The Most Unique CRNA Role in America? Shock Trauma Go Team & Austere Medicine

Most people think that anesthesia is something that happens inside the operating room. But what happens when anesthesia leaves the hospital? What happens when a CRNA is delivering blood products at the side of a highway, managing an airway during a prolonged extrication, deploying by helicopter to uncontrolled trauma scenes, or responding to disasters in austere environments with limited resources? This episode is about far more than trauma anesthesia. It's about identity, autonomy, leadership, austere medicine, and it's about expanding the imagination of what's possible within nurse anesthesia. For our trauma ICU nurses, flight nurses, military-minded providers, and aspiring CRNAs listening today, this conversation may completely change the way that you view this profession. Joining us today is Bonjo Batoon. He is a CRNA and staff nurse anesthetist at the world-renowned R. Adams Cowley Shock Trauma Center in Baltimore, Maryland. This is where he specializes in trauma critical care, and he is part of the Shock Trauma Go Team, which is a hospital-based rapid response team that brings anesthesia, surgical, and critical care services directly to the point of injury through ground and air deployment. He is also a member of the National Disaster Medical Systems Tactical Critical Care Team, or the TCCT, which provides medical assistance during disasters nationally and internationally. In addition to his clinical work, Bonjo speaks nationally about trauma, prehospital resuscitation, and currently serves as the president of the Filipino American Nurse Anesthesiology Society. This episode explores austere medicine, this practice of delivering critical care in uncontrolled, resource-limited, and high-pressure environments, and how Bonjo's career challenges traditional view of what it means to be a CRNA. Welcome to the podcast here, Bonjo.

Hey, thanks for having me, Tyler. Pleasure to be here.

Absolutely. I am thrilled to get into this conversation. This is something that when I first met you, this was back in Washington, DC about a year ago, and I was talking to Chris Bosch from Virginia and he pointed to you and I see this guy backwards hat, t-shirt out the bar, and he goes, that guy right there is one of the top 5 CRNAs in the country clinically. And I'm like, I gotta meet this guy. And that's where I met. And I'm super interested in your story, Bonjo, because I've never heard anything like it before. We're gonna talk all about, you know, how you got your start here and got involved with trauma medicine. And it really, when we got to talking about it, it wasn't something that, you know, I thought you were coming from all this pre-hospital experience, you're a flight nurse, and we'll get into it here shortly, but Bonjo, tell me a little bit about your background before becoming a CRNA.

Well, interesting enough, I always tell the story about becoming CRNA, right? Because being a CRNA is one of those weird professions that people hear through the grapevine, you know what I mean? Like, people— it's not like one of those professions that people have heard of. And so I'll tell this quick story where in high school, my friend had just graduated from high school, and his family took me on a travel, um, out to California. And so, you know, we're like traveling from Arizona to California. We wound up going to like LA, and we're in the middle of LA, and this— go to his aunt's house, and his aunt's house is huge in the middle of LA. I'm like, what does your aunt do, right? And he's like, she's a CRNA. And I was like, I don't know what that is, but that's what I want to be, right? And so that was kind of like the, the seed that was planted back in the day about being that. So me and my buddy were like we're going to be CRNAs, whatever that's at, whatever that is, and had no clue what it was. But then as I like kind of went on in, um, you know, trying to get into school and also the good stuff, you know, I wanted to be a nurse because nursing was— you could work anywhere, you know, there were jobs everywhere, jobs were plentiful. Um, maybe not at the time I started school, but in general. So there was always a place where you can go and XYZ. And then eventually I started researching about CRNAs and what they do, and I really enjoyed the, you know, like the autonomy portion of it, the procedure portion of it. Um, with that said, like, my goal ultimately going into nursing was in fact going to be a CRNA afterwards. And so, um, you know, that was always my plan initially when I went to nursing school. I completed nursing school. I wanted to get in the ICU right away. Unfortunately, I couldn't because right at that time— this was like 20 years, 1998, something along those lines— so I just finished and there was actually a nursing surplus. So you couldn't just go to the ICU and you actually had to like work on the floor, do all this other good stuff, and then eventually get your way into there. Even at the hospital I was at currently— not currently, but at that time— I was working on the floor and I was trying to get in the ICU, but they wouldn't let me in the ICU because they said I didn't have enough experience. And I was like, well, how am I going to get experience? I would never get into the ICU. And one of my friends happened to, you know, introduce me to Washington Hospital Center in D.C. They had a critical care fellowship. And so she was leaving to go, you know, to that thing. And I was like, you know what, I'm gonna follow you. And so the funny thing is, after I decided I was gonna go to that fellowship, the ICU called me back and they were like, we want you to stay. And I was like, it's too late. I already made up my mind. You know what I mean? And so I wound up going to Washington Hospital Center in DC. And again, it was great cuz I, you know, that was my way into the ICU and that was the next step in order to become a CRNA eventually. And so during that time we went into the PACU, which was the critical care PACU. So we did, you know, regular PACU stuff, but we also did all the, you know, post-op ventilation and taking patients to the ICU. But we also were trained in that institution to go from all the different ICUs. We had a burn ICU, we had a surgical ICU, we had a cardiac ICU. And so I kind of moved around in that institution and then eventually went to the open heart recovery where I learned a ton about cardiovascular and respiratory stuff and critical care drips and also good stuff. And then the next evolution for me, I was like, in that time period, I was starting to try to figure out how I was going to make my way to anesthesia school. I wind up, you know, started to apply for anesthesia school at the same time I started going into the trauma unit at the hospital center. And interesting enough, at the hospital center, the trauma unit itself is separate from the ER. And so the nurses that worked in the trauma unit were all flight nurses or flight paramedics, and because they staffed that, that trauma unit by itself. And then, you know, so I got to meet a lot of the flight nurses and also good stuff and learn a great deal about autonomy, all the procedures they did. And I was like, that was really exciting to me. I really thought that, you know, that was the kind of the path that I wanted to go into. But at the same time, I was like, I was applying for anesthesia school, they offered me a position. I was like, it depends on what happens with, you know, the application. And luckily for me, I got an application, you know, I got accepted to a couple of schools. Um, and that was kind of my way into nurse anesthesia, but I always had like the love for trauma critical care. I really enjoyed that, you know, ER, that, you know, in the moment thing where you, you could do these things to make a difference in somebody's life. And that was always kind of what appealed to me about that trauma ER critical care thing.

