Anesthesia Guidebook

Adrian Moran, MD, MBA currently serves as the Chief Medical and Transformation Officer of MaineHealth, a not-for-profit, integrated health system with over 2000 providers and 23,000 care team members serving patients across Maine and New Hampshire. Dr Moran joined me to talk about his views on transformational leadership and his professional journey from a pediatric […]

This is part 3 of a 3 part series titled The Pressure is On: Enhancing Anesthesia Care for Parturients with Hypertensive Disorders of Pregnancy. In the first episode, Joe Navarrete walked us through the baseline physiologic changes of pregnancy. In the last episode, David Barksdale covered the pathophysiology of hypertensive disorders of pregnancy. And in this episode, Isabella Sosa is here to tell us what to do about it. Isabella, Joe & David are each SRNAs at Yale New Have Hospital’s Nurse Anesthesia program and are completing this 3-part series as their doctoral project for anesthesia school. Isabella was a nurse in the cardiac-surgical ICU at Montefiore Medical Center in the Bronx, NY. She decided to pursue anesthesia because she saw what a positive difference anesthesia providers can make on what is the hardest day of many patient’s lives. When she did her OB rotation, she saw the direct impact CRNAs make in the delivery process and how we impact outcomes in these high risk patients. She was inspired by how we can improve the quality of care and birthing experience for patients. Her and her colleagues who produced this series, Joe Navarrete and David Barksdale, are all advocates of women’s health and through this doctoral project hope to empower other providers to cultivate excellence at their facilities when caring for patients with hypertensive disorders of pregnancy.  This three part series will equip anesthesia residents and providers alike with the core knowledge to effectively manage hypertensive disorders of pregnancy. Many thanks to Joe, David & Isabella for putting this series together! Please see below for full show notes and references. Show Notes: #124 – How to Manage Hypertensive Disorders of Pregnancy with Isabella SosaDownload

This is part 2 of a 3 part series on hypertensive disorders of pregnancy. Part one with Joe Navarrete covered the baseline physiologic changes with pregnancy. In this episode, David Barksdale is going to walk us through the pathophysiology of hypertensive disorders of pregnancy. And in the next episode, Isabella Sosa joins us to walk through how to manage hypertensive disorders of pregnancy as anesthesia providers. David Barksdale is a Nurse Anesthesia Resident at Yale New Haven Hospital School of Nurse Anesthesia and Central Connecticut State University. Before CRNA school, he worked for three years as a Surgical Intensive Care Unit nurse at Rhode Island Hospital and is a combat veteran. He served in the United States Army from 2012-2015 as a combat engineer. In 2013, he deployed to East Paktika Province, Afghanistan, conducting route clearance operations to provide freedom of movement to the infantry and local populations. David framed his doctoral project around this topic to deepen his understanding of hypertensive disorders of pregnancy and to explore how podcasting can support learning for anesthesia providers. This three part series will equip anesthesia residents and providers alike with the core knowledge to effectively manage hypertensive disorders of pregnancy. Many thanks to Joe, David & Isabella for putting this series together! References: 1.     American College of Obstetricians and Gynecologists. Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020;135(6):e237-e260. doi:10.1097/AOG.0000000000003891 2.     Dimitriadis E, Rolnik DL, Zhou W, et al. Pre-eclampsia. Nat Rev Dis Primers. 2023;9(1):8. doi:10.1038/s41572-023-00417-6 3.     Torres-Torres J, Espino-Y-Sosa S, Martinez-Portilla R, et al. A narrative review on the pathophysiology of preeclampsia. Int J Mol Sci. 2024;25(14):7569. doi:10.3390/ijms25147569 4.     Sibai BM, Dekker G, Kupferminc M. Pre-eclampsia. Lancet. 2005;365(9461):785-799. doi:10.1016/S0140-6736(05)17987-2 5.     Hall JE. Guyton and Hall Textbook of Medical Physiology. 14th ed. Philadelphia, PA: Elsevier; 2020.Chestnut DH, Wong CA, Tsen LC, et al. Chestnut’s Obstetric Anesthesia: Principles and Practice. 6th ed. Philadelphia, PA: Elsevier; 2019.

This episode is part of a three-part series on titled “The Pressure is on: Enhancing Anesthesia Care for Parturients with Hypertensive Disorders of Pregnancy.” In this first installment, Joe Navarrete, a third-year student registered nurse anesthetist (SRNA) at the Yale New Haven Hospital School of Nurse Anesthesia, delivers a high-yield, system-by-system breakdown of the expected physiologic changes of pregnancy. Part 2 will be #123 – Pathophysiology of Hypertensive Disorders of Pregnancy with David Barksdale Part 3 will be #124 – How to Manage Hypertensive Disorders of Pregnancy with Isabella Sosa             In this episode, Joe Navarrete guides listeners through changes in the respiratory, gastrointestinal, renal, endocrine, musculoskeletal, nervous, hematologic, and cardiovascular systems, with an emphasis on how these changes impact anesthetic management. Joe covers pertinent topics including airway considerations, anesthetic requirements, dilutional anemia, hypercoagulability, neuraxial anesthesia, cardiac output, and fluid shifts throughout pregnancy. The episode concludes with a brief recap of clinical pearls for anesthesia providers to remember when caring for obstetric patients.             This is an in-depth review for SRNAs, CRNAs, and all anesthesia providers alike looking to refresh their understanding of maternal physiology. Whether providers are preparing for clinical rotations, board exams, or managing complex obstetric cases in practice, this review attempts to cover the bases.             At the time of this recording, Joe Navarrete was a 3rd-year SRNA at the Yale New Haven Hospital School of Nurse Anesthesia in Connecticut, pursing his Doctor of Nurse Anesthesia Practice (DNAP) degree. He earned his Bachelor of Science in Nursing from Rhode Island College in 2019. Joe began the first year of his nursing career on the surgical stepdown unit at Rhode Island Hospital (shoutout to 5 stepdown!).              Within his first year of nursing practice, the COVID-19 pandemic transformed the stepdown unit into a COVID ICU. There, Joe gained experience in managing critically ill patients and often worked alongside anesthesia providers during emergent intubations. These experiences sparked his interest in nurse anesthesia, and he never looked back. He went on to work in the Surgical Intensive Care Unit for 2.5 years before matriculating into anesthesia school and moving to Connecticut with his significant other Rebekah and their beloved cat, Bubba.  References Chestnut DH. Chestnut’s Obstetric Anesthesia: Principles and Practice. 6th ed. Philadelphia, PA: Saunders; 2020. Bleeser T, Vally JC, Van de Velde M, Rex S, Devroe S. General anaesthesia for nonobstetric surgery during pregnancy: A narrative review. European Journal of Anaesthesiology and Intensive Care. 2022;1(2). doi: 10.1097/EA9.0000000000000003 Bauer ME, Arendt K, Beilin Y, et al. The society for obstetric anesthesia and perinatology interdisciplinary consensus statement on neuraxial procedures in obstetric patients with thrombocytopenia. Anesth Analg. 2021;132(6):1531-1544. doi:10.1213/ANE.0000000000005355 #122 – Physiologic Changes of Pregnancy Show NotesDownload

What’s up y’all! I’m back at it after a summer hiatus. I actually wrote/recorded this episode back in May 2025, but then summer hit with camping trips, work projects, grad school, home renovations… you know, life! I’m pumped to bring this episode to you finally and this will be followed pretty quickly by a three-part series on hypertensive disorders of pregnancy, which is going to be stellar! Check out these continuing education conferences with Encore Symposiums if you want to connect in person, as I’ll be speaking at each of them: 2025 October 20-23: New England at the Cliff House, Maine 2026 October 19-22: Autumn in Bar Harbor, Maine 2026 November 14-18: O’ahu Turtle Bay, Hawaii (Ritz Carlton) This episode dives into tactical empathy: how to turn resistance into momentum in your conversations. This could be useful whether you’re negotiating with your 4-year old on taking a bath, rebooking a flight after yours got canceled or in the boardroom trying to implement a new project or proposal. In this episode, we’ll walk through: The role of loss aversion in negotiation Techniques of tactical empathy: naming, mirroring The power of “yes, and…” (a tool from improv comedy) How to “start with no” in a negotiation by asking “how am I supposed to do that?” in a kind, vulnerable way. Why listen to this episode? If you want to become a better communicator, get the best deal in a negotiation or learn how to have entertaining conversations from over the drapes in the OR to a cocktail party, this is for you. Tactical empathy is about leveraging what really matters to you and other people with clarity when communicating. Don’t hesitate to reach out with questions, comments or feedback. Remember, the work you do is extremely important and incredibly valuable. You are the provider your patients need. Keep up the hard work. Be well and enjoy the journey! References Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement. https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com Camp, J. (2002). Start with no: The negotiating tools that the pros don’t want you to know. Crown Currency.  Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Harvard business press.  Kahneman, D. (2011). Thinking, fast and slow. Farrar, Straus and Giroux.  Voss, C., & Raz, T. (2016). Never split the difference: Negotiating as if your life depended on it. Random House. 

