Anesthesia Guidebook

My guests today are Abigail Lee and Johanna Bennett, two Doctor of Nursing Practice graduate students at the University of New England who focused their DNP project on perioperative use of IV methadone.  Abigail Lee attended Southern Maine Community College and transferred to the University of Southern Maine to study nursing. She worked at Maine Medical Center in the Cardiothoracic Intensive Care Unit. She intends to head down to North Carolina to work as a CRNA. Johanna Bennett went to Saint Anselm College. She started her career in healthcare in the Medical/COVID ICU as a new graduate nurse and worked there for three years before starting CRNA school at the University of New England. Jo will be joining our team at Maine Medical Center to work as a CRNA. This episode is on the longer side, so here’s your TL:DL, too-long; didn’t listen summary of perioperative IV methadone – the opioid-spairing opioid.  Standard short-acting pure mu-agonists—like fentanyl, hydromorphone, and morphine—often leave our patients trapped in a roller coaster of ‘peaks and valleys,’ leading to oversedation, unexpected pain spikes, and high total opioid consumption in the PACU. In this episode, we explore why methadone is uniquely positioned as the ‘opioid-sparing opioid.’ Beyond its strong -receptor agonism, methadone boasts NMDA receptor antagonism and serotonin/norepinephrine reuptake inhibition, targeting pain at multiple pathways to blunt central sensitization and wind-up phenomenon. Key Clinical Takeaways from the Literature: The Effective Dose: An ideal single dose on induction is 0.2 to 0.25 mg/kg ideal body weight (or roughly 10-20 mgIV). Underdosing (<0.1 mg/kg) eliminates the long-term benefit, while dosing over 0.3 mg/kg slightly increases transient PACU sedation without adding extra analgesia. Where it Shines: Greatest reductions in PACU pain scores and overall post-op opioid consumption occur in high-nociceptive surgeries—like multi-level spinal fusions, cardiac, thoracic, and major reconstructive procedures. Safety Profile: A single intraoperative dose displays a safety profile comparable to short-acting opioids—with no increased incidence of delayed respiratory depression, PONV, or QT prolongation in acute, single-dose settings. I want to share one particular guideline that I’m familiar where the hospital developed a clinical guideline to help their team incorporate IV methadone as a perioperative analgesic. The key points in this guideline include: 1. Consider using methadone in surgeries lasting greater than an hour which are at high risk of significant postoperative pain, especially when patients are not candidates for epidurals or regional blocks. 2. Avoid the use of methadone in patients who have a baseline prolonged QTc or with those patients who are on buprenorphine or in surgeries less than one hour since the peak respiratory depression is about 45 minutes after administration.   3. The typical dose proposed in the guideline is 0.2 mg/kg of ideal body weight IV with consideration to reduce the dose to 1.5 mg/kg for surgeries that have a same day discharge plan.  Rescue doses of 3 to 5 mg are used instead of hydromorphone after the end of the procedure if needed for post-operative analgesia.  4. This center continues to use standard PACU orders for IV and PO analgesia following the use of methadone 5. On the buprenorphine point: Methadone has a significantly lower binding affinity for mu-receptors than buprenorphine so in patients who are actively taking buprenorphine, single dose perioperative methadone is relatively ineffective without alternative strategies like weaning the buprenorphine or interventions tailored for patients with chronic pain or opioid use disorder – which are both beyond the scope of this podcast.   If you want to hear a little more about the challenges around pain management with patients on buprenorphine in particular, please go listen to episode 13 of Anesthesia Guidebook with Aurora Quaye, MD, one of the leading researchers in this space and a pain management specialist at Maine Medical Center in Portland.  We recorded that show way back in March of 2020, so it probably is time to check back in and get the latest on all the research and amazing work her and her team have been doing in the last several years. So, that’s a little primer on where we’re headed today.  I want to thank Johanna and Abigail for their incredible walk through of methadone in this conversation, as all as for the tips they share on navigating the DNP project process. If you’re looking to eliminate PACU pain spikes, optimize your patient’s chance for enhanced recovery, or rethink your perioperative analgesic strategy, this deep dive is for you.  And with that, let’s get to the show. Bennett, J. & Lee, A. (2026) Intraoperative Intravenous Methadone in Adult Surgical Patients: An Integrative ReviewDownload