Yeah. So it sounds like, and this was the part that really, uh, I was surprised by your journey. I really, like I said, anticipated some pre-hospital stuff, but you had, you know, that interaction with these, these flight nurses that trained you in the ICU and that in a sense, planted that seed maybe in the back of your mind, right? That this is like a cool environment. These people are super engaged. They have great autonomy and a lot of the similarities, you know, you see in anesthesia. And I've had a number of colleagues that were flight nurses and you just, they have this kind of edge about them, you know, and this independent thinking. You mentioned when we spoke prior that you rotated through shock trauma as a student. Yeah. And it completely changed your perspective on what a CRNA could be. Uh, what stood out to you in that experience?

So when I went to shock trauma, it was actually really busy. It was, um, in July. So like, once this weather starts getting warm, May, June, July, it really starts to pick up at the trauma center, obviously. But I got that at a very busy time, and it was just— I saw so many things, and it really completely changed the way I thought about anesthesia, especially critical care and trauma anesthesia, um, the way things were being done, right? Because when I was a trainee at other places, we did trauma, but it was different trauma, you know what I mean? Like, it was, it was the occasional trauma. Like, you would get one, you know, trauma case, and that'd be such a big deal. But at this place, like, trauma was just like every day. It was not even, you know, like, you could be back to back to back, like, bad trauma cases. Um, and that's— that was my experience during that time in that July. And like, I did everything. I did a bunch of lines. I did A-lines. I did, you know, central lines. And like, I did so many things in that one month, um, that I was just like— it blew my mind. Um, the thing that would really made the impression to me was the CRNAs. When you're going through training, you know, like, you have good days, you have bad days, right? You know what I'm saying? Like, you're going through it, you're like, oh, you know, am I going to learn anything today? Or you're doing the same thing over and over again. It was never the same thing. And each of the CRNAs that I interacted with had something good to teach me, you know what I mean? So like every day that I went in, I learned something new, whether it was vascular access stuff, airway stuff, you know, stuff about regional anesthesia. And again, like, you know, one of the biggest things was like how to give an anesthetic with an appropriate amount of analgesia and opioids that would wake a patient up smoothly. I'll tell you a good short story. So a patient came in, he had a tib fib fracture, he needed to get it fixed. We were going to do it overnight. So the preceptor— and this is going to probably sound wild to most people, but this really completely changed, blew my mind when it happened to me. So we get into the room, I do the typical student stuff, right? 2 of Versed, 100 mics of fentanyl. And so, you know, my preceptor gives me a 3cc syringe of some fluid. It wasn't labeled or anything along those lines at the time. Remember, just 20-something years ago. Um, he said, just give it. I'm like, what is it? He's like, 30 milligrams of morphine. I said, what? 30 milligrams of morphine? You want me to get 30 milligrams of morphine to this guy? And I was like, all right, whatever. So I gave the guy the 30 milligrams of morphine, and then he's just like, ask him to move over. And so like you could tell like the morphine started hitting them, right? And then he asked them to move over, and the guy literally like scooted over to the operating room table with his leg in a crappy splint on, and his tib fib was like bent in the middle of his tibial shaft, and he just moved over and didn't even flinch. And I was like, this is strange. I've never— you know, like, this doesn't make sense to me. How can this guy move his broken extremity with no problems whatsoever? Um, but it was like he knew the pharma couldn't kinetics and dynamics and the timing at which the, you know, the morphine was going to hit. And by the time we got to the table, we were ready to pre-oxygenate, intubate that patient. So we wound up, you know, this is the back in the day where we would give like Pentothol. We had, we were using Pentothol and succinylcholine and vecuronium back then. So we Pentothol, succinylcholine, gave vecuronium, did the I am nailing. At the end of the case, we didn't even give him any additional opioids at all.