Want to work on changing things? Want to learn about your team and listen better? Interested in a pretty good pathway to do that? Appreciative Inquiry is process of: Discovering what’s working well Dreaming about what could be Designing for future change & success Realizing the Destiny that this process will bring about In this podcast, we’re gonna walk through Appreciative Inquiry and Theory U and how these 2 organizational development processes meld together to create a powerful tool for listening to and helping to improve the work your team does. It’s so good! Our CRNA team at Maine Medical Center worked through this process – really, we’re still working through it – this spring. The full story is in the podcast. I made a video for this podcast but I haven’t been able to get it loaded to YouTube yet and apparently, it’s too big for this website. In the meantime, you can see the core show notes to the podcast in the PDF below. There’s photos of the Theory U and our list of 10-questions we developed as our Appreciative Inquiry survey we used at Maine Medical Center. I hope this episode gives you some very practical tools for how to engage with your team better. I’ve found appreciative inquiry to be a great way to have a conversation with groups and find a new way forward. Let me know how it goes for you! #120 – Appreciative InquiryDownload References Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons.  Hollnagel, E. (2020). Synesis: the unification of productivity, quality, safety and reliability. Routledge.  Scharmer, O. (2016). Theory U: Leading from the future as it emerges. Berrett-Koehler Publishers. Scharmer, O. (2025). Theory U process of co-sensing and co-creating.  Presencing Institute. https://www.presencing.org Whitney, D., & Cooperrider, D. (2005). Appreciative inquiry: A positive revolution in change. Berret-Koehler Publishers.

Yo yo! Today, we close out our 3-part series on systems thinking with this episode on psychological safety & just culture. Part 1 (Episode 117) introduced systems thinking & high reliability organizations. Part 2 (Episode 118) walked through resilience engineering, safety differently and synesis. Part 3 (this episode) threads these topics together with psychological safety & just culture. This three part series invites you to think about your home team and professional practice. How does your team handle errors & mistakes? Are you safe to fail and be honest about mistakes & near misses? Are mistakes and mishaps talked about? Do you usually take feedback well and look for ways to grow or get defensive and think it’s always someone else’s fault? What about the other folks on your team? Psychological safety is about the freedom to speak up without fear of embarrassment or punishment. Psychological safety doesn’t just happen. Organizational leaders need to talk about it and normalize it – truly, make it part of your team norms. Psychological safety doesn’t skirt accountability. Accountability is a key part of a psychologically safe culture. We’ll talk more about it in the show. Just culture extends the idea of psychological safety to the organizational environment and the team’s approach to errors and mistakes. Just culture encourages teams to look at systems factors for why things break down. People don’t make mistakes willfully. Willful harm with malicious intent is recklessness or sabotage. That’s not a mistake. Mistakes are always unintentional because people don’t show up to work planning how they’re going to accidentally drop the ball and screw things up. Just culture looks at mistakes from the standpoint that perhaps the system is broken and sets frontline staff up for failure. A systems fix is like a rising tide that lifts all boats. Just culture sees the systems as the usual point of failure, not the frontline worker. Front line workers are often the source of resilience and capacity within systems. We talk about these things and more in the podcast as we thread all three parts of this series together. As a reminder, I’ll be in Hilton Head, SC next month teaching with Encore Symposiums and back at the Cliff House in Maine this October with Encore. Come check us out if you’re looking for a great continuing education conference! Your values build your system, your system creates your culture, your culture generates your results. References Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com Conklin, T. (2025). PAPod 540 – Swiss Cheese Actually In PreAccident Investigation Podcast.https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000702329202 Dekker, S. (2016). Just culture: Balancing safety and accountability. crc Press.  Dekker, S. W., & Leveson, N. G. (2015). The systems approach to medicine: controversy and misconceptions. BMJ quality & safety, 24(1), 7-9.  Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons.  Edmondson, A. C. (2023). Right kind of wrong: The science of failing well. Simon and Schuster.  Schein, E. H. (2010). Organizational culture and leadership (Vol. 2). John Wiley & Sons.  Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Broadway Business.  Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. John Wiley & Sons.  Willink, J. (2017, February 2, 2017). Extreme Ownership TEDx, TEDx Talks. https://www.youtube.com/watch?v=ljqra3BcqWM

This is Part 2 of a 3 part series on organizational development – how we work and live together as teams in healthcare so we can do our best work, master our craft, take amazing care of patients and actually enjoy the work we do. (no big deal) In the first part (Episode 117), we talked about systems thinking and patterns of high reliability organizations (HROs). Systems thinking helps us zoom out to consider the complexity of situations and the various levers that influence outcomes. High reliability organizations adopt specific systems thinking practices to achieve consistent success in safety-critical, complex environments. Resilience engineering builds on systems thinking and HRO theory by teaching us how to develop adaptive capacity, build for success (not just avoiding error) and bounce back when things don’t go well. Safety differently is about seeing safety as not the absence of mistakes and errors but the capacity for the right thing to happen. It also recasts the worker not as the weak link in a complex system (the point of failure), but as the source of resilience and capacity. Front-line healthcare workers – you and me – are often the ones who find the workarounds and get the job done despite suboptimal conditions. No one shows up to their job with the intention to make mistakes, get hurt or put patients at risk. Mistakes are always unintentional. Willful acts of harm are something totally different. Blaming and shaming workers (forms of punishment & embarrassment) are counterproductive and stem from leaders who do not understand what’s actually going on or the best ways to run their organizations and build thriving teams. Synesis, which sounds like a scary word, stems from the same Greek word that system and synergy come from and is actually kind of a cool idea. It’s the way we balance the often competing interests of productivity, safety, reliability and quality. We need to figure out how to do all of these things concurrently in healthcare. I’ll share some stories and examples of how to do that as an anesthesia provider in this episode. So that’s where we’re headed with this podcast! In Part 3, we’ll come back and talk about psychological safety and just culture, which thread all three episodes in this little mini-series together. As a reminder, I’m teaching with Encore Symposiums next month in Hilton Head, South Carolina and back at the Cliff House in Maine this October. If you’re looking for a continuing education conference where we’ll talk more about all of this – or if you’re a resident or graduate student looking to check off one of your state/national meetings, come check us out! I’d love to see you there! As always, you can come work with us at MaineHealth – Maine Medical Center. We have a phenomenal team of CRNAs, physician anesthesiologists, surgeons, OR nurses & CSTs, anesthesia techs and admin specialists. If you want to be part of a growing team of providers doing world class work at a level 1 trauma center in a spectacular city, check us out! References Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com Conklin, T. (2025). PAPod 540 – Swiss Cheese Actually In PreAccident Investigation Podcast.https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000702329202 Epstein, R. M., & Krasner, M. S. (2013). Physician resilience: what it means, why it matters, and how to promote it. Academic Medicine, 88(3), 301-303.  Hollnagel, E. (2020). Synesis: the unification of productivity, quality, safety and reliability. Routledge.  Larouzee, J., & Le Coze, J.-C. (2020). Good and bad reasons: The Swiss cheese model and its critics. Safety science, 126, 104660.  Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Broadway Business.  Sutcliffe, K. M. (2011). High reliability organizations (HROs). Best practice & Research clinical anaesthesiology, 25(2), 133-144.  Wears, R., & Sutcliffe, K. (2019). Still not safe: patient safety and the middle-managing of American medicine. Oxford University Press.  Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. John Wiley & Sons.  World Health Organization. (2021). Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care (9240032703). 

