From Penn to Solo CRNA Practice - The Unexpected Growth of Independent Practice

Most anesthesia providers assume growth comes from increasingly complex cases, bigger hospitals, and higher acuity patients. But what if the opposite can be true as well? Today's guest left one of the most prestigious academic medical centers in the country and transitioned into solo CRNA practice at an oral surgery office outside of Philadelphia. 3 years later, he says he's a better provider today. Than when he was when he left. In this episode, we're exploring what that transition looks like, the lessons learned from practicing independently, and how one CRNA is helping redefine what autonomous CRNA practice can look like in Pennsylvania. Today's guest is Dr. TD Carnahan, a CRNA practicing outside of Philadelphia and the owner of Sandman Slumber Services, where he specializes in providing independent anesthesia care in ambulatory and office-based settings. In addition to his clinical practice, TD is deeply involved in advancing nurse anesthesia profession through advocacy, leadership, and mentorship. He currently serves as a trustee and is the incoming vice president of the Pennsylvania Association of Nurse Anesthetists. TD has also helped lead federal government affairs efforts to advocate for CRNAs on Capitol Hill. At a national level, TD serves as the inaugural chair of the ANA membership committee, He also is passionate about education, regularly speaking at nurse anesthesia programs, participating in admission interviews, and mentoring future CRNAs as they navigate the path to nurse anesthesia school. Welcome to the CRNA Mentor Podcast here, TD.

Thanks for having me, Tyler. I'm excited to be on.

Yeah, I'm happy to have you here. And quite honestly, TD, uh, you know, as, as one of my friends, you joining even after, you know, we talked on the phone last night, I just get amped up talking to you, buddy. And it's, it's one of those things like when I do my mentorship phone calls every day after work and I, I really connect with somebody, it's like a shot of adrenaline. And it's the same thing when I talk to you, and I think this episode today as well. So, uh, I'm super excited to talk to you all about your practice here, uh, independently in Philadelphia.

Yeah, man, I'm excited to be on. Let's get into it.

Yeah, so, so TD, tell me a little bit about your background, uh, your current role, and, and kind of let's start, I guess, with what ICU you started in for all of our listeners who are aspiring CRNAs.

Absolutely. It might come as a surprise to people because I work exclusively in, uh, mostly geriatrics, but adult care. I was actually in neonatal ICU and pediatric ICU for 5 years before anesthesia, and I loved it. I did a fellowship, uh, I, you know, got my CCRN. I did all sorts of different things, and now I don't even wanna think about pediatric anesthesia at all. I'm gonna stay away from peds. Uh, but I loved it while I was there. I was out at Children's Hospital. Of Pittsburgh, and it was a fantastic experience.

That's great. Yeah, uh, peds, that's not my specialty either, and that's okay. Everybody finds their, their little niche here. Um, so you were working, uh, like you said, uh, down in Philadelphia. You were working at Penn. Um, how did you stumble across your current CRNA role?

Man, um, honestly, by accident. So I had spent 4 years at the University of Pennsylvania after training and I was doing heads, hearts, everything between, transplants, livers. I mean, just crazy cases. You know, I felt like every single case was like an ASA 4, ASA 5. It was intense, very, very challenging days. And one day I had a fantastic nurse anesthesia resident with me, shout out to Ashley Bell. She could take care of me any day. She works there now and she's phenomenal. And then I said to Ashley, hey, you know, you're gonna, she decided she was gonna work in Philadelphia at that point. I said, let's go on, um, ANA Motion Gas Works. Let me walk you through and let's— I'll just talk to you about what to look for with jobs. So I put up Gas Works and I'm looking through jobs and right at the top of the page there was this full-time 1099 solo, um, CRNA. And I had dabbled a little in the 1099 world at that point. I had worked in some GI offices. I had a locums contract, like a PRN contract with a hospital. And I knew I wanted to eventually go 1099, but I thought that it was gonna be traveling. I thought it was gonna be working remote somewhere across the country, 2 on, 2 off, maybe coming home on weekends or something. And this one was right in my backyard and I was like, hold on, Ashley. And I emailed it to myself right on the spot.

Mm-hmm.

And I talked to the group later. Fantastic CRNA group out in Utah. Shout out to Elite Anesthesia out there. Phenomenal guys. Mike, Sean, Casey, all you guys. And, You know, we had a phone conversation and initially I was like, I think I just wanna do this PRN. I think I wanna do this part-time, maybe job share with somebody. And they said, you know, you're kind of exactly what we're looking for in this role. And I thought a whole lot about it and I said, you know what, let's do it, man. Let's just do it. Let's see what happens. And here we are 3 years later, all because I was just trying to help a resident find a really good job.

That's great. You know, that's a big jump, right? Coming from this big academic center, going 1099. TD, what concerns did you have before you left?

Oh my gosh, everything. Like, first of all, I gotta get new health insurance. I gotta now, I have to change my professional liability insurance. I'm gonna be working solo, and I had worked solo in a GI office before, but that wasn't full-time, and that's somewhere where I felt really comfortable. This was going solo into an environment where I had literally never done this surgery before. I, I didn't even know about it until I interviewed for the job, and it is on an island in an office by yourself, and you know, I'd always had a backup system. I'd always had support. I always had somebody I could call, right? And also, this was a brand new office, and so I didn't know if it was going to sink or swim. And there were so many unknowns, um, but I was ready for a change. I loved my coworkers at Penn. They're still amazing people, amazing CRNAs. For me, it was time for a change, and I decided, you know, I go all in and I was like, let's do it. And I just jumped right in. And that's what it is.

Excellent. Yeah, I mean, I can see how you have some reservations making that jump. You mentioned, you know, oral surgery office or dental office. And I think, you know, listeners immediately kind of start making these assumptions as to what this practice might look like. And I think before we kind of dive into some of the autonomy and some of your professional growth with it, let's help our listeners understand exactly what you're doing on a daily basis. So, can you kind of describe your current role, you know, in this office?

Of course. I mean, I had ideas about what I was going into and I was wrong. So, I thought, oh, you know, I'm going into an environment. This Oral Surgery Center specializes in one case and it's one surgery that they do and they do it very, very well. They have offices across the country and I was like, Oh, so these patients are gonna be ASA 1s, ASA 2s, and they're gonna come in. It's a smaller surgery, not a whole ton of recovery. Uh, no, I was totally wrong. So these cases are full general anesthetics. Um, everybody goes to sleep, everybody has a breathing tube. Um, I'm gonna get a little more into the technicalities of the anesthesia in a little bit, but—

Yeah.

Mostly geriatric patients, but I see patients across from, I think my youngest patient in the office was like 21 or 22, all the way up to, I mean, I've had nonagenarians in the office. I had one guy who was like 95.

Wow.

