CRNA Presence

Walking into a new environment

I’m just about to walk into week 3.  It’s amazing to find a new place to work.  Each new place has its’ nuances and differences.  

I find that each place has a few people that are challenging to work with that challenge the way in which we are used to working.  This comes full circle into relationship building.  Most of the time I do awesome at saying “this is what I’d like to do and this is why”.  For the first time ever (as I recall) I found someone that didn’t respond to that and has been a bit difficult to work with.  However, I have tried to maintain a high road and be respectful.  I try to daily go in positive on the day and the work that has to get done.  With each case and with each good day I feel the rest of the group becoming more relaxed in understanding that I bring some ability to the practice.  

I take every opportunity to tell the person running the board I’m available and ready to work.  I come in a little early and set-up my room.  I have my coffee early and don’t assume I’ll get out right away for a break in order to get coffee or breakfast.  I try to be available and flexible in order to get the work done so others can go home.  I don’t ask to get out early assume that I’ll be afforded the same opportunity to either go home or take a break.  Most places I go to seem to want to test any new CRNA in case types, personality, proficiency, & the willingness to do within the group.   

This all comes down to relationship building and interpersonal communication as much as it is about CRNA skills.  A place can usually work with someone that needs a skill or a case set more than they can teach flexibility and good attitude.  So, continue to grow in personal development as much as your CRNA development as you continue your journey.  

Start getting involved

Today, I’m supposed to see one of my congressmen at MYA.  While I appreciate the attempt to make it easier for a non-political person such as myself to see our representatives I think it’s less likely to see dramatic changes when I’m going with the idea of three bullet points.  Not one has specific actions.  Not one has to do with the key function that opens the door to the full practice and autonomy that full billing rights does.   

I say this quite possibly out of naivety.  My idea is that if we can bill independently at 100% for all of our services then the right to work autonomously would be a natural progression.  

I see the ASA involved in so many layers of government and see our CRNAs in so few places.  Honestly,  the MYA was much more expensive than I expected and less well attended than I expected.  

I went to the Region 2 update and was impressed to hear about our reactivity to each of the bills in each state.  I heard of 1-5 bills presenting legislation in each state that would better AA, ASA or decrease CRNA practice.  IN EACH STATE!!! I didn’t hear that we presented bills, we sat on these committees and task force set-up by.   I heard the AANA did a first ever state leadership retreat to Vegas though.  Several were happy about this.   

I see that the Cultural Assessment is in full swing and I know people cried for this but the membership slid down a few more points this year.  I guess I don’t understand the cultural piece as this is a business and professional organization that should be fighting for CRNAs based not on culture, ideals, or in an unbiased opinion.  I think the political piece is a large part of what should be our organization but we don’t even raise 3 providers income among 50,000 CRNAs in any given year to work with.   

I offered to put a link on the page that would say to support the PAC and was told that it was illegal to do so.  I learned something new.   

I don’t know what is in our future but am quite aware that we need to do better as a professional organization and we all need to be more involved than we are.  Billing rights and autonomy of practice will be paramount principles for independent practice and advancing our profession.  As a locum that enjoys nearly all practice environments I think that this focus and becoming more involved in each states organization can only help us.  But, involvement means action, knowledge, and fricking membership for those that aren’t even a member of our professional organization.   

You have seen my financial information and I’m still a member of our AANA, donate to the PAC monthly, and despite my poor political affiliations I am here trying to learn and grow just to maintain or improve our profession in the future.  I am starting to get some of the knowledge beyond just being a provider, or clinical educator in the OR. 

Please take some time to go to the state meetings or national meetings and start getting involved in what we need to do for ourselves.  Consider a contribution to either the AANA which is tax deductible or to the PAC which is not.  Both advance us as a professional organization just in different ways.   

Just my 2 cents.  


Mid Year Assembly

I am admittedly non political by nature.  It’s very different for me here at the mid-year assembly and I sometimes feel an almost uninvited vibe being here.  Maybe it’s not uninvited but almost disingenuous vibe.  That feeling of people meeting people to say they know them but no uniform familiarity.  I have to say I came here on a whim and not as a planned event to where I would meet with certain people or advance specific agendas.  I am excited that I have seen some people that I knew from years ago.   

I’ve seen some of the very active and vocal people in the profession and learned from the sessions despite my critiques.  I think we all have our roles and I’m still wondering where mine will be in the coming years.  Totally worth trying new things though.   

I feel like I’m trying to grow but I’m still at the kids table.   I look forward to my meetings over the next few days and will totally share with you some pictures of our trip in DC.  It’s a great time to be out and about and I know Francisco and Elizabeth are getting plenty of pictures while here :).


Every day I spend time with podcasts or learning in some way.  I listened to multiple this week.  Some of the things I learned this week. 