Yeah.

We just ran him on 70% nitrous And that was it. Not even like C4 or anything. I was like, turn the, you know, turn the nitrous off, um, let it go off a little bit. He tapped the guy on the forehead. He's like, open your eyes, open your mouth. Took the tube out and he moved over himself. And I was like, I've never seen anything like it, you know what I mean? And it was just like, that was that point where like how to give appropriate analgesia changed my mindset, you know what I mean? It was like, you know, and then, you know, whether it was just resuscitation being the ones that were in control of what was going on, especially during an acute resuscitation. The CRNAs were like expected to be the ones that were run the resuscitation, you know what I mean? And so, you know, our physician colleagues, they were great, you know what I mean? Like I said, they pop in, you need help, if not, they just leave, right? And you would just be free to do the things that you needed to do to resuscitate and take care of this patient. And it was really, you know, mind-blowing for me. Again, for me, like it was the percentage of people that are really, really good at that institution that really made the difference for me, especially, you know, just learning so much. And I always tell even my current students, I'm like, you know, you do all these things that all these different training facilities and XYZ. And, you know, I always tell students, I'm like, you know more than you think. You just haven't put it all together yet in this, you know, amalgamation of all the things that you You already know, it's like my job is not to pimp you on this or that. My job is hopefully to get you to a point where you could take this piece of information, put it with this piece of information, and then you know exactly what's going on with it. You know what I mean? I had amazing like mentors that encouraged me and maybe they saw something in me that I didn't see in myself at the time, but, um, it really made a difference in my trajectory for sure.

Good preceptors. And, and just, I, I really feel like that's the summation of, of anesthesia school is, is, you know, taking a piece here, taking a piece here, you know, all these different things and making it into your anesthetic, uh, you know, approach. And, and really, you know, as you're talking about that tib fib fracture, in my mind— and this is something that I'm teaching aspiring CRNAs— is, you know, this art of anesthesia. You know, it's this marriage of, of anatomy, physiology, pharmacology, and, and your experiences. Like, your preceptor knew exactly the timing of all these things, that this guy could actually do this task, and then you're ready to go. And that's, that's one of the beautiful things about this profession. And, and I completely get why that stands out to you, especially being in such a high acuity environment and still having, you know, a lot of this autonomy that you had going through school. How did you kind of make this transition? So you're through anesthesia school, you're working at Baltimore Shock Trauma, and you're like, huh, this pre-hospital thing, you know, was again, the seed was planted earlier, but how did you make that transition to, you know, getting on the helicopter? Yeah.