And looked like he was 75. I mean, just great. You know, a healthy guy took good care of himself. So, we're really seeing patients across the lifespan continuum, which is pretty wild. So, I get in in the morning, I set myself up. You know, I've got, uh, responsibilities that you don't think about in hospital. So when I roll in, the first thing I do, I enter through the side door, and this is something I can guarantee almost no other CRNA does. I have to turn on my own oxygen tanks in the closet. I have to turn on my H tanks, and if I don't turn on those cylinders, there's no air, there's no, you know, fresh gas flow. Um, and that's like one big difference. You know, you have to, you walk into a hospital, I'm not even thinking about, I mean, I'm gonna, I'm gonna check my machine, but the, the oxygen's always there, you know?

Right.

So that's like one big difference, you know? I am— I have all the patient information beforehand, but I'm still going through a full H&P. I'm discussing with them, you know, medications, making sure they're appropriate, making sure that they've taken the medications I want them to take, that they're holding the medications I want them to hold, and making sure obviously they've not eaten since, you know, my instructions. Um, monitors, consent, everything. I am the pre-op. Uh, I am the consent. I'm the CRNA. Yeah. You know, I'm the tech, I stock the room, you know, I set everything up. So you're wearing a lot of different hats when you roll in. But ultimately, I really enjoy that ownership of everything. There's a lot of— as CRNAs, we like to have that control over it, and I really enjoy that control. Um, surgeon comes in, talks to the patients, I get them off to sleep, things go nice and smooth, I wake them up, and we do 2 or 3 of those a day, and that's it.

Nice. So, you know, you're describing your day. You mentioned one surgery that you primarily do.

Yeah.

What is that surgery?

It's a surgery that was completely new, and my anesthesia training was phenomenal. I trained all over the place at the University of Pennsylvania, various hospitals around Philadelphia, Fox Chase Cancer Center, Children's Hospital of Philadelphia. I was at Cooper University Hospital, Johns Hopkins. I mean, I had a phenomenal anesthesia training. I felt really well prepared. The surgery that we do, I had never even heard of. I didn't even know it was a thing. I thought, oh, in an oral surgery office, I've done TMJs and Leforts and mandibular, you know, distractors and all these other things. And, you know, maybe frontal sinuses and midface stuff. This is totally new. So it's called an All-on-4 dental implant. And you're actually gonna start seeing a whole lot more of these in the anesthesia world. When a patient says, oh, I have dental implants. You know, when we ask anything chipped loose or removable in your mouth, the patient says, no, no, no, I have implants. Implants, and we just brush it off and go, oh yeah, okay. What it means, it is an all-on-4 implant. So all, meaning all your teeth are on one prosthetic piece. It is, uh, this company mills it out of zirconium, and then you have 4 screws that go up into the maxilla, 4 screws down into the mandible, and it's 2 different prosthetics, uh, that are not removable. This is not a denture. There's a lot of advantages for the patients with that. First, uh, dentures are temporary. Dentures have to get refitted every 5 or 10 years, and these are permanent. So the screws in, they provide tension on the bone, and then that bone continues, you know, some growth, and you maintain that bone. We've all had patients, uh, I said yesterday, you know, 80-year-old Meemaw comes in and she's had dentures for 30 years, and you take her dentures out and you get a mask ventilator and her whole midface just collapses. And, you know, you lose— you atrophy all of this bone. The advantage of getting dental implants is that you provide those micro torsion, that micro flex on the bone, promoting osteoblastic activity, and then you maintain that bone. So patients are not only not only having a nicer aesthetic of having an actual smile, but they're able to eat how they want. They don't have to worry about dentures moving around in their mouth like a hockey puck. So then they're increasing their healthspan and their wellspan for longer. So it's, it's nice and satisfying for me on an anesthesia side, because you know that you're improving a quality of life for this patient that they just didn't have. And all of this happens in one day, which is pretty wild. They come in, they tear all the teeth out, just like you're doing a knee surgery where you kind of make a nice plateau on there. You can make that nice tibial emphemeral plateau. It's the same idea in the mouth. They kind of saw everything off, make it nice and flat, and then put the screws in. The transformation is almost immediate, and surprisingly, it's like not that painful, which is great. I send everybody home on Tylenol and ibuprofen, and they do well. These were all things that I had to learn. I had no idea. There was no, you know, what was it, Maxie, I think was the book that I used when I was in school about you know, preparing for cases and all that. This isn't in there. This is a brand new surgery for me. I mean, you could throw some crazy stuff at me and I'd be like, oh yeah, I've done that, I've done that. I still haven't done anesthesia for a BBL, I will say. Never done one. Uh, but that's like the only surgery I haven't done. But it— I'm like, this was totally new for me. So there was a learning curve with that as well, of like, how do I manage this case because it's new?

Yeah, that, that's interesting. I, I Personally, I've never been involved with one of those cases, but this surgery, I mean, you think dental implants and it's like, okay, but this is— sounds like it can be life-changing for these patients, their quality of life, right?

Absolutely, it can. I mean, you know, you're talking about having patients that we want to optimize them for surgery. We want them to come in and because it's elective surgery, because it's outpatient, I want them to be in the best shape they can be. I always tell people it's optimization, not perfection. You know, when patients are in the hospital, we can just be like, let's do anesthesia. It doesn't matter what your underlying health is because I've got a cavalry I can call in, right? I can call a code. There's gonna be a million people that show up with a code cart. And I've got backup if I need help or a second set of hands or if I have questions. Or, you know, okay, they took their lisinopril this morning. We'll manage. We'll be all right.

Yeah.

And here you have to own every little bit of the practice and you have to be able to stand for and answer every single choice that you make. And that's tricky. That's the hard part.

That is the hard part. And I think, you know, in our phone conversation, you just said it there, like ownership. You're really owning this entire experience for these patients. Whereas in the hospital, you know, if you're working in an anesthesia care team model, you often have somebody else, anesthesiologist, you know, seeing these patients pre-op, you have a pre-op clinic that's working with them. You have all these different, players, uh, it is just you and you are owning essentially, uh, so much of this even before the patient sets foot in the hospital. Uh, what does, what does this like 100% solo practice actually mean?

Oh man, when you're working solo, and again, I'd done it in a GI center, but when I showed up in a GI center, um, you know, the gastroenterologists do a pretty good job of selecting the patients and getting them in there. Here, um, these patients are kind of coming in blindly and we get their records well beforehand And there was such a shift in my brain that had to happen from the, the preoperative standpoint. When we're working in a hospital, we have the luxury of having all the records there, especially if you're using Epic or Cerner or anything that's connected to all the different hospitals and the systems where these patients are seen. You can just grab and go, you know, I, oh, I wanna see their last EKG. Bam. It's right there. Oh, I wanna see their most recent set of labs. Bam. It's right there. And you can just. Okay. I've got all that information. Well, when you're in an outpatient setting, you have to chase that all down. And I don't do that. I'm really fortunate that this office has a team of people that do that for me. But if I want to see an EKG and they say, oh, I haven't had one in 5 years. You know, it's me saying you've got to go get a new EKG. Uh, if they're type 2 diabetic and they haven't had an A1C within 90 days, well, you got to get a new A1C, you know? Um, there's so many different things and it comes down to even like, What medications are they on and what do I need them to take before surgery? You know, these are things I didn't even really think about. Sure, we think about—

Yes.