Yo! This episode introduces the concepts of systems thinking and high reliability organizations. It’s the first part in a 3 part series. Part 2 is gonna dive into resilience engineering and safety differently. Part 3 is all about psychological safety and just culture. These 3 shows unpack crucial intel for front-line providers, equipping them to understand their roles and how to develop their clinical impact. It’s also for organizational leaders and practice managers and will help you think about how to design better systems and support your team so they can thrive. Systems thinking is the process of zooming out beyond simple cause-and-effect understanding (i.e. linear causality models) of how errors happen. It encourages people to consider the complexity of their environments and the power of leveraging changes in your processes and systems. In this episode we cover: Learning organizations and their 5 characteristics: Personal mastery Mental models Shared vision Team learning Systems thinking High reliability organizations and their characteristics Preoccupation with failure Reluctance to simplify Sensitivity to operations Commitment to resilience Deference to expertise How these ideas link to resilience engineering and safety differently “Every organization is perfectly designed to get the results it gets” (Batalden, 2015). If you don’t like the results you’re seeing, you need to change the system. Whether this is your anesthesia team, hospital/OR or your personal life. If the outcomes are not what you desire, you need to adopt a systems thinking approach to change. This episode will walk you through how to do that. The values you embrace shape your culture. Your culture builds your systems. Your systems generate your results. Quick reminder: I’m teaching at Encore Symposium’s Hilton Head conference May 19-22 and then again with their fall conference at the Cliff House here in Maine that runs October 20-23, 2025. I love seeing y’all in person at these conferences. If you come because you heard about it here on the show or are just there and have checked the show out before, come holler at me! I’d love to chat with you about what you’re up to and what your practice is like. Be sure to check out Part 2 and 3 of this series and I’ll see you there! References Batalden, P. a. C., E. (2015). Like Magic? (“Every system is perfectly designed…”). Institute for Healthcare Improvement https://www.ihi.org/insights/magic-every-system-perfectly-designed?utm_source=chatgpt.com Conklin, T. (2025). PAPod 540 – Swiss Cheese Actually In PreAccident Investigation Podcast.https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000702329202 Epstein, R. M., & Krasner, M. S. (2013). Physician resilience: what it means, why it matters, and how to promote it. Academic Medicine, 88(3), 301-303.  Hollnagel, E. (2020). Synesis: the unification of productivity, quality, safety and reliability. Routledge.  Larouzee, J., & Le Coze, J.-C. (2020). Good and bad reasons: The Swiss cheese model and its critics. Safety science, 126, 104660.  Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Broadway Business.  Sutcliffe, K. M. (2011). High reliability organizations (HROs). Best practice & Research clinical anaesthesiology, 25(2), 133-144.  Wears, R., & Sutcliffe, K. (2019). Still not safe: patient safety and the middle-managing of American medicine. Oxford University Press.  Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. John Wiley & Sons.  World Health Organization. (2021). Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care (9240032703).  If you don’t like the results you’re seeing, you gotta change the system! Every system is perfectly designed to get the results it gets!