Yeah, so interesting enough, it wasn't anything I had to do really, because at the Shock Trauma Center, they had what's called the Shock Trauma Go Team, which was established well before I even stepped foot in the Shock Trauma Center, where CRNAs and surgeons would be deployed to the field, or at the point of injury. And most of the time, it's usually for patients that are going to experience, you know, prolonged extrication, they're going to be there for a while, they need some critical their services. So it was already built into that. And so, you know, at the trauma center, we have a really close relationship with EMS in general. And so especially within the state of Maryland, and we work really closely with the Maryland State Police Aviation Division. And so we train them, they train us, we do a lot of like cross-training between, you know, EMS stuff as well as they come to our place, and we teach them about airway management. I talk about coagulation with them, you know what I mean? And I talk about resuscitation. And so we really have a really great working relationship with the state of Maryland. And again, like, you know, Shock Trauma in itself is really the pinnacle of the Maryland state EMS system, and everything kind of flows through that system. But again, we are all very integrated within that system as well. And so, you know, my opportunities of being part of the GO team Really led me to become invited to a lot of different places, especially with, you know, fire departments and things along those lines where we do like tactical rescues. And so they would invite us to go to, you know, their place to, you know, learn about how they do things. And then at the same time, you know, we have something to teach them as well. So like I said, airway management, mass ventilation, intubation, LMAs, you know, stuff about pain management, resuscitation. And it was really like a give and take, right? Like, you know, I went there, I learned how about scene safety, how they go about extrication and planning and making sure all the things are safe while people go in and do the things that they have to do. On the flip side, like, my job always felt like I was teaching them stuff about how to manage, like, you know, their procedures, whether it's vascular access, you know, I've taught surgical airways to people. Even amputations, we'll teach amputations for people as well. So we'll do stuff like that. So there's a lot of opportunity for us at the trauma center because we interact with so many different people.

So, so kind of for our listeners, uh, could it kind of formally defining, um, this Go Team? So it's, it's, it's part of shock trauma. Um, who, who makes up the Go Team? Um, when you, when you go out?

Yeah, the Go Team itself is really, there are two people. There's a shock trauma Go Team physician, who can be a surgeon, could be an ER physician. We had an anesthesiologist that did a lot of stuff for pre-hospital stuff back in the day. He's no longer with us, but, and, or some of our orthopedic traumatologists, they could all go on the Go Team as long as they had some training. And they've been in the, you know, done some stuff in the pre-hospital setting, they could. The other half of that are the CRNAs. And so the, so the two people that are on that team are a Go Team shock trauma physician and a shock trauma CRNA. And so the reason being is because at the shock trauma center itself, CRNAs are in-house 24 hours a day. And so that way, if there's a call, we always have somebody readily available from the anesthesia department, especially the CRNAs, to be able to deploy.

Mm-hmm.

And all the stuff that's associated with our equipment and our team is actually stored in the shock trauma center. And like, we have our own little bunker where we keep all our stuff. And so There's surgical stuff, there's anesthesia stuff, but it's, it's those two are the main components. Um, like I said, I always mention like the Maryland State Police because they are really a huge component with the transportation and the paramedics that come along with us. And again, a lot of times the Maryland State Police are the ones, especially get on scene and they think it's, you know, get a little bit hairy, meaning they think the patient needs more care than that's available at the scene. They'll make the suggestion to call for us. Nice. You know, it's, it's, you know, a physician and a CRNA. So that's the team. And then again, there's no team in the United States like this where you have two advanced practice providers going to the scene, right? So most of the prehospital EMS, if you're talking about HEMS and helicopter EMS, are by either a pair with a critical care nurse and a critical care paramedic.

Mm-hmm.

Um, there's some, there's a small subset that have physician and paramedic or physician and nurse, but We're the only one outside of the military that has a CRNA as a part of the, you know, the pre-hospital care team that goes out.

That's fascinating. And I think, you know, for our listeners that might be flight nurses and thinking about this, it's something that I've never heard of this before. And I'm sure many of our listeners have not either. That's why it's such a unique thing. But walk us through, Banjo, you get a call. Talk about, you know, how you're, you mobilize, get your equipment, uh, the helicopter deployment, like how, how does that all shake out? And how long does that take for you guys to mobilize?

Ultimately the goal is once a call comes in, um, is to get out the, get out the door, be ready by 15 minutes, right? Like, and so the helicopter should be landing, we should have all our equipment and be ready to roll. And again, it's pretty efficient. So the thing that holds us up a lot of times is the call from the field, right? So, you know, sometimes they're not sure whether this is a go team call or not. And like I said, we always say, if you think, if it pops up in your mind, you probably should just call us, right? You know, it's a free service, you know, you know, just call us. We're— many of us are happy to get up and go in the helicopter and, you know, come out and treat patients, you know what I mean? So, but so the call comes in, uh, to the, uh, Syscom, which is kind of the system-wide communications thing for Maryland. If the go team is requested, then another page goes out to express care. And then there's a system-wide page that goes out. And really, there's really no system to like who deployed, it's really who's available. Somebody's outside, out of the room, or somebody really wants to go, then that person goes and also gets up. Once that call comes out, you know, my priorities really are getting the equipment and the blood from the TRU, which is the trauma resuscitation, which is like our ER that's strictly for trauma. So the nurses will grab the blood for us and they'll put it in a cooler, put ice on it. I'll get the Go Team medication bag, which has almost every medication you could think of for ACLS, you know, any type of narcotic, sedative, pressor is all in that box. And it's a, it's a huge like box that has all the medications in there, 3% saline, anything you could think of that, you know, could be useful in the field, we have it. We have 2 bags that are exactly identical, and then we have different equipments in there. So we have a GlideScope Go that we bring. We actually have a KynFlo fluid warmer, so like if you have to give blood, we can give warm blood. And we have an ultrasound, right? So we can do POCUS, we can do, you know, ultrasound-guided IV access, regional anesthesia, whatever it is, because we have all those pieces of equipment. Obviously we have airway vascular access. The surgeons have like surgical equipment, right? So they can do stuff for like amputations, chest tubes, anything you could think of for, you know, short, you know, procedures that you can get in and out with, we have with there. We also have, some of your people don't know, probably never heard of a REBOA, which is the resuscitative endovascular balloon occlusion of the aorta. We're basically taking a balloon putting up your femoral artery and occluding it and basically applying an internal tourniquet to reduce blood flow below the level of the balloon. And so we have that capability as well. I don't think it's been deployed here in the United States, but we're—