Oh, your blood thinners, you know, Metformin and things like that. What about stress dosing steroids? You know, what about their Jardiance and Farxiga? Are you holding those for 72 hours? When's their last dose of Ozempic or Mounjaro? What if they're on any biologics? Because that can impact the healing. And there is a million different biologics out there. And even things that they could be on for eczema, psoriasis, rheumatoid arthritis, Sometimes the surgeons don't catch those and I have to catch those. And you're thinking about all these different things, you know, does, does the patient have gastric reflux? Can they lay flat when I intubate them? Uh, do I need to put them on 24 hours of clears or are they gonna be okay at NPO at midnight? And I run like a modified ERAS protocol. So it's like, um, am I gonna have this patient drink a Gatorade the morning of, or sugar-free Gatorade, or do I want them on clears? Like there's, there's a million different things you have to think about. Um, so owning the practice means a whole lot more than just making the anesthetic decisions intraoperatively. It's also about when I send them home, do they have to walk upstairs to get in their house? What drugs am I gonna give them? Are they gonna be okay at discharge, or do I need to sit around and wait for that Aldrete score to meet, you know, the requirement where I think they're gonna be okay? Uh, who's gonna be with them when they go home? And is that person gonna be capable of taking care of them? Are they gonna understand? My post-operative instructions. This all falls on you when you work by yourself. Uh, it is a shared responsibility with the surgeons. I have such a great relationship with the surgeons that I work with. I mean, they're— they've all been phenomenal. I've covered offices, uh, throughout the country for this company, and the surgeons are amazing. But really, at the end of the day, I also have to own that, and those decisions come back on me. So it's not just about like, what are, you know, oh, I own the practice, I have my own company and own that, but it's like, I'm owning this patient from long before they set foot in the door until after they go home. And I have to make every single one of those decisions. It's a lot of pressure.

It's essentially, I mean, you're almost like a functioning, like a primary care physician at the start of it, right? And you're managing the entirety of the periop period and there's nobody else kind of making these calls or assessing these patients. It's just kind of you. That's, yeah, that's very interesting. I kind of take for granted, you know, coming from the hospital setting. Now I will say like in our ambulatory surgery center, I was doing our outpatient endoscopy today where it's CRNA-led and we are, you know, involved in the patient selection. We do have a pre-op clinic, but we're back and forth with them. Like how do you determine what patients are eligible to come to your practice?

Oh man, that's, that's the hard part. I would love for everybody to be able to walk in and just have surgery. And I would love to be able to say immediately yes to everybody. But the reality is that this is elective surgery, it's outpatient, and I'm on an island here, I'm by myself. And so you do have to be very judicious about what you, who you pick and, and what your disqualifying factors are. I've learned also consistency. Um, there are certain things that I'm just not gonna bend on, you know, and I feel terrible anytime I have to disqualify a patient. That's, that's my last resort. But there are certain things, you know, patients come in and they have a BMI of 50. I'm like, I'm sorry, it's not a permanent DQ. It's a go get Ozempic, lose weight, come back in 6 months, go hit the gym, come back in 6 months, you know. Um, solid organ transplants don't fare well for dental implant surgery because the immunosuppression tends to cause those implants to just fall right out. You really never get osseous integration. So, I have to disqualify those patients, which is a real bummer. There's some other things, you know, end-stage renal disease. I've learned if a patient is on dialysis, the coordination of that is just incredibly onerous. And it— it's just— I'm not saying it's not worth my time. It's just— we all know the fluid shifts, the electrolyte shifts, things like that that can happen with end-stage renal patients. And— Uh— it's just ultimately it's, it's a little too tricky. Um, you know, cardiac issues and stuff like that. I don't necessarily permanently DQ them. It's more of a case of like, go get this examined, get this fixed and maybe come back. We had one patient, uh, this guy came in and this was one of those ones you give yourself a little pat on the back. And I say, good job because this guy came in, um, physical exam checked out, PCP note checked out, but there was a little note in the PCP note about they heard a systolic murmur. And I thought, oh, that's interesting. They graded it a 2 out of 6. That, that's, I don't know, that's not terrible. Um, but the patient endorsed dyspnea with one set of stairs. And for me, that's like red flags. I'm going, he, this guy can't climb one flight of stairs and he has a systolic murmur. So I said to the guy, hey, before you come in here, why don't you go see a cardiologist? So he went and saw a cardiologist. His aortic valve area was 0.7 centimeters squared. And they said, sir, you need a new aortic valve.

Yes.

And I said, uh, yeah, I'm happy that we made that decision because you— this guy would have died on induction. There's no doubt about it. Oh, sure, sure. He would have died. He would have died right there when I pushed propofol. And, uh, I said, go get your valve, come back in 6 or 9 months, let's get clearance and a risk stratification from your cardiologist. I'll work you up again, we'll get some new blood work get a new echo. And sure enough, it was a 12-month process, and this guy eventually got his surgery. So it's things like that where you're like, I might not want to touch you now, but we'll do it later. Get this all teed up. It's about optimization, not perfection. Um, and I tell people, I'm not a cowboy. I'm actually very conservative. Um, sometimes though, you have to reach out and see if the stove is hot. Yeah. And sometimes when you touch it, it's hot and you're gonna get burned. That's the reality of doing anesthesia solo. It's the reality of growing into that practice. Um, fortunately, all my patients have done really well. I've not had any, like, terrible outcomes, but you got to reach out and you got to touch it to find, is that stove hot? Uh, and sometimes it's not. And then you say, you know what, I can actually safely manage these patients here. I can, I can definitely take care of this. So there was, for me, a tremendous amount of growth of learning Who is eligible and who am I going to disqualify? And again, there's certain things I'm not going to bend, I'm not going to break on those. But then there's other things where I'm like, hey, you know, come on in. And I know that, you know, my safety and my sort of repertoire with everything is going to work out. So optimization is key here.

Certainly. And that's— I love that analogy, you know, touching the stove to see if it's hot. You talked about, you know, your growth. Growth since you left, uh, Penn. And obviously major academic center, and you have this idea of potentially sacrificing growth from, from being there, from these high acuity patients. But you said something, uh, yesterday on the phone that, that really kind of stuck with me. You said that you're a better and stronger CRNA today than you were 3, 3 years ago when you left. Yeah, let's unpack that a little bit because what, what exactly do you mean by that?