Adrian Moran, MD, MBA currently serves as the Chief Medical and Transformation Officer of MaineHealth, a not-for-profit, integrated health system with over 2000 providers and 23,000 care team members serving patients across Maine and New Hampshire. Dr Moran joined me to talk about his views on transformational leadership and his professional journey from a pediatric cardiologist at Boston Children’s Hospital to executive organizational leadership roles. I’m excited to share his story with you because we don’t talk enough about how to transition from being specialized clinicians to working in healthcare leadership. I asked Dr Moran to join me for this interview given his unique vantage point and journey to executive leadership. MaineHealth’s flagship level 1 trauma center, Maine Medical Center, is where I serve as the Director supporting the Department of Anesthesiology and Perioperative Medicine. Over the last decade, I’ve watched Dr Moran move from his clinical role as a pediatric cardiologist to MaineHealth board member to Associate Chief Medical Officer. I then saw him leave MaineHealth to take on a system level CMO role for a large health system in Wisconsin and then back to MaineHealth as the Chief Medical and Transformation Officer. Over the years, I’ve seen his leadership style in action and recently heard him describe how the principles of high reliability organizing and servant leadership inform his work, which are ideas we’ve talked about here on the podcast over the last year or so. In this conversation, we talk about: the challenges facing healthcare organizations today and what leaders can do to be effective in supporting their teams what transformational leadership looks like the value of gaining practical experience and credibility as a healthcare leader when and why additional education, like an MBA, might make sense for leaders what motivates Dr Moran and what he sees as his core purpose In full transparency, this interview was imbedded in a qualitative research course I’m taking as part of the PhD in Leadership & Organizational Develop at the University of Southern Maine. My goal was to explore the narrative arc of Dr Moran’s professional story and hear more about his leadership philosophy and work with MaineHealth. I think yall are really going to enjoy this episode. Dr Moran is a remarkable leader, a pretty good story teller and incredibly generous for taking time out of his busy schedule to meet with me and share a bit of his story. With that… let’s get to the show! MaineHealth Announces Adrian Moran, MD, MBA as Chief Medical and Transformation Officer

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

This is part 2 of a 3 part series on hypertensive disorders of pregnancy. Part one with Joe Navarrete covered the baseline physiologic changes with pregnancy. In this episode, David Barksdale is going to walk us through the pathophysiology of hypertensive disorders of pregnancy. And in the next episode, Isabella Sosa joins us to walk through how to manage hypertensive disorders of pregnancy as anesthesia providers. David Barksdale is a Nurse Anesthesia Resident at Yale New Haven Hospital School of Nurse Anesthesia and Central Connecticut State University. Before CRNA school, he worked for three years as a Surgical Intensive Care Unit nurse at Rhode Island Hospital and is a combat veteran. He served in the United States Army from 2012-2015 as a combat engineer. In 2013, he deployed to East Paktika Province, Afghanistan, conducting route clearance operations to provide freedom of movement to the infantry and local populations. David framed his doctoral project around this topic to deepen his understanding of hypertensive disorders of pregnancy and to explore how podcasting can support learning for anesthesia providers. This three part series will equip anesthesia residents and providers alike with the core knowledge to effectively manage hypertensive disorders of pregnancy. Many thanks to Joe, David & Isabella for putting this series together! References: 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 […]

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 […]

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 […]

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. 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 […]

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 […]

What’s up yall! This is Jon Lowrance and this is episode 111 – How to Prepare for Medical Mission Trips with Stacey Such, MSN, CRNA. (Stacey pronounces her last name, Such, like “Suke/Duke.”) Before we get to this show, I’d like to give a quick shout out to the CRNAs, SRNAs & physician anesthesiologists who […]

What up yall. This is Jon Lowrance with Anesthesia Guidebook. This is episode #110 – How we do interviews with Alison Kent, MSN, CRNA & April Bourgoin, DNAP, CRNA. In this episode, April, Alison & I talk about how we conduct CRNA interviews as a leadership team with our Department of Anesthesiology at MaineHealth – […]