I've done that a couple times at our trauma hospital and it was pioneered from, it was just like a Foley, right? In the military.

Correct.

A Foley would blow up. Yeah, yeah, yeah. Interesting concept, right? Wow, you guys have that? That's crazy. I mean, I guess it makes sense.

One of the guys is a vascular surgeon, so he's the, you know, he's the go team physician chief and he's a really, really good, but he's a trauma surgeon slash vascular surgeon. So like not all of them can do it, but he's definitely the one that can deploy it. But we can get the vascular access for it, right? So femoral artery, you know, we have an ultrasound, we can, you know, put in the sheath and also the good stuff. So again, it's like a, it's a teamwork thing, right? You know, Once we get in the helicopter, like I said, we get, sometimes we get a little brief about what's going on with the patients. Sometimes we don't. And again, we know very little about what's going on with some, most of these patients anyways. We may get something like the patient is in a tractor trailer, got crashed, you know, crashed and is, you know, stuck and can't get out. And that may be the extent of what we get. So once we get on scene, we will actually get a report from the incident commander. So we'll talk to them, see kind of the gist and safety protocols and also the good stuff and update of what's going on with the patient and the interventions or things they think may be needed. And then we'll go see the patient and get a quick assessment and see what the idea is. And again, as a CRNA, as you get older or more experienced, you get really good with your assessment, right? You know, what are the basics? Is the airway intact? Is he mentating, right? Is he diaphoretic? Can you feel a radial pulse? You know what I mean? Like, or something along those lines. And you go off a lot of that information because like standard monitors are something that you don't have, right?

Right.

Or you really, you know, when we're on the field, the scene, we're really relying upon the field providers to give us that information, you know what I'm saying? It's like, what do you think? You think he's doing okay? Is he meditating? Like I said, for me, if somebody's not meditating well, that bothers me, you know what I'm saying? Because why is he not meditating? Is because he bonked his head, or is it because he's so hypotensive that now he's not getting enough blood flow to his head, you know what I mean? So then I have to differentiate which, which treatment do I need to be— do I need to be giving 3% or do I need to give blood, you know what I mean? And so my mindset is that I want to do the things I need to do for this patient, right? Does he need an airway? Does he need blood and blood products? Does he need vascular access? Right? If I can do those things, do they— and a lot of times when I've been deployed, the two things that I'd probably give the most in the field, number one, blood, number two, ketamine, right, for sedation and analgesia. It's a great sedative for the prehospital setting and also good stuff. And Those are the two things that my two most common treatments when I'm in the field. And again, like, I had one scene where I was at where it was a prolonged extrication. The guy was okay, but he was meditating, he was answering questions, kind of lethargic and all that good stuff. We got him out. We did give him some blood while he was actually in the cab. So, you know, there's a picture of us, we're giving blood to the guy, he's still stuck in the truck. And they have a basket over him and we have blood running into the cab as we're giving this guy blood to kind of resuscitate him, but got him out. And on the scene, there were a couple of physicians on scene and what they wanted to do was they wanted to get this patient extricated and go into the back of the ambulance. And I was like, I'm not going to do that. There's no need. You know what I mean? Like I said, if this dude's bleeding, the only way to treat that, especially you need that patient to the surgeon. So completely bypassed the, you know, ambulance. I did all the assessments, treatments, like, on the way, you know, to the hospital. If I get stuck in the back of an ambulance for 15, 20 minutes, that's 15 or 20 minutes that patient could have been in the operating room having a surgery. So, like, priorities are different. The other thing I think about when I'm out there is that you have limited resources. You only have what's in your bag.