When I left, I felt like I was at the peak of my practice. I was like, man, I'm taking care of these sick hearts. I'm doing these crazy neuro cases, transplants. I was doing trauma anesthesia. I even, I had covered labor and delivery. Obviously there was everything going on with COVID that I had taken care of. I was working in anesthesia at that time as well. Just like wild things. And I thought, man, I have seen and done it all. I was on top of the world with anesthesia. And I was like, it's not, It's not gonna get any better than this. What I didn't realize were just my own blind spots and what I didn't know. So much of the preoperative stuff when you are in a hospital setting is taken care of for you. Patients go in and they see physicians, nurse practitioners, and PAs in the pre-op clinics and the pre-op areas. My lights are having a seizure behind me. Sorry, I don't know what's going on.

We're having storms up here. So if you guys hear thunder—

I think it's sending them down my way too, man.

Yeah, yeah.

But it's like so much of this is taken care of by everybody else and they just roll in for surgery and you're not really thinking of that. You're not really thinking like what's going on with the meds they took this morning and what, what antibiotics are they on and what do I mean? Like when was their last EKG? You just kind of trust that all of these bricks are stacked in place. And so that then that patient comes in and you have their complete medical history all taken care of. And most of the time in a hospital setting, it works that way. In the outpatient setting, that's not the case. That is just not how it is. And so, like I said, you kind of have to take ownership of all of this. And when you're practicing independently, owning all of those decisions, um, it is pressure, but it also changes your confidence. It changes your confidence in the patients I'm able to care for. It changes the way that you think. You had said, you know, and I do, you think a lot more of like— a preoperative, like PCP, primary care kind of standpoint, because you're examining the patients now of the drugs they're on and how that polypharmacy affects what your anesthetic is going to do. Of course, I was thinking about that stuff before, but really quite at that depth, you know, and now you're, you're the one giving the instructions for the drugs to hold, the drugs to take. You're the one giving the NPO instructions. You're not relying on anybody else to do that. And so if— Right. I don't tell them it's not gonna happen, you know. So when all of that comes from you, you realize, oh, I've, I've gotta not just step through one hoop now, I've gotta go through 5 or 6 different hoops to make sure that this patient, when they come in, I'm not gonna have to cancel their surgery. Um, there's a lot of potential revenue that's lost, a lot. And, uh, I am in the business of providing anesthesia for this company. And so they do the work to put the butts in the chairs, and I put those butts to sleep, right? And if they come in and there's something that I missed that I'm like, oh guys, I forgot to tell the patient not to eat after midnight, so they had steak and eggs for breakfast, sorry, I gotta cancel the case. That's—

Not a good look.

A tremendous amount. Yeah, not a good look. It's a tremendous amount of revenue loss. It's trust that's lost more than the revenue. It's trust. They lose trust in you as a provider. And so what you learn is that. You have to own those decisions, not just for your patients to trust you, but for the business to trust you, so that then they bring in more business. And when they bring in more business, you perform more. And when you perform more, you make more money. And we all like money. So, um, but again, it's not, you know, it comes down to patient safety at the end of it, which is, I want my patients to be safe.

Mm-hmm.

And I know the care that I can provide, but my care is only as good as the instructions that I can give. My instructions that I give are only as good as my knowledge. And the knowledge that I have, you have to be willing to put yourself in a vulnerable state and say, what do I not know?

Mm-hmm.

Find what you don't know. I actually went out and bought— there's a great book if anybody needs a little, you know, light reading for, uh, evenings. There's a great book about preoperative assessments. Uh, it's gone through a few different editions now, and it kind of walks you through how to think of preoperative assessments as a nurse anesthesiologist. And that's— that for me, that was super helpful because again, you're coming into the hospital and somebody else has done your pre-op. Your pre-op information's already filled out. Your EKG's already in the chart. Your labs are already there. So really shifting gears to now think about all of that preoperative stuff in a new way.

Mm-hmm.

That was the biggest thing for me to learn. It wasn't the case or the anesthetic. That's the easiest part of it. The biggest part was how do I make sure that my patients are gonna be safe and how do I own that?

Yeah, no, well, um, do you know the name of the, the book off, offhand? If not, we can— I can list it in the show notes because that's something I'm interested in as well.

It's on my bookshelf. I can go look.

I'll put in the show notes.

I'll message it to you and we'll put it in the show notes. It's going to be a good read for anybody that's working in a solo practice environment, um, anybody that's doing any sort of pre-op testing and assessment of your patients. You're gonna really be able to dive deep and understand and give good rationale for why, why you're looking at what you're looking at, you know? And this is even beyond just labs and EKGs and stuff. I'm talking about, uh, interpreting echocardiograms. I mean, you get a summary of an echocardiogram and the cardiologist says, oh, they're low risk for surgery. Are they? You know, patient comes in. I had a guy a couple weeks ago, EF of 35%, good activity tolerance, but his global longitudinal strain. Yeah. Was negative 6%. What does that mean? In a hospital setting, it'd be like, I don't know.

I honestly, I couldn't tell you.

Yeah. Right. It's, you know, effectively how much the apex of your heart is shortening during contraction. And so a more negative number means more contraction. Negative 6 is not a good number. You want it like negative 20, you know? Uh, and this guy had poor activity tolerance. His DASI score, do you know what the Duke, uh, Activity Standardized Index is? So DASIE score was like right around 4 METs, GLS of like -6, EF of 35, and he couldn't climb a flight of stairs. And, you know, are you able to bring all of that information together to make that assessment for that patient? Because again, if I induce that, there's a high probability that that guy just dies right on the table with induction. And in the interest of keeping patients safe, You've gotta know all that information, you know, the PFTs and stuff. Yeah, it's just, you're looking at so much more. It's kind of, it's fun.

Yeah, yeah, no, it's a completely different mindset. You know, myself coming from a trauma hospital where you just do and you make do with what, you know, this patient's coming crashing through the door, you know, you just go to work. Whereas what you're doing, completely different mindset. You know, TD, would you say that your patients are safer now based on what you know and what you've gained over this time, even, you know, talking about getting these patients in the door and ensuring that they're appropriate for your center?

I think with me, um, and my care, they're safer now. Um, and I'm not saying anything about working in a hospital or whatever. I think there's, there's an inherent safety net of working in a hospital. I feel now that I know so much more about my patients when they come in, and because I have better knowledge and better understanding of everything, I can care better for all of my my patients. You know, I did trauma anesthesia for years, just like you've been doing for 10 years. And yeah, I mean, patients come in and, you know, trauma, strokes, and things like that, and you just do the anesthesia and you don't know anything about John or Jane Doe that's on the table in front of you, but you just make it happen. And yes, there's a certain finesse to that. There's, um, and I love, uh, Bonjo, who was your recent guest, and this guy does trauma anesthesia for a living and That's his bread and butter. He can do an anesthetic on anybody that walks through the door. There's no doubt. And I can as well. But for me, my idea is when you're paying for elective surgery, it's all cash payment. You're paying for this red carpet kind of service. Um, I'm gonna deliver that in my anesthetic, and that is from start to finish, you know, all encompassing. And so really knowing everything about these patients for me is crucial, not just to deliver the best for them, um, But also just for me, at the end of the day, I felt really good knowing that I did the absolute best for every patient that I could. And that feels good. And it's not that I wasn't doing that before, but now it's just so much more in depth. There's just a different depth to it, um, than working in a hospital setting where there's multiple hands all in the same pot. Now it's just kind of like my hands are in that pot, you know? Nobody's cooking in my kitchen.