On the corner of Skyland Drive and 23 in a little town called Sylva in Western North Carolina, sit’s PJ’s gas station. One hot summer day back in 2005, I was filling up the tank in a convalescent transport van on my very first day as an EMT-Basic. That’s the most basic, entry-level certification of working as an Emergency Medical Technician or EMT.  My convalescent transport van had a wheelchair ramp and my role as an EMT-B was not to do 911 calls, but to drive this glorified shuttle bus. My role was to transport people to and from their doctor’s appointments. Maybe to help them get home after being discharged from the hospital. If you were too sick for a taxi but not quite sick enough for an ambulance, I was your guy. The guy training me that day, a senior paramedic, was actually a good friend of mine and happened to also be my boss at a local outdoor education company. Everyone affectionally called him “the Padj,” a shortened third-person version of his last name, Padgett. The Padj ran Landmark Learning, which offers wilderness medicine educational courses for outdoor guides and enthusiasts and eventually became the Southeast training center for NOLS Wilderness Medicine. Pretty much everyone who taught for NOLS Wilderness Medicine had a part time gig working in EMS and so that became my path too and this was my first day on the job. I felt supremely important because of two things: as part of my standard issue uniform, on my thick polyester blue shirt, I was wearing a chrome name badge that said “J. Lowrance, Since 2005” and I had a big, heavy, professional walkie talkie. We had no more checked out the van and driven a mile down the road from base to fill up with gas at PJs when the tones went off on the walkie talkie, indicating a serious 911 call had just been dispatched. As I was pumping gas and the Padj was relaxing in the passenger seat, the radio crackled with the call: there was an unresponsive patient about a half mile down the road from where we were. We looked at each other and shrugged, knowing that even though we were essentially in a shuttle bus with next to no medical supplies, we wanted to see if we could help. We hurriedly paid for the gas, jumped in the van and ended up beating the ambulance to the house where the 911 call came from. We were met by a distraught woman in her 60’s who told us she couldn’t wake her husband up. We went in the house through the side door, immediately finding ourselves in her kitchen. The bedroom was just off the kitchen and walking in, I remember the time on the bedside clock – one of those little rectangular digital clocks with red numbers: the time was 10:10 in the morning. Photo credit: OpenAI (2025). ChatGPT 4o version. [Large language model]. https://chatgpt.com.  The man was large, heavy and not moving. He looked like he was still asleep except he was a deep shade of purple… not quite blue yet, but definitely not alive-looking.  The Padj called out to him and checked a pulse. Nothing. My heart, however, was racing.  As my palms began to sweat, the Padj looked at me serious, which he never did, and said quietly out of respect for the man’s wife, standing in the doorway, “dead on arrival or do you wanna run the code?” I could hear the sirens of the ambulance approaching the house. “Let’s do it.”  We heaved the man onto the floor… he was heavier than I thought he would be. It dawned on me that dead people don’t try to help you like our wilderness medicine students do when they’re trying to act like patients in simulated scenarios. This was not a scenario. Padj said he’d get the O2 tank in the van and that I should start CPR. I knelt down, looked left and right for our jump bag, which contained a bag-valve mask or BVM, which we used to breathe for patients in cardiac arrest. We left the jump bag in the kitchen. I was in rescue mode. No time to waste. I looked at the man, zeroed in on those purple lips and scrubby, lifeless face, pinched his nose and leaned in to do mouth-to-mouth resuscitation. As time slowed down and I leaned in to my new career in EMS, a paramedic shouted from the front door, “STOP,” shaking his head. He had arrived just in time to yell at me and snarled, “JLo, we don’t do that! Somebody get him a BVM.” A bag-valve-mask was thrown at me from the kitchen. I quickly pumped two breaths with the bag into the man and started chest compressions. We all worked together as hard as we could to save that man’s life but our efforts were in vain. Who knows when he had died before his wife found him that morning. We ran the code, started an IV, intubated him and did CPR the mile and half back up the road to the hospital, where the code was called. I walked out as his wife, crying, walked in to see him. It was my first day on the job. It would be her first day without him. Two things happened that day for me:  I became hooked on resuscitation.  And I realized that the people and teams doing this kind of work have their own special flare in the midst of the chaos. For the first time, I saw the human factor in emergencies. Not just my ignorance and naiveté. But how more experienced providers find work arounds. How seasoned clinicians have unspoken rules that govern the work they do. A certain sort of knowing that only comes with experience. I’ll come back to that in a minute. That first call on my first day in EMS in Western North Carolina seared into some deep squishy corner of my brain a true love of resuscitation. I was hooked. I thought this is definitely the kind of work I want to do, and I want to learn how to do it better and how teams can do this kind of thing better. That drive would become a central theme of my professional career moving forward and is why I’m writing this now. The other thing it did was create a certain level of cognitive dissonance. It interjected the reality of human factors in resuscitation and emergencies in an incredibly powerful way.  There was my ignorance coupled with an overwhelming desire to do the right thing. I’m going to breathe for this patient because that’s the right thing to do! And then there’s the disruption to that plan; the alternative approach; the wisdom of a senior clinician. Here I am about to follow the algorithm and get the job done despite my immediate resource limitation… adapt and overcome and all that and then there’s the senior paramedic saying, “What are you doing? We don’t do that!” I was like: but we’re supposed to save lives! In every TV drama I’ve ever seen – which I happen to be literally in the middle of right now on my first day on the job – EMS people are supposed to save lives; and now I’m an EMS people.  WE are supposed to SAVE LIVES!  Not wait for an AMBU bag because I left it in the kitchen.  This disruption to my preconceived notion of how things were supposed to go was a poignant introduction to the idea that humans will often deviate from expected work patterns to best get the job done.   What I learned was there is a way more senior people do things that the newbies don’t know about. They have that special kind of knowing that only comes with experience.  Check this out: the Greeks have several different words for different kinds of knowing. There’s knowing about something, like scientific facts & figures, which is where most new anesthesia trainees are with their knowledge. This is gnosis (‘nō-sis), to know about something in a general way. Similar to this is epistēmē (ep-uh-steam), which is knowing more scientific, academic knowledge. Epistēmē is where we get epistemology (eh-puh-stuh-mo-lo-gy) from, which is the study of how we know things, what we know and the limits of that knowledge.  There’s the work as imagined, which is informed by protocols and standards and expected norms of behavior or even expectations that society has on healthcare providers: we will save lives even if it means putting our own lives at risk.  And then there’s the work as done, which is often shaped and determined by this special kind of knowledge about how to do things. What I’m talking about with experienced resuscitationists is ginōskō (gi-know-sko). Ginōskō is an experiential knowledge that only comes through deep experience or relationship with the subject, practice or person. You only get this kind of knowledge through experience.  If you know, you know, you know what I mean? All right, so there’s your Greek lesson for the day and where my gnosis of the Greek language ends.  So, what this very first resuscitation taught me is that providers who do this kind of work have a very deep, experiential knowledge that guides their decision-making. This goes beyond the algorithms. Gary Klein talked about this within his recognition-primed decision-making model (Klein, 2017). Daniel Kahneman (2011) spoke of System 1 and System 2, with System 1 being our intuitive decision-making and System II our more deliberate, concentrated thinking.  These modalities of decision making are important parts of how people operate on a daily basis in jobs that require people to be very knowledgeable about their work.   There’s the work as imagined and then there’s the work as done. There’s the protocols, rules & regs, expected behavior and then there’s the work arounds, real adaptations and the way the work actually gets done. This little moment in my career taught me that resuscitation is a wild place. You have all kinds of experience levels converging on a moment and each of those people has a different mental model of what’s supposed to happen. And that’s just the front line staff that actually get their hands dirty during a resuscitation. We’re not even talking about safety or risk professionals yet who might review cases or senior leaders who don’t actually do the work that they’re charged with overseeing, supporting, reviewing or administrating. The human factor in emergencies is a bit of a wild card.  When humans are managing emergencies, there will inherently be variability in performance despite the expectation for consistent execution of normal behavior.  While reducing variation is a noble goal that organizations and even individuals should work towards, we have to recognize that variable performance is likely normal in volatile, uncertain, complex and ambiguous (VUCA) settings (Edmonson, 2018). Resuscitation is a classic VUCA setting. While not all resuscitations are volatile, most have uncertain outcomes, are complex and contain ambiguous elements to them requiring judgment, rapid differential diagnosis and decision-making.  Algorithms, rules & regs and policies guide care, but it’s people who actually do the care.  There’s the way we think healthcare providers will act – because of the incentives or constraints in place, the rules and regulations and the system we’ve set up. Then there’s the way healthcare providers actually behave. There’s the way we imagine work will be done and then the way work is actually done. And usually the folks on the sharp end find the most effective, expedient, efficient way to do things. So, what does this mean for you?  If you’re a provider, keep practicing. Keep finding the best path forward. Don’t stagnate with what you know. There may be better ways to do something. You may need better systems to operate in. You may need more experience to develop judgment and wisdom beyond the rule book, protocols and algorithms. Why was the BVM not brought to the bedroom on this call in the first place? Whose responsibility was it to haul the gear in the house? Did we talk about the plan ahead of time? Were we following a pattern of performance or just winging it and seeing what would happen? Remember, the way you do anything is the way you do everything. As healthcare providers on the path towards mastering our craft, we have the responsibility to engage in self-reflection about our practice and our habits.   Elaine Scarry, a professor of English at Harvard, has this quote which I love: “What occurs in an emergency is either immobilization… incoherent action or… coherent action.  If we act, we act out of the habitual.  If no serviceable habit is available, we will use an unserviceable one and become either immobilized or incoherent” (Scarry, 2011). What this means to me, especially when coupled with all of the science on deliberate practice and expertise from Anders Ericsson and others, is that we have a responsibility to develop good work habits.  Because when push comes to shove in an emergency, we don’t rise to the occasion, we fall back on our training and our practice… we fall back on our habits.   Now, if you’re a practice leader, be open to the fact that your team may not follow the rules because the rules may not be in their best interest. It’s not your job to get your team to follow the rules. It’s your job to build an environment that optimizes your team’s ability to do their job – yes, safely; yes, in congruence with standards & regulations. But you may have dumb rules that need to be re-written. You may have policies that don’t align with work as done or as it should be done. You might need to do some really boring background work to clean up your rules and regs, and more importantly, to improve your processes, so that your team can do their jobs better, more efficiently and more effectively and in a way that is in alignment with what the organization expects. By the way, don’t punish people when you hear they’re not following the rules. Think: why did they do it that way? What kind of work environment are they adapting to? What incentives are they operating with right now? Are there ways we can improve the environment or change the incentives in which these really smart people work? I was out on a run yesterday listening to Todd Conklin’s Pre-Accident Investigation podcast (Conklin, 2025).  Conklin is a leading thinker in the organizational safety & development space.  He was talking with another safety scientist and said something to the effect that if you’re best people are breaking your most important rule, something in the system is wrong.  It’s not the people’s fault.  They’re just trying to do their job.  As a leader, you need to improve the system. It’s not about finding bad apples and weeding them out.  It’s about improving the entire system.  Because safety is not about minimizing errors but rather building a capacity for the right kind of work to happen.  Errors will be inevitable in complex environments – VUCA environments (volatile, uncertain, complex and ambiguous).  Things will not always go as planned or imagined.  Safety is about recognizing that the people on our teams don’t show up to work planning to make mistakes and hurt people or get hurt themselves.  Mistakes are not intentional or willful acts.  Safety is about figuring out how we as providers and all yall out there who are leaders can build more resilient systems with a higher probability of the right kind of work happening.      So I know we’ve wandered a bit today.  There’s something about that very first resuscitation that I was a part of that stuck with me.   Actually, since we’re on the topic… there was actually a resuscitation, or an accident, before that one on my first day as an EMT that really sparked things for me.  I’ll share this quickly as it does tie in to the whole trajectory that I’ve been on for quite some time now.   On another hot summer day… this one in southwest Missouri when I was in between my junior and senior year of high school, I was on a flat-nosed school bus leaving a summer church camp when our bus crested the hill of a highway going about 60 miles per hour and we hit a tractor that was pulling a trailer full of hay.  For whatever reason, the bus drive didn’t see this tractor, which was probably going about 25 miles per hour at best, was straddling the shoulder and the right-hand lane. By the time we crested the hill and he could see, it was too late; we slammed into the back of that trailer and it seemed like everything on God’s green earth went airborne and time slowed down.  A could see the little particles of broken glass suspended in the air, the hail bails exploding in the wind, the trailer and tractor being lifted off the hot pavement, and then we all came crashing down as time sped up and the bus screeched to a halt.  I had just finished an Advanced First Aid & CPR class at my high school the previous semester.  Advanced First Aid, mind you.  I had my keychain CPR mask on me… one that was big enough to hold a pair of gloves and a little flimsy CPR mask… and I grabbed a blanket from the bus thinking the farmer on that tractor could be in shock and I jumped out of the bus and ran back to him along with some of the adult youth leaders.  The guy’s head was split open from his forehead down between his eyes to over his cheek.  He ended up living and making a reasonable recovery but standing there in the heat and sun, I was immobilized.  I had no idea what to do other than feebly offer up a blanket even though it must have been over a hundred degrees on the pavement.  I got to watch the firetrucks shut down the highway and the helicopter land, which was pretty cool.  But I couldn’t do much.  So like Elaine Scarry said: I became acutely aware that despite having some first aid training, I was pretty much unequipped with any serviceable habits so I just kinda stood there and waited for EMS to show up. Fast forward a bunch of years and I was through college with an outdoor recreation degree, teaching wilderness first responder courses and on my first day as an EMT I found myself kneeling over a patient in cardiac arrest.   These moments highlight steps in my personal journey where I decided to level up.  I knew I didn’t know everything, and I needed to keep training, keep studying.   They also serve as really interesting reference points on systems thinking and human factors in emergencies.   Mistakes and errors are going to happen.  Progress is not inevitable or permanent.  How we build systems and maintain systems of care has a profound impact on how people work and how we generate the outcomes that we want.   I hope this was fun for you and interesting.  I hope this spurs some thinking for you on how you operate as a provider and maybe how your organization thinks and talks about risk, errors and safety.   Drop me email if you want to talk more.  Leave a review on Apple podcasts if you like this show: that helps other people find and trust Anesthesia Guidebook. Thanks for the work you do and for checking this show out!   Conklin, T. (2025, March 15).  PAPod 537 – Unveiling the myths of modern safety: a conversation with Todd and Georgina. . PreAccident Investigation Podcast.  https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000699305329 Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons. Kahneman, D. (2011). Thinking, fast and slow. Farrar, Straus, and Giroux.  Klein, G. A. (2017). Sources of power: How people make decisions. MIT press. Scarry, E. (2011).  Thinking in an Emergency.  W. W. Norton & Company, Ltd.  “If we act, we act out of the habitual…” Elaine Scarry