How much blood do you have on the helicopter when you fly?

Back in the day, we used to, you know, you could pick and choose what you wanted to bring for blood, right? Depending on what the situation was, because what you didn't want to do was waste blood, right? And so a lot of times we would at least bring 2 units of RBCs and 2 units of FFP, right? So that would at least give you a liter of blood product to give back to a patient. Once you get out there, I can't send the helicopter back to get me more blood. You know what I mean? So you really have to kind of like think about how, you know, what the potential is for blood need is going to be there. Now we actually have whole blood, so we can give whole blood in the field. And we've been doing this for, I don't know, probably like 4 or 5 years now where we've had whole blood available. So we'll take whole blood. So 2 to 4 units of whole blood is good when we can bring in.

Uh, what, what, Bonjo, uh, some of that you talked about these prolonged extrications, what are some other types of cases that you are responding to as traumas?

So we can be, um, deployed to like mass casualty stuff, right? Something goes wrong, something, you know, some man-made disaster such as a terrorist attack, we can go to those things. We've been deployed to, um, swift water rescue where somebody got caught with their leg being like into, uh, you know, caught in a rock in a river, um, and the water whooshing around, um, them. Uh, we've been called to like, you know, a lot of the— interesting enough, there's like, you know, building collapses, right? We had a parking, um, garage collapse on a person in Baltimore. And then, um, a farming accident, um, where, you know, I don't know if you've seen like those augers where they keep all the seeds and the grain and stuff like that. People would like fall in there and get stuck.

Yep.

Um, I've been on scenes where patients were, you know, digging a ditch on the side of a house and then just got caught in there and the stuff fell onto them and they were like buried up to their chest. So those are a lot of the calls that we'll, uh, get into. Obviously the— there's motor vehicle accidents, okay, you know, prolonged extrications from those things and things along lines, but those are probably the primary stuff that we'll see or respond to.

Gotcha. Um, Banja, why do you think that, that CRNAs are so uniquely valuable in, in these types of environments? You know, looking pre-hospital, uh, mixed or, or critical care experience, what, what makes us so valuable in these situations?

We're like a catch-all provider, right? You know what I mean? Like when I think about, you know, especially like myself, like I do adult trauma care primarily. But again, we all come from critical care backgrounds. We all have that, you know, assessment stuff. There's plenty of us that were pre-hospital providers even before becoming a CRNA, whether you're a paramedic, EMT, worked in ER, were a flight nurse. There's so many stories like that that go about that. And again, you know, one of the reasons why I think that we're really unique is that we have everything that the ideal pre-hospital provider has. Great airway management skills, right? Great vascular access, ability to assess, you know, take care of critically ill patients, the ability to make quick decisions on patients, and making sure they get to the next phase of whatever care that they're receiving. But we do a lot of that stuff. You know, we're pharmacy, we're critical care, we're the airway management person, you know, we're ER, we're like all those things combined. We have a great understanding of physiology, pharmacology, like I said, airway management. And if you think about all these things, these are the things that many of the prehospital providers out there want to have. They want to be airway experts, they want to have that, you know, vascular access. You know, we now, many of us use ultrasound quite frequently, right? You know what I mean? Like, not just vascular access, regional anesthesia, POCUS, right? So I'm a big POCUS fan. Like I said, I use POCUS on anybody that, you know, I have a question about, I'll stick up probe on a patient and look at their heart and be like, is it a heart thing or is it a volume thing? And you could tell by using that piece of equipment. Many of us are really skilled at those things, probably not the POCUS thing, but I always encourage people to become better with POCUS because once you learn POCUS, your ability to like pick the right treatment is gonna increase exponentially. I'll touch on this a little bit, but you know, the military has it figured out, right?

Because— Yeah.

The military really has to use their personnel to the maximum potential. And like I said, many of our CRNAs in the military, they're far forward. They are literally at the point of injury, right? Running around with Special Forces and are the only anesthesia provider for an entire part of this country. You know what I mean? And so, like I said, they do this on a regular basis. You know what I'm saying? So shout out to all my military CRNAs out there. Mm-hmm. They do this stuff, all the stuff I'm doing, the civilian stuff, they do this every day in the, in the, in the military setting. And again, I think they got it right, because they make use of all the providers that they have, and especially their skill sets. And so although what I'm doing is unique, it's not unique in the military, in the military sense, because there's plenty of— I know plenty of Special Forces CRNAs out there that are just killing the game and doing amazing things.