And I love that idea. You talk about this red carpet service, like you're, you're really trying to do best for these patients for this elective case. Let's Let's talk a little bit about your anesthetic. It's fascinating to me, you don't even have an anesthesia machine, right? Can you explain your anesthetic a bit?

Before, before the viewers come at me, there's no anesthesia machine. Yeah. And yes, it's safe. Yes, it's not because my machine is broken and I sent it out for service. I don't have an anesthesia machine. You know, I always ask when I bring this up to people, they're like, Oh my God, you don't have an anesthesia machine. And I say, what are the two functions of, of an anesthesia machine primarily, right? It's gas delivery, uh, and it's ventilation. So I keep all of my patients— so first of all, it is a full general anesthetic. It is, it is general anesthesia. Um, they're intubated. Uh, I keep everybody spontaneously breathing. I do not use any neuromuscular blocking drugs. Uh, people are like, how, how do you 'You put a breathing tube in with no neuromuscular blocking drugs. You must be using succinylcholine.' Nope. I don't even have succ in my office because I don't have an MH cart and I don't have Rianidex or Dantrolene. And so I just, you know, I have Rocuronium and Sugamidex if I need it in an emergency. So it's all general anesthetics with a nasal tube. Everybody goes off to sleep. I have a nice little concoction. I will give most patients— here's, here's, I'm going to throw one out there. Nalbufene. And people are like, uh, I haven't used that since OB or peds. Um, it's a really nice agonist-antagonist. You hit a ceiling effect with it, but it provides a little bit. I give that first with a little Presidex and it provides just a little bit of anxiolysis, gives them some upfront analgesia. And then I have them, you know, just breathe oxygen for 5 minutes. I give them a little midazolam, plus minus on the midazolam. Cause I said, you know, a lot of geriatrics. Yeah., some ketamine, and then I induce with propofol. I LTA the cords with 2% lidocaine. So I use 3cc of 2% lidocaine on a little, uh, Magic, uh, atomizer and ventilate them for another minute and just kind of let that lidocaine marinate and numb things up. Um, the way I put the tube in, I just keep it simple because again, when you're working solo, time is a huge factor, right? I can't wait for the patient to desaturate, and they call in somebody else and say, oh, I'm having a hard time mask ventilating them, or whatever. It's me and a surgeon. And again, the surgeons I work with are phenomenal, but I'm the airway expert in the room, uh, and I never want to have to crack my— or to crack my emergency cric kit because that's never a good day. So, uh, you know, getting that tube in quickly and safely is my primary objective with induction. Um, so I keep it simple. I think we overcomplicate nasal intubation, uh, by a lot. And I've been fortunate to teach at a lot of airway labs recently where I've showed people my technique and I've said, just simplify the process. We, we overcomplicate it. Right? So I don't use any phenylephrine. I use no Afrin. Um, I don't pre-warm my endotracheal tubes because it's— I don't find that it helps. And I also don't use any nasopharyngeal airways to dilate the nostrils. Um, what I do is I take a 12 French red rubber catheter, the ones that you're gonna have in your urology cart and new nurses, if you ask 'em for this in the hospital, they're gonna be like, this is a foot case. And you're gonna be like, yeah, just get it. Just get it. Yeah. So anyway, so we're using a red rubber catheter, 12 French is kind of that sweet spot of size. I trim it, not the whole thing. The whole thing's like 16 inches long, right? Where am I? I don't know. It's long. I'm on camera, but, um, I trim it to about 6 inches long and I just pop that right on the end of the nasotracheal tube. What that does is it's gonna find the pathway. Least resistance through whatever side I go through. I also have a CT scan on every patient, so I just scroll right through and I'm looking, seeing, you know, who broke their nose, uh, who took a basketball to the face as a kid, and they're, you know, septum's all crooked in there. So I find the side that's going to work based on their CT scan, um, and I allow that red rubber catheter to just find the path of least resistance, and then the endotracheal tube just follows that right down. The Murphy eye on that endotracheal tube is one of the biggest offenders here that just— we're performing turbinectomies when we shove that thing in, and you know, we're always, you know, we always say, oh, dilate, dilate in. Uh, really, that Murphy eye is the biggest problem. I'm also fortunate that I don't use the Shiley brand tubes. Most everybody is going to have Shiley branded nasal tracheal tubes on your carts, your difficult airway carts, and whatever in your central core in the hospital. I use a Parker FlexTip pre-curved nasotracheal tube. It's a million words.

A mouthful.

Yeah, it's a mouthful. It's, uh, I'm able to downsize the tubes because they're longer for a given diameter. Uh, somebody in the audience is now shouting at me, what about Poussé's law? Yes, Poussé's law, sure. I understand that I'm decreasing the radius. I've done this hundreds of times, and I'm going to tell you that it is not clinically significant to downsize from a 6.5 nasotracheal tube to a 6.0 for, you know, a normal-sized American female. They're going to maintain normal capnia throughout, even breathing spontaneously. And then coming to that, yeah, so coming to that, they're breathing spontaneously throughout the case. Um, this is a little bit weird one, and you're gonna need to go revisit Nagelhout. Uh, I use a modified Jackson-Reese circuit. So the fun thing—

Let me, let me stop you right there. I actually did before this podcast because you said that on the phone last night, and I'm like, uh, I remember the name What, how does this work? Because I have never used one.