Be Better:  Every day or every week work on how you can be better.  A little change that will help you approach your goal or commitment.  It doesn’t have to be something earth shattering.  If you do 52 weeks of little changes toward your goals you will find yourself inching toward it and be there before you know it.  I read my books this way.  I’m paying down my debt this way. I’m growing the websites this way.  I grow my life, family, & relationships by spending seconds or minutes to interact and tell people thank you or awesome job.  Make a commitment and not get overwhelmed by doing something everyday.  

Attitude:  The attitude you approach something with is how it’ll go in most instances.  You can’t say I hate I hate I hate and then get to the point of doing and expect not to hate it.  I get to work and genuinely say good morning, hi how’s today and yup I’m annoyingly upbeat.  I do this for everyone and myself.  If people see me pissy and depressed everyday I’m adding an attitude that just brings down the whole team.  I’m there to work... not to complain, be unhappy, & just be a body.  I’m there because these groups have people that act this way or they can’t keep people because they are all stressed... if I can be a stress-free person at work.  I’m more likely to be asked back. I’m more likely to feel like my days go well.  I’m more likely to truly have fun and make the days go by.  I miss my family at home and I’m so excited to see family pictures or video and I share this with the people I work with.  Kids and dogs make everyone light up a little.  

Stick to it:  If I sign a contract or give my word.  That’s it.  I’ve said I’ll do something. I’m going to darn well do it.  I’m not going to tell someone that I said I’d do their room tomorrow then not because I found out the surgeon I like has just two easy cases for the day.  If I get what I want and ask for ... I honor what I said I would do.  This makes me reliable, dependable, the person to go to, and sought out for as a provider.  I’m reasonable in my expectations, experience, and what will come.  I know the business of anesthesia, each hand in the cookie jar and the expenses that come after the reimbursement income and how the expenses trickle down.  

These are just some of the things I’ve learned this week and application is always the challenge in what I learn.  I choose to hear most of my education, so I then proceed to the application and notes to myself in how I can apply it towards my day/week/month.   

I’d like to tell all to have an amazing weekend!   

Traveling attitude

It’s another traveling day and of course I’m up way to early.  I have two options though.  #1 I can say I hat the airport, the rental car return, the drive, getting gas, & generally people at airports still act as if they have never seen one.  #2 I am sooooo excited to be on my way, I was upgraded on my 20 minute first leg of the flight and I see the family in just a few hours!   

Mind-set is everything right?!  It’s the same way when going to work.  If it’s a locum job, a full time gig, or your kiddo doing the chores they have been assigned.  It’s in how you approach it.  Yes, I understand that bad things happen and unforeseen circumstances can change things but ... by and large this is the everyday approach.  If you want to love locums, love the time that you spend at many places... you have to decide that it’s going to be good.  If you have decided that hospitals, people, this job, and working with medical professionals suck... you won’t be happy ANYWHERE.  So, find some joy, work on finding why you want to do this, then reach out with all your positive energy and let everyone know just how great you think things are.  Happy people are infectious.  People, surrounding the upbeat, are more relaxed.  These people are perceived as more personable.  These are part of the reasons people are invited back or not invited to return to facilities.    

I’m told over and over of people that are extended or given notice because of their attitude.  I’m also told that places are more flexible with those that have better people skills.  That may be that the individual is flexible or the work place is flexible?  I wonder if both are true at the same time.   

I get an earful of complaints here or there and find that misery loves company.  I had a nurse in the room that said I can’t stand so and so... they always lean-in the room and say “you good?” Thumbs up!  “It’s like he’s trying to run away as quick as possible”.  I say well... this is his first job... he was trained here and it’s what the other nurses do in his room... he’s been here a year right?  So, is this a person issue or is this what he’s been trained to do over the past year?  We are training people by what we exude, show, teach, act out, what’s said, and the daily attitude we display.  So what are you teaching those around you? 


I was listening to someone talk in the lounge saying they would never leave this area.  Her husband was offered an amazing opportunity and they said no as it wasn’t in the city.  Their kid was going to college and they begged to have them closer to home and now they think they might return to the same city.   

I guess this idea of staying in one place for life or not entertaining moving for career or home is foreign to me.  I’ve moved around and met new people my whole life.  Freinds of the long term capacity can be hard to come by.  However, within the military life of moving i found lifetime friends.  I know moving has allowed me to make friends around the country and understand different types of people, culture, and demographics. 

I tend to think anyone could do the locum life if they were so inclined but I’m learning that the more rigidly settled a person is the less likely for them to do locums.  Per diem in multiple hospitals in the area might be their perfect gig and while it may be 1099 it is unlikely to be billed as locum.  Others find a w-2 job that will allow them to work 2 full time jobs.  I see them race from call shift to call shift and i wonder how they do it when i know how it feels working 60-80 hour weeks and how lovely it can be at 40 hours.   