Yeah, Banjo, one of the things that I keep thinking about as you're talking about all these experiences and you're the anesthesia provider out at these scenes, autonomy. This is something that I harp on all of my mentees. As you're going through schooling, getting experiences in the ICU, you need to be thinking like a provider. You need to be practicing with as much autonomy as possible. Uh, talk a little bit about how autonomy has kind of played into your role in, in the setting of, of, uh, trauma.

That was one of the main reasons why I went to the trauma center, because there was so much autonomy, right? Because it was just like you had to make decisions. And I think it's one of the hardest things to teach, um, new CRNAs or, you know, new resident CRNAs, because especially during training, they're used to somebody telling them what to do or doing what their mentor or, you know, preceptor wants them to do and also does. But I always challenge them like, what do you wanna do? How do you want to think about this? Because what if I'm not there? What if somebody else isn't there immediately available? You have to put yourself in the situation. Now, before I say anything, I always make the preference, like, if you need help and you're in a situation, you call for help, period. It doesn't matter what— your physician, doesn't matter if you're CRNA, RN, whatever. That's always my go-to, like. But at the same time, there's nothing that's going on that you can't do, or service that you can't provide, or or something that you can't figure out. Maybe you haven't seen it a whole bunch, but if, like I said, you have to train yourself to be like thinking about these things. And I always tell my students, I'm like, it doesn't matter who you're working with, always think about what you want to do. As new residents, you know, what they want to do is they want to do all these procedures, but they don't think about the things that go on down later on down the line when you do these procedures. You have to manage all the things that happen during those procedures. And so I'm like, you want to do a central line? That's cool. Like, so what happens if you do this, right? What if you give a pneumo? What do you, you know, like what's your treatment? And also the good stuff. And again, You know, for me, like, we get requests from the ICU, can you put a central line in the guy? And do I need to put a central line in this guy, or can I get away with— you know what I mean? Like, and so when I was younger, I'd be like, yes, I'm gonna put a central line in this guy. Now I'm like, hmm, can I put a 14-gauge in the periphery? Yeah, I always liked autonomy, right? The syringes that I worked with at the trauma center and other places as well, but especially at the trauma center, were super autonomous. And I was like, just made the decisions, made the calls.

You're talking about autonomy, you're talking about this world-renowned trauma center, and you know, our physician My colleagues will tell you that, you know, CRNAs don't practice autonomously in these, you know, super, super high acuity trauma centers, but you're living proof. And, you know, you're speaking to this of 20 years experience. And I think that's just something really to key in on in this conversation is you'll hear oftentimes, oh, you know, CRNAs, they practice independently at, you know, these rural hospitals, you know, ambulatory surgery centers, but here you are, Banjo, you know, and I think that's great. One of the things I want to talk about, Banjo, is you're also part of this National Disaster Medical Systems Tactical Critical Care Team. What exactly is, is that role? And how does it connect to your experience at Shock Trauma?

It's very interesting. That's a great question. You know what I mean? Like I said, I've always been interested in like austere environments and like the military things. And I saw like, this is the next best thing to the military. My wife was not excited about me trying to like go in the military and be gone for months on end. So I convinced her that I could do the National Disaster Medical System. And I'd only be gone for like 2 weeks at a time. And she was happy with that, you know what I mean? So that's kind of how I kind of fell into it. But I was always interested in like, you know, disaster and things that you could do. And again, like, you know, to me, I think about those things. And I'm like, we have so much to offer, you know what I mean? And so as far as our skill set, and again, some, some of our deployments, you know, it's not— I'm not, you know, although I'm the anesthesia provider, I've done many, many things outside of being the anesthesia provider, right, from being an ER nurse, or, you know, being the respiratory therapist. But as far as the NDMS thing goes, again, you know, it's something I kind of found out by accident. Haiti happened, the earthquake in Haiti. We sent the team down from Shock Trauma down to Haiti to, you know, see if we could help out and also good stuff. And again, there wasn't really much organization to it. They were just like, we're just going to go down, we'll see if we can help and blah, blah, blah. And you know, my wife was pregnant at the time, so I couldn't go. But at the same time, I was like, man, you know, there has to be something more organized. I started like doing searches and all that good stuff. And then I kept seeing like NDMS and DMAS, which is the Disaster Medical Assistance Team, which is basically like MASH, you know, like ER departments that are like in these tents and all that good stuff. But they're really designed to help the local infrastructure. Mm-hmm. Especially with ER type stuff. Interesting enough, kept seeing the CRNA pop up, right? Like this one CRNA, I think he was out of Boston. I think his name is Mike, can't remember his name, but it was like a pediatric CRNA. And like I kept seeing these pictures, he was like in a helicopter, like, you know, bagging a little neonate, you know, dropping patients off at the USS Mercy, which is that, uh, the military hospital boat and all sort of good stuff. And I was like, oh, that's pretty cool. And that's kind of like my introduction into that system.