It's a rare circuit. You're really not gonna find it. They, I have to special order them from McKesson, but they're out there. The fun part about this is that I run fresh gas flows at about 4, yeah, around 4 to 5 liters a minute. I'm effectively just trying to run your fresh gas flow at your minute ventilation rate. Right. So somewhere between 4 to 5 liters, maybe a little less, maybe a little more depending on the patient's habitus. Um, part of your fresh gas flow would determine your rate of CO2 elimination. So if I notice that they're maybe starting to climb, I just turn my fresh gas flow up a little more, maybe go from 4 to 6, and I'll see that CO2 drop down. Um, but patients maintain, you know, normal capnia, they're breathing spontaneously throughout. Um, I usually will give a little recruitment breath after Uh, you know, after getting the tube in, but they maintain that fine. And then when they wake up, one of the biggest things I do is after I deflate the cuff, I actually suction the tube as I'm pulling it out, which people don't even think of. Um, of course I'm using a Yankauer and I'm getting some nice deep glottal suctioning, but you don't know how much, uh, stuff is sitting right back on top of your cords until you suction that tube on the way out. You'll be shocked. And that was another thing I learned that I was like, oh my gosh, I don't think I've ever suctioned an endotracheal tube on the, on the way out. And, um, with that, again, the idea of just owning everything. If this patient goes into laryngeal spasm, I don't wanna reintubate them at the end of the case. There's blood in the airway, there's blood in the mouth, there's blood in the nose. This is gonna be really ugly for all of us. So, you know, part of just optimizing them throughout the entire perioperative course is like, let's decrease their chances. Of laryngeal spasm when they wake up. And so suctioning the tube on the way out, um, works really well. I wake patients up and, uh, who do I hand off to? Well, I am the PACU. And so now I recover them, you know, and this is another thing you're like, okay, where's, where's the PACU? No, no, no. It's just all right there. It all happens in this one dental chair right there. And so I stay and I recover the patient until their Audrety score is, you know, ready for handoff. I hand off to a prosthodontist who's a general dentist that is specialized in making, you know, prosthetic teeth, and they assume care of the patient. And then they send them home, they work for an hour or two, and then the patient goes home with their ride later. So it's, it's so, it's a crazy process. It's so different from anything I've done before. But now I've got it down to a really nice, well-oiled machine and a really kind of smooth, flowy art. And I just love it.

And you mentioned nasal intubations. That's something that I do on occasion, but, but not very frequently.

And just a quick story here.

One of my students, Jillian Moyer, and shout out to Jill. Shout out to Jill. She had approached me. Yeah, you know her pretty well. She came to me, I was in charge one day, and she's like, Tyler, she's like, are you here tomorrow? I really wanna do TD's nasal intubation technique with you. I'm like, oh Jill, I said I'm not here, but I will find you a CRNA that will be willing to do it. And so I get my one buddy and he's like, So wait, you want to do what? She's got it down. I said, TD is a good guy, he's not going to lead her astray. And she ended up doing that technique the next day. I don't know exactly how it played out, but I think she reconnected with you and she's like, oh, I had to tweak something, maybe get the red rubber catheter off a little bit. I don't know exactly the details of it, but, but, you know, you're spreading the good word here, my friend, these nasal intubation techniques.

I'm trying, man.

And, and I think probably many of our, our listeners, uh, aspiring CRNAs, might not even— that might not even be on your radar. You know, you're working in the ICU, or maybe you're not there yet, uh, there's different ways that we can intubate. And if you're working in the mouth, if you're pulling all the teeth, if you're putting all these posts in, it's got to be free and clear of obstructions, and you're not going to be moving that, that tube back and forth like we commonly do, right?

Absolutely. And I have patients, uh, at least once a week You know, most people have come in and they've had an anesthetic before, they've been put to sleep. Most patients have a general idea of, you know, I'm gonna— you put me to sleep, you put a breathing tube in. Probably once a week somebody says, well, how are you gonna work in the mouth if you have a breathing tube? And my answer to that, I always say, how much do you wanna know? Because I don't always— you know, of course I'm gonna inform the patient and I let them know you're going to have a breathing tube. Sometimes people are like, no, no, no, I don't wanna know anything.

Anything. Sure.

But, you know, I'll tell 'em if they ask, you know, it goes through your nose and then they go, oh yeah, there's a whole bunch of different ways. I mean, you know, working with oral surgeons, these guys are also proficient in submental intubation. We don't do those for this surgery, but totally another technique that can be done going through the floor of the mouth, which sounds wild, but it's pretty fun. And it's just one of those things that, You know, we have— we always talk about this toolkit that you have as CRNAs, and you can't ever get just stuck or get complacent. You know, my very first, like, month of CRNA school, my program director said, don't be a hammer because then everything looks like a nail. You need to be an entire toolkit. And the more that I get into this career, the more that I work solo, the more I see, the more I realize That could not be more true. You have to know everything that's available to you because someday your patient safety is gonna matter for your knowledge and, and what you know, and you are gonna be the one, everybody's gonna look to you to step up to that plate and have those answers. And they do. And we deliver.

I love that, TD. That's a great little pearl there. Uh, TD, I, I wanna talk about, you know, you're, you're, you're practicing independently. Just outside of Philadelphia. You're surrounded by Penn, Jeff, Temple, uh, residency programs, major research institutions. You know, why is this important, uh, in Pennsylvania and, and in this setting to be practicing independently as a CRNA?

Yeah, I mean, a little backstory for me going into anesthesia. I was not even aware, um, when I was in nursing school, I didn't even know the CRNAs could independently. I thought that every CRNA just worked in a hospital, in a collaborative practice with a physician anesthesiologist, and then that was the end of it. That's all that there was to the career. And I was really happy to— with the thought of doing that. And now, of course, I know more. Um, Philadelphia and the entire Northeast corridor is very heavily academic and very, very heavily, uh, anesthesia care team model or medical direction. So CRNAs are working, uh, up to 1 to 4 with a physician anesthesiologist. Anesthesiologist in a team. And, uh, in Pennsylvania specifically, um, CRNAs can work with any physician, you know, so we don't have to work with a physician anesthesiologist. Uh, there's only one state in the country, it's New Jersey, that requires that your anesthesia care be working collaboratively with a physician anesthesiologist. So in Pennsylvania, um, you know, we can work with oral surgeons, we can work with general, uh, surgeons, we can work with gastroenterologists, podiatrists, you know, and we're really fortunate to have that practice in Pennsylvania. And it allows our patients better access to care specifically where I am though, you know, it's like you mentioned, there are a ton of medical anesthesia, uh, residency training programs around. There's a ton of nurse anesthesia training programs around, and it's, uh, such a physician-heavy area. Finding true solo CRNA practice in this area is— It's a unicorn. It almost doesn't exist. There's a couple small groups doing it. Um, PAC is doing it really well in, uh, the greater Philadelphia area. And there's a couple smaller centers. But a lot of it centers around maybe cataracts, GI, um, a couple outpatient plastic offices. My idea with this is, you know, I'm doing full-on general anesthetics. These surgeries have real blood loss, they have real consequences, they have real outcomes as well. And my thought with this was, I'm gonna get in here and not just prove this to myself, you know, because now I'm taking that step up and I'm challenging myself. I am going to challenge the status quo. And in this area where you have CRNAs working under medical direction, they might think that, you know, that's all that there is. There's no greener pastures, and I'm just gonna work in this ACT model for the rest of my career. I want to change the narrative of what anesthesia in and around Philadelphia looks like. We know what our training looks like. We know what our skillset, our expertise, we know everything about ourselves and getting that out there and actually proving it. Surgeons and patients and maybe people that aren't paying attention, at the end of the day, we can come back and say, you know what? Not only do I walk it and, or do I talk it, but I walk it as well. And proving ourselves from me in an area that is so heavily saturated with physician-led care, and it's not to diminish physician-led care, but it's to say there's another option that it's just as safe, it's just as effective. This is all supported by data literature. And here we are, and we're the answer, you know. And I have always had a passion for increasing access to care. And when patients have access to care, we're healthier. And when we're healthier, we all do better. And so if I can improve access to care while still maintaining the highest quality of outcomes and show other people that that's possible, other people are going to make that same leap of faith that I did, and they're going to be like, oh, I think I could do that too. And they will. And it starts with one person, and that's how we change that narrative. And, uh, if that person is me, then that's awesome. Let's do it.

