181bbc6cf Motoyama, E. K. (2009). The shape of the pediatric larynx: cylindrical or funnel shaped? Anesth Analg, 108(5), 1379-1381. doi: 10.1213/ane.0b013e31819ed494 Ovassapian, A., & Salem, M. R. (2009). Sellick’s maneuver: to do or not do. Anesth Analg, 109(5), 1360-1362. doi: 10.1213/ANE.0b013e3181b763c0 Rice, M. J., Mancuso, A. A., Gibbs, C., Morey, T. E., Gravenstein, N., & Deitte, L. A. (2009). Cricoid pressure results in compression of the postcri...
January 15, 2015
Dr Walter Rose, D.O., attending anesthesiologist at Kosair Children’s Hospital, discusses the specific attributes that make caring for pediatric patients unique as anesthesia providers.  Dr Rose is the Director of Pediatric Cardiac Anesthesia at Kosair Children’s Hospital and also serves as an Assistant Professor of Anesthesiology with the University of Louisville School of Medicine.  He is a Diplomate of the American Board of Anesthesiology. A quick overview of how pediatrics differ from adults. •Hypothetical Patient HR 190, BP 60/30, RR 60, HGB 19, WBC 30,000, K 7.5, NA 160.  Is you patient in trouble? •It depends because these are all normal values from a New Born. •Commonalities between adults and kids. •Same Species •Same Basic Anatomy •Generally use the same Anesthetic techniques •Generally use the same Pharmacological agents •Anesthesia Goal are the same •Sometimes the case is done the exact same as an Adult •Differences between Pediatrics and Adults. •Things tend to happen quicker in pediatrics •Kids desaturate more quickly and they will resaturate more quickly •Pediatric baseline heart rate is usually faster •Takes more finesse to work with pediatrics •Pediatrics have smaller airways, smaller veins, ect… •Physiology is different especially in newborns •More unique surgical procedures, such as a congenital diaphragmatic hernia repair •Pediatric Anatomy is slightly different from adults, therefore miller blade used more •Psychological concerns are different at different ages •Also must deal with the parents psychological concerns •NPO guidelines are shorter in pediatrics
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