What’s up yall! This episode dives into fundamental concepts related to leadership and casts a message for why it matters to all of us. Whether you’re primarily a clinical CRNA/physician anesthesiologist, resident/SRNA, a practice leader/manager, business owner, educator, researcher or policy advocate, leadership has a fundamental role in your day to day life. In this […]

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 […]

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 […]

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 […]

What’s up yall! This is Jon Lowrance and this is episode 105 of Anesthesia Guidebook – the impact of precepting on clinical learning with Jennifer Heiden. This episode is coming out on February 21, 2024. Jennifer Heiden is completing her Doctor of Nursing Practice in anesthesiology at the University of Arizona and this podcast is part of […]

Chuck Biddle PhD, CRNA is a Professor Emeritus of anesthesiology at Virginia Commonwealth University and served as the editor in chief of the AANA Journal for 35 years.  His anesthesia education & master’s degree are from Old Dominion University and he completed his PhD in Epidemiology at the University of Missouri.   Chuck is one […]

What’s up folks! This is Jon Lowrance with Anesthesia Guidebook and this is episode 103… a deep dive on dexmedetomidine with Eliana Zimmerman. This episode is coming out on January 21, 2024. Before we get to the show I want to remind folks that I’ll be speaking in person at the Encore Symposiums’ Autumn in […]

Brad & Madisson Marcum join me to talk about the dynamics of being married and going to anesthesia school together. They met in nursing school, had divergent paths professionally for a bit, with Brad starting nurse practitioner school and Madisson considering anesthesia school. They ended up sharing the same goal of becoming CRNAs and we […]

This is an incredibly special podcast that I’m thrilled to pull forward from our old show, From the Head of the Bed, to Anesthesia Guidebook. I love that this episode is number 101 because EKG lead selection should be 101-level knowledge for anesthesia providers, yet so many folks have not mastered this fundamental knowledge as […]

Have you noticed how stoked podcasters get about their one hundredth episodes?  It’s kind of a thing. If you want to hear interesting shows – check out the hundredth episodes.  Or 200th.  Or 1000th.   Podcasters usually get super stoked about hitting triple digits with their shows and often set up the number 100 episode as some sort […]

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

Elisabeth Stewart, MSN, MSNA, CRNA focused her Master of Science in Nurse Anesthesia project on the pharmacology of Toradol (ketorolac) and she’s here today to tell us all about it. Elisabeth hails from Wisconsin, holds a BS in Mathematics with a pre-med concentration and engaged in HeLa cell cancer research prior to going to nursing […]

What up folks! This is another short podcast on the idea that safety is a capacity, not an outcome. This idea comes out of Todd Conklin & Sidney Dekker’s work on organizational safety where they discuss two ways of looking at safety: The Safety 1 Perspective or the old way of thinking is that safety […]

What up yall this is Jon Lowrance and this is episode 96 – virtual reality in anesthesia education: SIMVANA with Peter Stallo.   This show is coming out in early August of 2023. First up: I want to give a quick heads up that our team from Maine Medical Center where I currently serve as […]

Quick 5-Question Post Podcast Survey HERE Today I’m joined by John Fratianni who created the content for this episode as part of his Doctorate in Nurse Anesthesia Practice at Virginia Commonwealth University in Richmond, Virginia.  John earned a Bachelor of Science in Nursing at the University of North Carolina at Chapel Hill, a Master of Science […]

All right what’s up folks this is Jon Lowrance and it’s May 16, 2023. This is episode 94 – and I’m calling it “shorts: cue ball.”  And I don’t mean shorts like the things you wear but shorts like, this will be brief and there will be more episodes like this to come… you know, […]

In this episode, I speak with Dr April Bourgoin, DNAP, CRNA about operating room fires – how they can start and how we can respond to them as anesthesia providers. This show was originally released in 4 years ago in February of 2019 on the podcast From the Head of the Bed and was recorded […]