Hey y’all! First of all: thank you to those of you who have subscribed to the website and get these posts right to your email inbox. That’s all that happens: the podcast is free and subscription to the show just means you get the content straight to you as soon as it’s live. I never sell or use your contact info for any other means. I’m just simply thrilled to have your support and interest in the show as the whole thing is geared to support you and help you thrive in your career as an anesthesia provider. Thank you! This podcast covers a run down on the NBCRNA’s Maintaining Anesthesia Certification (MAC) Program. The MAC Program is how CRNAs maintain and rectify their license with the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA). The MAC Program launched in 2024 as a revamped version of the old CPC (Continued Professional Certification) Program. There are some substantial changes that CRNAs should be aware of. First off, you need to know if you’re in the MAC Program yet. Most CRNAs (new grads and those who’ve re-licensed after 2024) ARE in the new MAC Program. This show will coach you on how you can log into NBCRNA’s website to see where you’re at and what you need to know about MAC Ed (Class A) & MAC Dev (Class B) credits and the quarterly MAC Check exam questions that you can take on an app on your phone. All the details are in the show! For the truth of what’s up with the MAC Program and your license, as always, check with NBCRNA! Things change over time. Be sure NBCRNA has an updated email for you. 30% of the emails they send to CRNAs bounce back as invalid addresses. That’s insane! Updatechur email! You can follow along with the podcast by checking out the attached PDF that outlines the show with lots of helpful graphs and more info than what I spoke about in the podcast. Two last points: First: Overall, I think the MAC Program is a really healthy and needed evolution to the CPC Program. NBCRNA has listened to CRNAs and made needed adjustments to the continuing education/relicensure program. We have to have a continuing education/certification program for the CRNA license to have meaning and value. The current iteration is the best it’s been, so there’s that. Second: Remember that your STATE Board of Nursing may require additional steps for you to re-license as a CRNA. For instance, NBCRNA does NOT require pharmacology-specific continuing education credits (MAC-Ed/Class A); however, the State of Maine (where I’m at) does! For example, Maine CRNAs must obtain 60 MAC-Ed/Class A and 40 MAC-Dev/Class B credits for recertification with NBCRNA every 4 years but we have to have 50 credits every 2 years, 15 of which (every 2 years) must be pharmacology credits, to re-license as CRNA in the State of Maine. So the requirements to re-license as a CRNA in the State of Maine are slightly more stringent (and more frequent) than to maintain the national license with NBCRNA. Follow along with the powerpoint for more details: MAC Program Overview – Anesthesia GuidebookDownload Go get you some deliberate practice!

This podcast is for leaders, clinicians, residents & students who need to get wildly important things done. It’s about how to prioritize when so much of your work seems important. How to find balance when so much seems to be coming at you. How to get started at achieving your biggest goals. This episode will walk you through the 4 Disciplines of Execution by Chris McChesney, Sean Covey & Jim Huling.  I have no financial relationship with these folks, the book or their publishers. It’s just a great concept that will help you get organized, identify your wildly important goal and figure out the work you actually need to do and CAN do to accomplish your goals. The 4 Disciplines of Execution (4DX) model will ask you to identify your wildly important goal. You’ll then create several lag measures (subgoals) and several lead measures (objectives) for each lag measure. These lead and lag measures are where the real work is. The wildly important goal may seem out of reach. Even the lag measures (which lag behind the work you’ll do in the lead measures) may seem a bit ambitious. That’s ok. The lead measures should be the specific actions you will take on a daily or weekly basis that will chip away at the lag measures. As you put the work in on the lead measures, your lag measures will come into sight and slowly be realized. As you stack up achieving the lag measures, your wildly important goal will become within reach. The next components of the 4DX model is the scoreboard where you track your progress on each lead & lag measure. This can be any relevant metric on any kind of progress tracker: a list on a whiteboard, a data point in an Excel file, the pounds on the scale, dollars in the investment account or left on the loan. Whatever. Lastly, is the cadence of accountability. You need to either personally set up a check in on your progress with yourself or you need to set this up with your team, mentor or coach. The authors of the 4DX model recommend this be a short weekly meeting where you review progress from the last week and plan actions for the coming week. Accountability is about follow through, taking steps (as small as they might be) and slowly, setting up the cadence of consistency. I was on the Peloton last night and heard Matt Wilpers say that the order of priorities in exercise is developing consistency, then duration, then load. You can’t go out hard all of a sudden and expect big results. Develop consistency. Show up a little bit each day or each week. Then put the time in. Build the duration of your investment towards your goals. Then you’ll know when to put the extra effort in. Check out the show and if you want to dig deeper, definitely check out the 4 Disciplines of Execution. McChesney, C., Covey, S., & Huling, J. (2012). The 4 disciplines of execution: Achieving your wildly important goals. Simon and Schuster. What’s your Wildly Important Goal?

Matt & Alison Moody took a year off of working as CRNAs to live and travel in Spain with their then 4-year old daughter. This is part of that story. Matt & Alison Moody in Granada, Spain The two were living and working as CRNAs in Asheville, North Carolina when they caught the idea to take a year off of work and live in Spain. Their journey to Spain went from the fall of 2023 to the fall of 2024 and over the last few months, they’ve been re-integrating back to the United States and Western North Carolina and back to their careers as CRNAs. Part of their inspiration to take a year off work came from listening to the episode I did with Kyle & Jen Steen on their decision to sell everything, build out a sprinter van and hit the road. That story is in episode 73. Side note: Kyle & Jen took about 18 months off from work before Kyle returned to his career in anesthesia through locum assignments. They’re still in the van full time and still crossing off new places to live & explore. I hope to have them back on the show soon! Matt & Alison wanted to head to Spain to work on their Spanish language skills and take time to connect with each other as a family. What they discovered along the way may surprise you. In this conversation with Matt, he walks us through what they set out to do and how that changed over time – from before they left through how their experience evolved while they were over in Spain. I think you’ll enjoy this story and hopefully find some inspiration for yourself to think outside of the box and consider what might be possible in your own life. It doesn’t have to be taking a sabbatical or selling everything and hoping in a custom built Sprinter van. It might be about re-prioritizing your work-life balance in other ways. It might be going back to school or picking up pottery like my wife, Kristin. It might be about moving to that area of the country you’ve always wanted to live in or finding a new way to explore your passions. Finding a way to prioritize your own story, dreams and aspirations along the way is possible and I loved chatting with Matt to hear how he & Alison arranged their life to pursue their goals. Matt grew up in coastal North Carolina; went to college and nursing school at UNC Chapel Hill; and then received his CRNA degree at Wake Forest. His heart and soul have always belonged in the Pacific Northwest, so after graduate school he moved west and started his career at the University of Washington Medical Center in Seattle, WA. Eventually, the pull of family brought him back to NC, and he has called Asheville home since 2017. Thus far in his career, Matt has had the fortune to gain experience in many practice areas – from major trauma hospitals to small surgery centers – and has experience in many subspecialties of anesthesia. In his free time, Matt loves to spend time being active outdoors, but he’s especially passionate about rock climbing and skiing. Lately, he and his wife, Alison, have been experiencing the joys (and frustrations!) of introducing their 5 year-old daughter to these activities. While in Spain, Alison created an Instagram page that they invite you to follow. It’s @ La Moody Aventura. @lamoodyaventura Matt also offers his email to anyone who might have questions about how they did what they did. In the show, he talks about how they felt like they were the only ones crazy enough to do something like this but then actually met several folks abroad – including another CRNA family from the States – who were pursuing similar dreams. Matt would love to help you take the next step and you can reach him at mattwmoody@gmail.com. And with that, let’s get to the show! – Jon Want to share this episode with your community? Click the link below! Subscribe Subscribing to the website lets you get these posts as soon as they’re live! We never sell or distribute your info and it’s always free! Jon Lowrance | Anesthesia Guidebook