I think it all comes down to motivation.  Part of my motivation is to keep up in all areas of practice so I’m well rounded.  My goal is to be flexible, work a fair amount and over.  I want to be capable of going into any room and being comfortable.   I love new sights and allowing family to see all that surrounds us and our opportunities as we grow together.  Others, look for safe, secure, & what is known.  Others look for moving up the ladder of success in leadership, research or business as they grow and that is their motivation.   

Its fun to learn where people are in life.  Then it is nice to remember those people and in going to new places meet those who might also mesh well with others and who might build people up to their potential.   

So, dream big and bring others along the journey.  Find a passion and a motivation!   

Talking to People

This is a social media site and so lets talk a little about speaking with people.  On-line, in-person, at work, or socially are all different social situations and yet your interactions are under scrutiny.  Did you know that people review what you do and say?  

Facebook, instagram, snap chat, and all the others are great social sites, right?  You get to keep in touch with everyone in one comment.  You get to post your amazing Friday night digs and afternoon off comments.  I know I'm not the first one to say these things but this is not just you and your friends.  Your words are out there on the web.  Your picture is available to anyone.  You partying it up and saying that you did what ever you did can be taken the wrong way.  I live my life as an open book for the most part.  I show pictures of my family and say my general day on-line a lot!  But, why is that ok or not.  People get to know me and they are not seeing parties, crazy life pictures, they are not seeing the worst or best things.  They see my average life.  I take a vacation to see family and enjoy a few days but they know I'm back to work on time and happy.  They know I'm working on my health.  They know I'm not sick all the time.  I'm not posting all the details of my contracts or the people I work with. 

I am sure groups, employers, and your fellow CRNAs are looking me up before I arrive.  Not because they want to get to know me but because they want to know what type of person is coming to work with them for 3 to 6 months.  They want to know if I'll be happy most of the time.  They want to know if I'm going to call in sick. They want to know if I'll complain about every little thing.  They want to know if I will work well with others at work.  

So, why is this important? I've heard this before!  OK, well it's pretty clear that people are not secure in any environment where there is more than one person.  If you choose social media as place to be, AWESOME. Just remember the more places you go and the more you speak or post or whatever.  Realize that an employer 5,10,15 years from now can find that post and either ask about it or just cancel you.  Many people say that it doesn't matter and are happy and content where they are.  Yup, you may be for 1 year, or even 4 years ... but then life happens and a change could come.  You never expected to move to mid-size town America and now you are applying to jobs or saying now I will be doing contracts for a little more flexibility.  You start sending things out and wonder... why is this difficult.  It's obvious there are needs.  You start to question what happened and when you go to an interview the Chief CRNA says "I took a flyer on you but your pictures looked like you go out more than you do anything else".  Then you say I haven't updated in over a year or two because life had changed and you became more private.  They don't know this... they only see what is available.   

Social Media and work.  Don't be that person.  The one that talks about your colleagues.  The one that takes offense to some comment and causes trouble.  Don't be the one sharing things that can be taken inappropriately.  If you wouldn't go to your family, parents, kids with it... well... think.

If you get time, Google yourself, your business, and things around you.  See what others see about you and the things you can improve for visual perception so you stand out in a good way.  I hope you totally see the implications of interaction on-line.  I hope it's an amazing weekend.  Comments or questions

Maintaining the contract.

I like to check in about this point.   We are at two weeks into the contract and I have to say it's always a bit rocky.  I wonder what people really think versus what is said behind closed doors.  Every permanent person is your critic.  From the janitor to the OR manager, permanent anesthesia staff and other individual locums.  One poor view of you from the wrong person and the OR tech who thinks she knows everything can affect your job, contract and if you are hired again by the anesthesia management group.  

I check in with the docs to see what can be done better.  I check in with the AMG to ask them if something can be done better.  I check in with the chief CRNA to find out how things are going and what I can do to help out.  I want to be taken as part of the team and not the one just here for money.  

I was with a locum MDA this past weekend and he was so very talkative.  I had to get him to focus, he would keep patting me on the back or chest to say things like "you know how it is, big guy"... so many things I despise about that but touching me is a big no.  I knew I only had a few hours and he would be at a different facility.  I bit my tongue and tried to focus on the patient throughout.  It's definitely a learning curve and despite my inherent self I have to be a people person.  I have to keep a smile and work to keep everyone happy even when boiling on the inside.  A tech in the room is criticizing the chief surgical resident for going to get the patient with me and the chart not coming down with the patient.  In all other hospitals I have been to the OR nurse meets the patient and goes through the chart prior to entering the OR.  All of this said the people pleasing is definitely part of the contract maintenance.  