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What up yall. This is Jon Lowrance. I’m still here. 😂 We’re still here. This is the first episode of 2023 and the first episode on Anesthesia Guidebook since October – October! I’m so glad to get back to the podcast and bring you this update. This is a re-cap of the last few months […]

Climate crisis is a growing global health problem, one which the field of anesthesia contributes to with its use of volatile anesthetic gases. This podcast is part of the doctoral project of Jacob Bonnema and it aims to increase knowledge and awareness of the environmental effects of volatile gases, particularly desflurane, to empower providers to […]

What’s up y’all this is Jon Lowrance and this is episode 89 – Distraction in the OR with Heather Turcotte, DO. Y’all, I am so stoked to bring you this conversation… I caught up with Dr Turcotte earlier this summer as she was finishing her residency in anesthesia and I’m pumped to finally get this […]

This is episode 88 and it’s part 3 off a three-part series with Dustin Degman, a CRNA formerly with the United States Army. In the first episode, we discussed Dustin’s experience in Afghanistan serving at a forward operating base in Paktika Province in 2012.  We talk about what makes up forward surgical teams and the […]

What’s up yall this is Jon Lowrance with Anesthesia Guidebook.  I am so pumped to bring you this series of 3 episodes on Combat Trauma Anesthesia!   This is episode 87 and it’s part 2 off a three-part series with Dustin Degman, a CRNA formerly with the United States Army. In the first episode, we […]

What’s up yall this is Jon Lowrance with Anesthesia Guidebook.  I am so pumped to bring you this next series of 3 episodes!   This is episode 86 and it kicks off a three-part series with Dustin Degman, a CRNA formerly with the United States Army on combat trauma anesthesia.   In this first episode, […]

Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium. Jason is clear that the McLott Mix helps achieve opioid-free anesthesia, not opioid-free analgesia, recognizing the role of opiates, if needed, in post-operative analgesia […]

Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium. In this episode, Mr McLott himself unpacks the story of the mix’s development, efficacy and principles for opioid-free anesthesia. He’s clear that this mix […]

“Positive deviance is really about… taking those things that people are doing right and sharing them with everyone so that everyone is doing things to improve our patients’ care, our patients’ outcomes.”  Cherie Burke, DNP, CRNA Dr Cherie Burke joins me to unpack how positive deviance can be a catalyst for change in healthcare. Positive […]

Randy Moore, DNP, MBA, CRNA and Desirée Chappell, MSNA, CRNA join me to talk about change management in healthcare. They are both on the leadership team with NorthStar Anesthesia, which provides perioperative services at over 200 facilities across 20 states. This conversation focuses on how leaders can navigate change, develop culture and build successful anesthesia […]

I caught up with Tracy Young, CRNA, MBA & CEO of YPS Anesthesia Services in Houston back in November 2019 to talk about the business of anesthesia. Tracy is one of the most sought-after experts on the business of anesthesia not just at CRNA conferences but throughout the healthcare management & business industry. In this […]

What’s up yall, this is Jon Lowrance with Anesthesia Guidebook. This is episode 80 – how to do 1099 anesthesia work with Sandry Gaillard, MSN, CRNA. This is the second episode in a short series on the business of anesthesia. I’m gonna do a little run of interviews and topics on the business of anesthesia […]

What’s up yall this is Jon Lowrance with Anesthesia Guidebook.  I’m really excited to bring you this episode on the future of healthcare with Dr Navin Goyal and Saket Agrawal of OFFOR Health. This is episode 79 of anesthesia guidebook and it’s coming out on June 24, 2022. This is one of the most interesting […]

This episode covers advice for the last six months of anesthesia training, transitioning out of training and into the first six months of your anesthesia practice. The year encompassing your last six months of training through boards and your first six months of practice is epic!   There’s a huge learning curve you encounter during your […]

In this episode, I talk with Jon Bradstreet, MSN, CRNA who at the time of this recording was the chief CRNA/Director of CRNA Services at Maine Medical Center, Maine’s only level 1 trauma center. Jon was the chief CRNA who gave me my first job in anesthesia. At the time he hired my wife and […]