What’s up y’all! This is Jon Lowrance and this is episode 112 – How to Transition from Clinician to Chief CRNA. Y’all are going to love this conversation. So… I almost don’t know where to begin cause there’s so much to talk about… This is an episode about chief CRNAs but so much more. It’s like when you watch one of those food documentaries about the best pizza kitchens in the world and you’re like: oh, a documentary about pizza, but then it’s really about the experience of chefs, small business owners, friendship and passion. This episode is like that. It’s about chief CRNAs. And we have a couple of guests that are going to talk with us about an article they published on the research they did into the professional experience of chief CRNAs. But this story is really about the transition that most healthcare providers take when they take the step from expert provider to clinician-leader, practice manager or owner. You’re going to see this through the lens of what these 2 researchers saw when they did a qualitative analysis of chief CRNAs across the state of North Carolina. But you might take something away from this about the physician who leads your team or the CMO or health system president that runs the show where you’re at. If you work in healthcare, cause you probably do – again, unless you’re my mom, who listens to all these podcasts – hey Gail! But for the rest of you, if you’re in healthcare, this episode will likely help you understand your clinical leaders better. I never set out to be a chief CRNA or practice manager. I wanted to be the best clinician I could. I wanted to stand in the gap between the chaos and the outcome. I wanted to master my craft as an anesthesia provider and take the best care of patients possible. Literally, like 6 months before our chief CRNA announced that he was going to step down after 8 years in his role, I had the opportunity to become a daily shift supervisor – like a board runner in the OR. I was like: I’m never going to do that. It seems way too hard. Then our chief stepped down and his role opened up and I was like… wellllllllll… This episode hopefully will be relevant to any clinician who, like me, has stepped into a role or is thinking about taking on a clinical practice leadership role that maybe they’re not totally ready for. You’re not alone. So we’re going to talk with Austin Cole and Robert Whitehurst, co-authors of an article about the competencies & professional development needs of chief CRNAs that was published in April 2024 in the AANA Journal. Austin framed his doctoral project at Duke University around this study. Austin Cole, DNP, CRNA began his career after graduating from the school of nursing at UNC-Chapel Hill. Following graduation, he spent two years as a Registered Nurse in a cardiothoracic critical care unit. He received his DNP and nurse anesthesiology training at Duke University and currently practices as a CRNA at Duke Regional Hospital in Durham, NC. Robert Whitehurst is the President of Advanced Anesthesia Solutions, a CRNA practice providing anesthesia services to a variety of outpatient practices. He graduated in 1997 from East Carolina University School of Nursing with his Bachelor of Science in Nursing and in 2004 from Duke University School of Nursing with his Master of Science in Nursing. Bob Whitehurst is also the Chairperson for the North Carolina Association of Nurse Anesthetist’s Political Action Committee and he’s passionate about patient access to high quality anesthesia care. He’s happily married to Amy Whitehurst; they have 4 children and in his spare time he enjoys hanging out with his family and playing tennis with friends. Austin & Bob’s paper is titled “A mixed-methods exploration of competencies and professional development needs among chief Certified Registered Nurse Anesthetists.” For the study, the authors contacted 85 chief CRNAs across North Carolina and conducted structured interviews and qualitative analysis with 10 of them. They set out to understand the competencies and professional development needs of chief CRNAs. I gotta say, when I read their article, so much of it resonated with me as a chief CRNA. The path for so many practice managers – including physician anesthesiologists and other Advanced Practice Providers, like PAs & NPs, is that a senior clinician with several years of clinical experience often steps into a practice management & leadership role that’s been vacated and their learning curve in leadership happens through on the job training. That’s kinda suboptimal. Yet it’s pretty rare for groups or hospitals to have dedicated mentorship and professional development programs established and to encourage clinicians to develop as practice leaders. It’s even more rare for clinicians to have formal leadership & management training prior to stepping into leadership roles. In the show, we hit on 2 important concepts – the double loss phenomenon and the halo effect. The double loss phenomenon is where the group looses a senior clinician when they step into a leadership role since they’re not doing clinical work as much and they gain an inexperienced leader & manager… someone with little to no experience in that kind of role. No bueno. The halo effect is the cognitive bias where people believe that because they’re really good at doing one thing – like being an expert anesthesia provider – they’ll automatically be really good at another – like being a practice leader. Competency in your clinical practice does NOT translate to competency in leadership & management. They’re two wildly different skill sets and you need to train, study and work hard at leadership & management just like you trained, studied and worked hard to become an expert clinician. So I think you’re going to enjoy this show. Regardless of your clinical background – whether you’re a CRNA, a med student or resident, physician anesthesiologist or some other Advanced Practice Provider. Even though we’re talking about chief CRNAs here, we’re really talking about the phenomenon of clinicians transitioning into leadership & practice management roles. I’m a big believer that if healthcare is going to change for the better… become more effective, efficient, safer and just better for both patients and the people providing the care, we will need expert clinician-leaders. We need these clinician-leaders to learn the art & science of practice management. We need clinicians to develop the key competencies to become expert leaders. That transition and development is not a given. It doesn’t just happen with on the job experience. You can be a very experienced practice leader and be terrible at your job. This episode is a great place to start for new and future clinician-leaders. I hope you enjoy it as much as I did! I’ve got links in the show notes to the article that Austin & Bob published. And with that, let’s get to the show! Cole, A. L., Simmons, V. C., Turner, B. S., Whitehurst, R., & Tola, D. H. (2024). A Mixed-Methods Exploration of Competencies and Professional Development Needs Among Chief Certified Registered Nurse Anesthetists. AANA journal, 92(2), 105–113.

What’s up yall! This is Jon Lowrance and this is episode 111 – How to Prepare for Medical Mission Trips with Stacey Such, MSN, CRNA. (Stacey pronounces her last name, Such, like “Suke/Duke.”) Before we get to this show, I’d like to give a quick shout out to the CRNAs, SRNAs & physician anesthesiologists who made it to Encore’s conference in Bar Harbor back in October as well as the Maine and Arizona State Association of Nurse Anesthesiology conferences, which were also in October. I had the privilege of speaking at all three of these conferences and really loved getting to see some of you out there. We had 2 SRNAs in Bar Harbor from different programs who came to that conference because they heard about it right here on the podcast, which is awesome! Somebody else in Bar Harbor let me know that after they listened to the episode on how ondansetron prevents spinal induced hypotension – which I recorded way back in 2021 with Jenny Li in episode 16, this guy went and did his own deep dive on the topic, ended up presenting on it at his group and they changed their whole practice as a group in managing c-sections. That’s amazing. I have so much respect for yall out there on the front lines, working to master your craft and make a difference for your patients. So, it’s always a blast to get to hang out with you in person at these conferences. On that note, for 2025, I’ll be back with Encore Symposiums down in Hilton Head, South Carolina in May and back at the Cliff House in October. That’s May 19-22 at Hilton Head Island in South Carolina and October 20-23 at the Cliff House Resort in Cape Neddick, Maine and those are with Encore Symposiums. All right, in this episode, Stacey gives us a run down on how healthcare providers can prepare for short term medical mission work. Stacey has been a CRNA since 2012 when she completed her Master of Science at Middle Tennessee School of Anesthesia. She worked as a CRNA for just over 10 years prior to returning to graduate school to complete her Doctorate in Nurse Anesthesia Practice at Virginia Commonwealth University. She framed her doctoral project around short term medical mission trips, their impact on global health and how healthcare providers can prepare to engage in this work. In this show, you’ll hear what motivate Stacey to engage with this work following a deeply personal tragedy. You’ll hear stories about her time serving with Mercy Ships, Samaritan’s Purse and the World Health Organization. Stacey walks listeners through her 8-step guide for how to prepare for medical mission work. This is an excellent introduction to short term mission work and will hopefully inspire you to get involved in serving others in new ways and give you a guide for where to start. Stacey included her 1-page guide to preparing for medical mission work in the show notes to this episode. She’s titled this Global Anesthesia Outreach: A Comprehensive guide To Preparing for Medical Mission Work. Global Anesthesia Outreach: A Comprehensive guide To Preparing for Medical Mission WorkDownload If this kind of work interests you, be sure to check out episodes 61 & 62 of Anesthesia Guidebook. These are 2 episodes I did with Dr Mason McDowell on how to do anesthesia for global outreach. Mason talks about his full-time service as an anesthesia provider and educator in Béré, Chad and you can learn a ton through those two shows and the one that you’re about to check out. And with that, let’s get to the show!