I, I love that so much, TD. That's so, so inspirational and just challenging the status quo. And especially where you're situated, as I'm, you know, I grew up in Lancaster, I'm not too far away from where you're at. And, uh, to, to just have that whole idea like I'm doing this for me, but I'm doing this for everyone else and kind of change this narrative. I love that. And that was so, that's the gem of this episode. TD, what do you kind of see your vision for growing this practice model? Are you guys looking to expand your company maybe in Pennsylvania or elsewhere?

Yeah, man. I mean, the goal now is I've been at this for 3 years now, full-time doing just this. Just me, uh, working solo in an office. I have, uh, quite a few CRNAs that both cover me when I'm on vacation, which I like to travel, so that's frequent. Uh, and I have other people that are just interested, people that now have been bitten by that bug a little bit, and maybe they've worked a locums assignment where they're working solo. Uh, they're just curious, and I think it starts with being curious, you know.

Mhm.

The next year for me is gonna look like getting out into more offices. Um, I think outpatient surgery is a phenomenal place to start. Um, because, you know, you're doing maybe less risky procedures, you know, we're, we're not doing heart transplants, you know. Um, but pushing this into offices and then pushing this into ASCs, starting to hire more CRNAs. And again, with the idea of just changing that narrative, um, not just for the public and for access to care, but also for the CRNAs just saying like, hey, Hey, you can do this. Uh, and when you work in a setting like in Philadelphia, again, you might think that that's all that there is to it until it's like, I always think of like The Wizard of Oz and when it like changes into color and Dorothy is like, oh, that's what it is. When you go work solo for the first time, it's like, now I can see that yellow brick road for what it is.

Is.

And I'm not just in this little silo of working, uh, in collaboration, which is a great— I am happy to work in an ACT model. I did it for many years. I love the physicians I work with. I love the CRNAs I worked with. Um, it's a great model. It's great for patient care, but so is this. And so just providing an alternative and showing that that alternative is just as effective, safe, and, uh, cost-effective for the patients, you know., and I just, that's where we're going.

I love that, TD. TD, let's get into some rapid-fire questions, kind of make this fun as we wrap it up here, okay? You're quick on your feet, I know you got this, buddy, all right? TD, biggest misconception about dental anesthesia?

Biggest misconception is that they're all ASA 1s or 2s, and then you're just coming in and pulling a tooth. No, it's real surgery. Oral surgeons are not general dentists. They go through a full surgical residency. They do general surgery with their oral surgery. They do anesthesia rotations. These guys are fully surgically trained. I mean, in a hospital, we're like peeling faces off with these guys, you know? So it is not just getting a tooth drilled. You're coming in and having real surgery, and there are real consequences, but also real potential with that. So that's the biggest misconception is that you're just getting healthy patients in the office, and everybody's gonna be coming in and, you know, they have nothing wrong with them. That is absolutely not the case.

I like that. One piece of equipment you couldn't live without.

Oh, well, I always tell people two things save lives. Those, I'm gonna say, these are a given. So I'll give you three. Two things that save lives, suction and oxygen. I need suction to clear an airway. I need oxygen to fix a bad airway. So those are two things that I definitely can't live without. My third would honestly be a video laryngoscope. Uh, I have a McGrath. Whether you're using a McGrath, GlideScope, I don't care. When you work as a solo provider, time is of the essence. Uh, we know that the literature and the data support your time to intubation is faster when you have a video laryngoscope and that your first pass success is higher. I'm not there to mess around. I'm not there to muck up anybody's airway. I certainly never wanna have to do a surgical airway on a patient, uh, especially for an elective surgery because it's something that was my fault. And so, uh, my video laryngoscope is something that I use every day. I've still got finesse, I've still got skill with my good old Miller 2, but I'm gonna go with my McGrath all day, every day, given the choice.

Nice. Most important trait for solo practice?

Oh man, um, boundaries. Boundaries in the sense that you can't compromise. You can't compromise on your knowledge, You can't compromise on letting other people walk over you. You can't compromise when you're negotiating contracts. If it's something you want and you want to ask for it and you're not willing to sign on the dotted line, if it's something that you don't want, don't compromise. You have to have boundaries with everybody. You have to have boundaries with patients. Patients come in and they say, I don't need to go get that EKG. I don't need to go see a PCP. I'm 65. I've never seen a doctor in my life. I'm healthy. You have to be willing to put your foot down. You have to have difficult discussions with people. I renegotiated a contract earlier this year, which resulted in a really great be, uh, you know, compromise between me and the company that I contract with. But I was sitting and having conversations directly with the COO and the CEO of the company. And the contract conversations, they're not always fun. You know, these people are business people. They're concerned about their bottom line, but there's also a quality of delivery of service that I bring. And so, you can't compromise. You can't, you know, we're nurses. We give. We give so much and you have to learn to have boundaries to say, you know what? No, I'm not gonna give. I wanna, I gotta take a little here because I'm delivering this service for you. And so you have to be very, you have to learn to be a little rigid, you know?

And, and know your value, right?

That's— Know your value. Oh my gosh. Somebody told me that, 'cause somebody, can we rewind 10 years and somebody goes, know your value, or 20 years when I like started in healthcare 20 years ago. Go, can somebody say to me, hey, don't take that crappy salary. Know your value. Know your value. Don't compromise on that.

Mm-hmm. Favorite thing about your current role?

Oh, man. My favorite thing is, it comes back to something that a nurse told me when I was in the NICU. I was in the NICU, and she was kind of this I don't know, crotchety old nurse. She's very stereotypical, you know. I've been a nurse for 30 years. She's rough around the edges, and but very, very capable, very smart and, and good. Um, and she said two things to me that were both critical, but they had different effects on me. One, she said, you're never going to be a CRNA if you stay here. And I was like, oh, uh, that one I took more as like a challenge. Uh, it's not true that you can't be a CRNA if you're in the NICU right now. You can absolutely be a CRNA. She said, um, if you go into anesthesia, you're just gonna sit and watch monitors all day. You're never gonna put your hands on a patient. You're never gonna— you're not gonna have that patient interaction. You're not gonna know them. You're not even gonna touch them. You're just gonna sit, you're gonna watch monitors all day, and that's boring. And I have so much greater depth of involvement with my patients now because I'm contacting them preoperatively. I call them on video calls and I do airway examinations and I call them and I talk to them on the phone and I say, hey, tell me about your usual day. You know, how do you, like, can you do your housework? Can you do yard work? Can you walk 2 flights of stairs? I feel so much of a better connection with my patients now. Um, because of that depth of involvement that I have in their care, that ownership that I have taken from that very beginning, all the way to when they're discharged.