I also think that self-reliance is very important.  The more you can figure out where things are without calling every two seconds for something to be brought, the better you are perceived.  Being able to search the stock room, store cabinets, OR carts, and anesthesia drawers/kits/carts will serve you 20 fold in how you are perceived.  I typically hate calling for things and feel horrible when they are right there in the room.  

Process, this is very difficult as most places have set process' in place.  What do you do when a process doesn't work or is obviously going to be a challenge?  I ran into a problem with a patient that was having a potentially large surgery in a hospital with little process for Arterial Lines, monitoring, ABG's and other lab work.  I sent them off and was unable to get my numbers back in a timely fashion and although stable I was hoping to be able to optimize the patient.  This case allowed me to understand some missing links in the chain and to find out who in the process was unwilling to help in a hospital process.  I'm still not sure how to go about solving this but as a new takeover.  I know that there is an administrative process that might make it easier in the future to get these items fixed.  I will be using the staff that are part of the facility to bring it to the management as a potential problem in doing similar cases in the future.  This type of case should be able to be done in just about any hospital in the country and had process issues but not detrimental to patient care issues at this point.  The last thing I should do is take something to administration or try to yell, complain and make trouble for the current staff.  I am here in place of permanent staff and not as admin or a person to make policy or even affect politics.  

OK... I should stop for now.  On to a 32 hour call shift in the morning.  Best of luck to all in the next week!


Let's talk skill set.

A recent question was posed about skills and the fact that some of us get rusty or haven't done XYZ in a ... while.  What do you say? How do you talk about them?  Let's use pediatrics as the skill in question.

First, have you just not done any kiddos 0-18 in years and you want to start doing them again?? Maybe the case is you want nothing to do with kids but over 12 is ok?  Where does your comfort level sit?  

When you talk to agencies you should know they want to be realistic with where you are and where you are willing to go.  Are you willing to do pediatric cases but want a hand in the room until you are comfortable??? The first 5 - 10 cases or maybe you say I'm not comfortable and don't want to go a place I'll have to do pediatric hearts or solo pediatric ER intubations.  

This is all ok.  But, you have to realize each case type you can't do or won't do may limit your opportunities.  It totally may have zero effect.  My current hospital will put you where you are comfortable.  No blocks, heads, hearts, cvl's, art lines, peds... it's ok.   

Important! Don't tell them you do and you can't do!  You should get a credentialing packet that will ask your comfort with procedures, cases, and numbers (estimated) per year.   

Please, let your agency know where you are and be optimistic about what you do and what your willing to learn.   

Continue to show your education, CEU's, ask questions, and when you are at your assignment take initiative.  Ask questions, act interested, & be ready for opportunities. 




Hi guys,

It’s another beautiful day.  We are going to talk about presence.  There are a lot of things that go into this.  We have to really think about this.  In this I would say that perception also plays a key role.

As a locum, key people have to know your presence during the day.  They have to see you working.  They have to see you available and hear that you are ready willing and able to work.  You can’t say yeah in 20 minutes after my break, at least not every time.  By that I mean, if they ask you to break in half every day and every second you get a 15 minute break or your lunch, I would not expect you to give it up.  But, in a special instance of the ICU called needing a stat intubation and you happen to be the only one free and the rest of the staff are saying we are at lunch.  It’s an opportunity to show you are the ultimate team player.  

So much of the time I hear about that locum that always seems to run and hide.  They rarely complain about the rest of the staff that don’t eat in the break room or immediately leave the OR area just after a case and then people are calling and looking for them.  It does seem however that if the rental is missing for 5 minutes they can never find them.   At which point, I say that I had to pee but I am back at their service.  

Presence is also a knowledge presence.  You have to exude the fact that you are knowledgeable regarding the cases.   For example, oh at the last place we only used Isoflurane and we seemed to always use Milrinone.  I hear your CV surgeon doesn’t like Milrinone. What does your surgeon prefer and do you know the rationale?  I hear your total joint guys don’t use Tranexamic Acid, do you find you have higher EBL’s?  What percentage of retro/peri bulbar block need supplemental topical or why does your surgeon require so many blocks on basic cataracts?  I’ve seen complications of the blocks and wonder if your surgeons are newer or older?  One of our cataract surgeons doesn’t do their own blocks and isn’t comfortable with them.  They only use topical and in event of it not working on a prior eye, they ask anesthesia to do them.  

I also venture to state understanding the billing structure and pay ratios is important.  That presence is important in the negotiation of your contract.  If you know the group, agency or people will keep you busy and you know the payer mix is strong, then you know that you will be earning the group 2-5 times what you bill.  If that is the case then you should be able to negotiate a higher rate.  That is typically true unless you are in a high demand area.  CRNA’s are like anyone else, they will take advantage, undercut  the higher person in order to get the life they envision as best.  

So keep a good presence about you and keep your eye, ears and body aware.