What up yall. This is Jon Lowrance with Anesthesia Guidebook. This is episode #110 – How we do interviews with Alison Kent, MSN, CRNA & April Bourgoin, DNAP, CRNA. In this episode, April, Alison & I talk about how we conduct CRNA interviews as a leadership team with our Department of Anesthesiology at MaineHealth – Maine Medical Center. Maine Med is the only level 1 trauma center in the state of Maine with 700-licensed beds. We run around 60 anesthesia sites of service a day with a staff of just over 130 CRNAs, 50 physician anesthesiologists, a physician residency & fellowship program and have clinical affiliations with 4 different nurse anesthesiology training programs. Alison Kent is the Manager of CRNA Services at Maine Medical Center and completed her Master of Nursing in anesthesia at the University of New England in 2006. She’s been at Maine Medical Center as a CRNA for nearly 20 years and has served in the Manager role since 2017. April Bourgoin is one of two Supervisors of CRNA Services at Maine Medical Center and completed her Master of Science and Doctor of Nurse Anesthesia Practice degrees at Virginia Commonwealth University in 2017.  Prior to becoming a CRNA, she served for eight years as an active duty commissioned officer in the Army as flight nurse with the 82nd Airborne Dustoff medevac team. She served two combat tours prior to transferring to the Army Reserves at the rank of Major. April joined me on episode 93 of Anesthesia Guidebook where we talked about OR fires and this is Alison’s first, but certainly not last, appearance on the show! These 2 folks are part of the core CRNA leadership team at Maine Medical Center. Together, they truly make the world go round for our team and are like the glue that holds everything together. It’s an absolute privilege to get to work closely with these folks on a daily basis and I couldn’t be more thrilled to have pulled them in on this podcast about how we do interviews. So, let’s tee this up a bit. In today’s anesthesia market, you can go anywhere and make a great money and do interesting cases but the thing that will differentiate your experience with a group is the culture of the team. And your experience of that culture begins with your interview. It actually begins a little earlier than that, even, with how the reputation of the team reaches you – maybe through things like this podcast, or when you reach out to inquire about a group or talk with friends & colleagues who may work or have worked with a particular group. But a really important deep dive into the culture of the team will come on interview day. You should meet some core folks on the team – CRNAs, physicians, trainees, administrative specialists. You should get in the operating rooms and actually see the staff do the work that you’re looking to join them in. You should leave the interview with a very clear idea of what you’re potentially getting yourself into, both in terms of culture and with a thorough run down of the benefits and compensation package. If you’re listening to this and you’re a practice manager or thinking about getting into a role in which you support your team as a leader, hopefully you find this podcast super helpful. Alison, April & I talk through our process & structure for interviews, what kinds of questions we ask, what we look for in candidates and how we work to both recruit folks and protect our culture by making sure we’re bringing in people who are a good fit for the team. A few years ago another chief CRNA asked me if I had any tips on how to conduct interviews. When we talked then, I of course knew that I wanted to get around to doing a podcast on the topic to share the same advice with you. And here it is! Oh, by the way, what we describe is our process as a leadership team. Our opinions expressed here are our views and do not necessarily represent the views or opinions of our employer. Seth Godin has this great definition of culture where he says, “people like us do things like this.” This is how we do interviews as a leadership team. We hope you enjoy our story. If you’d like to apply to work with our team as a CRNA, please reach out to chat or drop your application here: https://www.careersatmainehealth.org/jobs/search Search for the CRNA roles at Maine Medical Center in Portland, Maine. And with that, let’s get to the show.

What’s up yall! This episode dives into fundamental concepts related to leadership and casts a message for why it matters to all of us. Whether you’re primarily a clinical CRNA/physician anesthesiologist, resident/SRNA, a practice leader/manager, business owner, educator, researcher or policy advocate, leadership has a fundamental role in your day to day life. In this episode, we talk about: The art & science of leadership Position, power, influence Leadership & management  Leadership & followership Culture, and how we influence it  The Servant Leadership Model  Jocko’s leadership principles I’m pulling from my time as an instructor with Landmark Learning and NOLS (National Outdoor Leadership School), both outdoor education schools that thread leadership principles through their risk management and wilderness medicine programs. I’m also pulling from my experience as the chief CRNA at Maine Medical Center, a level 1 trauma center with over 200 staff in the anesthesia department. And some of the content is coming from the work I’m doing as I pursue a PhD in organizational leadership with a research focus on how high performance teams operate in emergencies. Hopefully you’ll find something you can hang your hat on here. Leadership is the art and science of influencing others to achieve shared goals. There’s a ton of different leadership styles & theories out there and I’ll touch on some in the podcast. My personal approach is the Servant Leadership Model, which flips the traditional organizational chart – a pyramidal/triangular structure – on its head and puts the leader at the bottom of the triangle and the most important staff up at the top. The most important folks in any organization are those who are doing the front line work to deliver on the mission and vision of the organization. In the Servant Leadership Model, these folks are the top and the leaders and managers are positioned below them. The job of leaders and managers is to support and empower the folks above them to do their best work in robust and resilient environments where the capacity for the right thing to happen flourishes. No big deal right? To find out more, check out the podcast! Servant Leadership ModelDownload Leadership Tactics By Jocko Willink Be humble  Don’t act like you know everything  Listen, ask for advice & heed it Treat people with respect  Take ownership of failures Pass credit for success up & down the chain of command Work hard  Have integrity – do what you say, say what you do Be balanced – avoid extreme actions/opinions Be decisive  Build relationships = this is the main goal of a leader Get the job done Willink, J. (2023). Leadership strategy and tactics: field manual expanded edition. St. Martin’s Press. Thank you to everyone who subscribes to the website & podcast… wherever you do that! YOU are the reason Anesthesia Guidebook is here. Take care and have fun out there! Jon Lowrance