Mm-hmm. What are you most excited about over the next 5 years? I know you have a lot on your plate. I know this VP role in Pana is big.

Yeah.

I foresee a lot more in your future here, my friend, but let's forecast the future. What do we got?

Oh, I've got a 5-year plan. I like to work, I chunk my life up into 5-year plans. I find that that's worked well for me. I started this when I was back in college, when I started my nursing program.

Program.

I said, hey, 5 years from now— when I started school, I said, 5 years from now I'm going to be an ICU nurse. And I was. And then that took me through to 2012. I'd been an ICU nurse for a year, and I said, 5 years from now I'm going to be in CRNA school. And I was. I started CRNA school in 2016. 2016, I said, 5 years from now, uh, I want to be working for myself. And I almost did that. I was a little behind because of COVID I'm gonna blame that one on COVID. Um, but 2022, I started my own company and started working for myself. And now, between 2022 and 2027, I said, you know, I'm going to grow this practice. And that's that 5 years. So, 2026, the next 5 years, I have some professional aspirations. You know, I've got a 5-year plan that involves some leadership roles and elected positions. On a broader level, not just for me, I see this expanding. And if we look historically over CRNA independent practice, and it has only increased. If we look at the timeline of QZ billing, which we're not gonna get into for the scope of this, but, uh, it has only increased every report that comes out. You know, CRNAs are working more and more independently. And what's happening with that is the patients continue to do well. We continue again and again to prove that we're the answer. Our patients have excellent outcomes. They continue to get sicker, yet we continue to deliver. And so if I can take what I know and pass it along to some other people, I'm also gonna learn from them cuz they're gonna figure out other things that I haven't figured out, you know, and just growing the entire profession and pushing people into this independent and solo practice role. Uh, it's, that's the next 5 years. That's where I'm gonna take this.

You're getting me amped up here again, my friend.

Hell yeah.

Question that I didn't, uh, to kind of tell you about. And I put people on the spot from time to time on this CRNA Mentor podcast, but TD, what, what is special about you as a CRNA, as a provider? What, what do you bring to the table that maybe some other CRNAs do not?

Um, I think I've always been told that I have the gift of gab, which comes as a real surprise because we've been talking for an hour now. I think that there is, uh, I credit this to my grandfather. I've been told that I could find a brick wall conversational and entertaining, and I'm not going to argue with that statement. I think that there is just an inherent ability that I have to be conversational, to put people at ease when they're coming in and sitting in a chair and, uh, handing over all of their vulnerability and, and all of their anxiety. And I'm saying, you know what, let me take care of that. Um, and you have to be able to talk to people. And Tyler, you're very good at this as well. And I think it's a skill that more CRNAs can develop and work on. Some are really, really excellent at it. Um, for me, I think it's just being able, you know, we have a matter of minutes to get to know these patients and to put them at ease. And when you can find in. Finding that way in is a skill. And I practice this in a lot of different ways. When I was back in nursing school, I had never, you know, none of us really had maybe ever worked with patients before nursing school. And I was working as a patient care technician at the hospital. I was also working as a tour guide for the University of Pittsburgh. And I had to find a way to kind of get that in with the families and the students to sell the school to them, you know, to figure out why is this gonna work for you. And it's almost the same tact that I take when I'm speaking to patients now of like, uh, I'm gonna get you to trust me. So I'm gonna sell you on me. Now I am the product and I'm gonna get you, uh, to trust me. So the gift of gab has served me well in that, uh, not all patients wanna talk, not all wanna be talked to, but Finding little icebreakers and little ways in is— I think it's just something I'm good at, and it's served me well in patient care roles. It's served me well in, uh, political roles as well, and working in Washington, DC with the ANA. And, um, I think it's something that has served me on various committees and leadership roles, and something I'm just gonna continue to do.

I, I couldn't agree more, and that is, is your gift, TD. Uh, you are 100% spot on. Uh, as we close this up, TD, for CRNAs that are listening today or aspiring CRNAs that foresee themselves feeling stuck or maybe too comfortable in a role or maybe just afraid to take this professional leap into a solo practice role as a CRNA, what would you tell them?

Um, I would say first of all, you're right, it is scary. I know, I did it. It is one of the most frightening things that I have ever done. If you operated your life out of fear and only being afraid of making wrong decisions or failing at something, you would not be a CRNA today. You cannot become a CRNA if you are afraid of fear, if you're afraid of failure, if you're afraid of not living up to expectations that you have or other people have for you. Um, first of all, don't listen to other people's expectations for you. Their opinions don't matter. Trust yourself. You know more than you think. You're more capable than you think. And at the end of it, is it scary? Yes. Is it an insurmountable obstacle? Absolutely not. There's a lot of things in life that are way harder than doing this. You've got the training, you've got the knowledge, you just got to kind of jump in and do it.

Good advice there, TD. And I really appreciate this conversation. You really opened my eyes. I may be one of those people that I was asking that last question for. But I really think that the biggest takeaway from this episode is that professional growth, it doesn't always look the same and don't expect it to. Sometimes it could be these big academic centers, high acuity cases, traumas, all these crazy things. But other times it could be this kind of greater ownership, greater responsibility, and this kind of willingness to step outside of what's familiar, right?

Yeah.

I really appreciate you, TD, for sharing journey, for, for sharing your perspective on, on independent CRNA practice. And I will be bringing on others that will share this because, again, I feel, as you touched on, not many people are aware of it as they're going through this journey. They often just are— think anesthesia care team model is all that is out there. So we're going to continue to open your eyes for all of our listeners that are out there. And I really appreciate all the work that you're doing for our profession, both in Pennsylvania and nationally, TD. So I can't thank you enough here, my friend.

Tyler, thank you just for the opportunity and for, I mean, you know, having me on and letting me speak to everybody about what I do. I'm honored that you even, uh, considered me for this. It's really— I'm just happy to be able to share, uh, and to kind of open the eyes of some of the listeners and everybody who might be thinking about this. And, uh, if you have any questions or anything, um, you know, we'll put my information in the chat as well. I would love for anybody to contact me and Um, I just wanna, I wanna keep making this better. It's that idea of just continuing to improve all of us. It's a common trope that we hear. It says a rising tide lifts all boats. Uh, but it's real true unless it's a tsunami and then you should just run. Probably. Yeah. You know, that's, we're not, yeah.

Oh, TD. Hey, this isn't gonna be the last time that you're on the CRNA Mentor Podcast. Uh, I appreciate you. And for all of our listeners, um, if this episode helped you, if it kind of opened your eyes to a part of anesthesia that you're not aware of, share this with your friend or somebody that is interested in anesthesia. And I appreciate you, TD. And until next time, we'll see you later.

Thanks, Tyler.