What up yall!  This is a quick shout out to those of you headed to the AANA conference this weekend, August 2nd, 2024 in San Diego.   I hope that yall have an incredible time and meet tons of new colleagues, see old friends and have fun gettin’ your learn on.   I was talking to one of the SRNAs from the University of New England this morning in clinical and she’s was getting psyched for the conference this weekend.  AANA Annual Congress is one of those times where you can kind of lift your head up from the daily grind and look around & see thousands of other CRNAs & SRNAs or RRNAs from around the nation who are all out there doing their thing in anesthesia.  It’s such an inspiring time!  While I will NOT be there reppin’ Anesthesia Guidebook, my clinical team from Maine Medical Center and MaineHealth will be.   So first, why am I not putting up a booth and talking about Anesthesia Guidebook… first & foremost, I’m not trying to sell you something.  Anesthesia Guidebook is still anchored in the concept of free open access medical education.  There’s no subscription fee and I’m not trying to make money off of CE credits.  There’s a hundred other ways out there for you to make Class A credit and that just hasn’t become a professional focus on mine.  Which brings up the reminder that any anesthesia related podcast you listen to will qualify for free Class B credit in the CPC program.  If you’re a CRNA and you routinely listen to anesthesia podcasts, all you have to do is self-report your credits to the AANA and you’ll rack up those Class B credits super fast. I actually did a brief podcast on this topic way back in Episode #9 of the podcast if you want to hear more about how to do that. So while there’s no Anesthesia Guidebook table at AANA Annual Congress, you CAN go meet my good friends and colleagues from Maine Medical Center in the exhibition hall.  April Bourgoin, Jill Guzzardo and Danielle Beaumont will be there staffing the MaineHealth booth to tell yall about the amazing career opportunities within MaineHealth.  We have everything from level 1 trauma center work with my team at Maine Medical Center where I serve as chief CRNA to a  full independent practice location in Conway, NH to several other smaller town medical centers throughout Maine, including Pen Bay Medical Center in Rockland, where Jill is the chief CRNA. So April Bourgoin will be out there this weekend.  Dr April Bourgoin one of our CRNA Supervisors at MMC, and she’s been on the show before talking about OR fires back in episode 93.  I actually just recorded an episode that I’m editing now with April and our CRNA Manager, Alison Kent, on how we do interviews as a leadership team at MMC.  That show is targeted towards other practice managers out there but is obviously also probably valuable for SRNAs as it gives you a behinds the scenes look at how we plan team interviews for people applying to be on our team.  So April’s out there… you can also meet Danielle Beaumont, our SRNA Clinical Coordinator at Maine Medical Center.  Danielle is amazing in that role as she supports SRN As from the University of New England and Middle Tennessee School of Anesthesia.  Danielle also just helped us establish clinical affiliations with Boston College and Northeastern University.  We’re pumped to start welcoming primary anesthesia trainees from BC and NU in 2025.  And then last but not least is Jillian Guzzardo.  Jill is one of our per diem CRNAs at MMC but she also serves as the Chief CRNA at one of our MaineHealth sister hospitals, Pen Bay Medical Center in Rockland, Maine.  If you’re looking for a small town, coastal Maine community hospital to practice at, Jill is your girl!  Pen Bay is literally on a bluff overlooking the Atlantic Ocean.  You have close up water views from work.  It’s amazing…. I mean, you can also see the ocean from the top floors of Maine Medical Center, but at Pen Bay, you can probably see what the lobstermen are having for breakfast as they motor by in the morning… it’s right there.  Jill is one of my favorite CRNAs… after a few years of holding down the fort at Pen Bay as the chief CRNA, she reached out to me and asked if she could come work off shifts and weekends at Maine Medical Center to keep her high acuity patient care skills up.  She literally asked if I would give her the shifts that my core team doesn’t want to work…  nights, evenings and weekends.  I was blown away.   All three of this CRNAs – April, Danielle and Jill – are baller clinicians.  I would let any of them take care of me or my family and just love working alongside them in the OR.  They’re also incredible CRNA leaders with a deep passion for helping SRNAs & CRNAs thrive in their practices. And they’re generally just inspiring, friendly humans…  Kind, generous, optimistic people… who are wicked smahat as we say here in New England. So if you’re headed to AANA Annual Congress, even if you’re not looking to move your practice to Maine, do yourself a favor and go meet these incredible people.  April, Danielle and Jill will be pumped to meet you. So that’s it… just wanted to drop a quick shoutout to those of you headed to AANA Annual Congress this weekend and say I hope it’s an amazing conference.  Go get your learn on, meet some new friends and stop by the MaineHealth booth and tell my friends I said hello. And with that… I’ll see ya next time!

What’s up yall this is Jon Lowrance and this is episode 107 – No Peace In Quiet with Keli Rueth. I’m pumped to bring you this conversation with Keli where we discuss her first published novel, No Peace In Quiet.   This episode was so much fun to record and I think you’re really going to enjoy it.  It’s a story that is worth sharing on an anesthesia podcast because it’s a story about how we as anesthesia providers explore the rest of our lives…  how we can step out from our clinical roles as anesthesia providers to express our creativity and joy in a different way than being mixologists and potion makers in the OR.   In this episode, Keli and I talk through her process and approach to finding her passion for writing and how she has snuck that in to the nooks and crannies of her life between working as a mother, full time CRNA and professor of anesthesiology at the University of New England.   Keli Rueth is the pen name of Dr Keli Scrapchansky, who, by the way, was one of my favorite people on planet earth even before I knew she was a novelist.  Keli started her career at Maine Medical Center just a few months before my wife, Kristin, and I did back 2015.  She graduated with her Master’s in Anesthesia from Old Dominion University in 2014 and went on to complete her Doctor of Nursing Practice at the University of North Florida.  Keli is one of those people who shows up anywhere with a smile on her face and brightens up the room she walks into.  It’s incredibly difficult to get through a conversation of any length with her without laughing about whatever topic is on the table.  She’s an easy conversationalist, a masterful clinician and educator and now, a published novelist.   No Peace In Quiet is Keli Rueth’s first novel in a trilogy, the next volume of which has a planned release for later this summer.  I thoroughly enjoyed reading No Peace In Quiet and literally couldn’t stop turning the pages as the story developed and unfolded in the small town and surrounding mountains of Quiet, North Carolina. You can check out Keli’s book at kelirueth.com. And with that, let’s get to the show!

What’s up yall! I am back after a few months off from the podcast. This is episode 106 – following up: what we know about anesthesia school formatting with Cassie Capps. This is a follow up show to the episode that Cassie brought to us back in December on the effects of anesthesia school didactic formatting on resident wellbeing… whether in-person, online, synchronous or asynchronous styles have any effect on your wellbeing as a trainee. Before we get to this show, I’ve got a couple updates for you… our crew at Maine Medical Center has been on a bit of tour this spring attending conferences, job fairs and universities telling the story about our team and why we may be where you want to invest your career as an anesthesia provider. Cat Godfrey & April Bourgoin were just down at AANA’s Mid Year Assembly in Washington D.C. and then Cat made her way on to University of North Carolina at Greensboro to chat with the residents at Terry Wick’s program. She followed up dropping in on UNC-G with a virtual lunch & learn session with Mary Baldwin University’s anesthesia program over in Virginia. And then, Kristin and I just returned last week from Florida International University’s job fair down in Miami. We were so happy to know that even the locals thought it was super hot cause oooooooo….eeeeeeee… it was swimmy humid and all kinda hot down in the Sunshine State. We were stoked to meet a bunch of FIU anesthesia residents and tell yall about our absolutely gorgeous summers and four season climate up in Maine and how we’re probably where you want to start your career if you’re looking for a top notch level 1 trauma center to be at where you’re treated with respect, well-supported and want to join a thriving team that has a ton of fun working together. Just saying. Part of my intention with Anesthesia Guidebook is to help CRNAs make a successful transition to practice and if you’re looking to do high acuity work in a busy tertiary medical center surrounded by an amazing team and in a phenomenal location, drop me a line and we can chat. I’d love to tell you more about our crew and see if we’re a good fit for where you’re headed. In other news, this fall I’m teaching at Encore Symposium’s Autumn in Bar Harbor and Acadia National Park conference. If you’re looking for a spot to come knock out some continuing education this year, Encore is headed back to Bar Harbor, Maine, which is just outside of Acadia National Park, from October 14-17. If you’ve never been to Acadia, or Bar Harbor or Maine… this is your chance. Come check it out. Acadia in October is simply stunning… a national park, on an island, in Maine. With your anesthesia friends! You’ll be hard pressed to find a cooler spot to come get your learn on. Hope to see you there! All right… with that, let’s get to this show. Cassie Capps is back. We first heard from Cassie in late December 2024 on episode 99 of Anesthesia Guidebook and now she’s back to walk us through the impact of anesthesia school didactic formatting on resident wellbeing. Thank to everyone who took Cassie’s survey and provided your insights… the data was actually a bit surprising so let me re-introduce Cassie to you and then she’s gonna get right to it. This podcast was part of Cassie Capps’ Doctor of Nursing Practice in anesthesiology program at the University of Arizona. Prior to anesthesia training, Cassie was a CVICU Registered Nurse for 8 years and worked in the cath lab for 5 years before that. Prior to nursing school, Cassie completed a Master’s degree in music with a focus on Piano Performance & Pedagogy. Cassie continued to teach piano on the side while completing her doctorate in anesthesiology at the University of Arizona. Her unique experience with anesthesia school included moving through her program as a single mom of an 11 year old daughter. She also continues to play a big role in the lives of her two former stepdaughters, who are now young adults.  This podcast is coming out in May of 2024 and with that, let’s get to the show! References Alajmi, B., & Alasousi, H. (2019). Understanding and motivating academic library employees: theoretical implications. Library management, 40(3/4), 203-214. https://doi.org/10.1108/LM-10-2017-0111 Baqutayan, S. M. S. (2015). Stress and Coping Mechanisms: A Historical Overview. Mediterranean Journal of Social Sciences; Vol 6, No 2 S1 (2015): March 2015. https://www.mcser.org/journal/index.php/mjss/article/view/5927/5699 Berry, G. R., & Hughes, H. (2020). 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