Mm-hmm.

Maryland actually was developing a team for itself. I was one of the first ones to kind of jump on board. Interestingly enough, when I went to go interview, one of the guys that was going to be the chief of the NDMS team was in fact one of the residents I trained when he was going through the trauma center doing airways. And so it was so funny. It was like he was an ER physician and also good stuff. And then he was like, hey, I didn't know you were here. And that's how I kind of got into the team. On the DMAT teams, there wasn't a lot for me to do as an anesthesia provider because it was mostly like, you know, ER type stuff and But they also have a surgical component to it, which is the TCCT, which is the Tactical Critical Care Team, which was initially known as MSRT. And they had like 3 teams throughout the country that could deploy and go to different places anywhere around the world or any disaster, provide exactly what I do for the GO team for the most part, critical care, surgery, anesthesia, wherever the need may be. I wound up popping on that team and then It was just interesting because like I've never turned— I try never to turn down opportunities and like things kept popping up, you know. So then they wanted to do like a, um, the Air Force has the CCAT team, which is the Critical Care Air Transport team, and they're responsible for doing a lot of the critical care transports, you know, from, you know, out of the country back into the country. Um, and our NDMS offered a partnership with the Air Force to do that course, and we were actually invited to go do that course. Now As a part of that, NDMS has a CCAT-like team, you know what I mean? And so we don't deploy it all that often, but there are plenty of pe— you know, people around the country that can be a part of that. So if they needed like critical care transport outside of the country and bring people back in, uh, we could do that as well. And interesting enough, there are many CRNAs that are part of that. And when I did the training, you know, it was trauma critical care. It was all the stuff that I do every day, you know what I mean? So it wasn't like hard, you know, hard for me. And also it was just the equipment and being in the back of the aircraft and also the good stuff. We do this, you know, most of our people on our teams, we do trauma, critical care surgery, like all the time. So like now we just take those skills and bring it to the austere environment and go anywhere, you know, in the world if you needed to. So pretty cool opportunity.

Yeah, no, that, that sounds like it. Um, Bonjo, I wanna pivot a little bit, uh, in terms of, of talking about, you spend a lot of time teaching. Mentoring, speaking on a national stage. What— why is this so important to you? I mean, you're involved in all these different things, all things trauma. But like, as we mentioned in the introduction, you're also the president of the Filipino American Nurse Anesthesiology Society as well. Why is this so important to you?

I just knew, again, like I knew the impact of like, you know, when you have that— and you've probably given a test of this— like when you had that good preceptor, that like changed your mindset and you're like, you know, you went into clinical and instead of getting bombarded with a bunch of crazy questions, somebody just taught you, you know what I mean? And they, they made it easier for you to learn or they challenged you to think in a certain way. And like, I always thought that was, to me, it was always important. My experience with shock trauma, I was like, I was like, I want to be like those guys, right? Because they were amazing teachers. They were just amazing what they did. Yeah. And again, like I said, I couldn't— I can't think of one person that didn't teach me something or wasn't value— valuable to me in that instance. And again, to me, I always feel like I'm, I'm an amalgamation of all those people, right? So I took something, each piece from some of those people, and then I made it into my own practice, you know what I mean? And so, but mentorship, I always think is really important. Again, like you said earlier, you were saying that a lot of people say, you know, some physicians say that CRNAs can't do trauma, can't do this and this. Yeah. We're the example. Like, the military is the example, right?

Yes.

We do this every day. We're really, really good. But it has to be given the opportunity, right? If you're given the opportunity, you can do that. And then part of me, early on in my career, I wasn't like lecturing or anything else, but I would go to like, conferences, and I would see people talk about it. And then I would be like, especially when I saw like a trauma lecture, I feel like I could do that. You know what I mean? Like, now, like the thing, I was like, I could do that. And then again, I have much more experience than most of the people that were doing it at the time, right? And so, you know, I gotta make people understand that they can do it. When you see somebody that's like us, like a CRNA, that are really, really good at something, you're like, then you think to yourself that I could be like that person, you know what I'm saying? Whether it's trauma critical care, regional anesthesia, POCUS, OB, pediatrics. I mean, there are so many different specialties that people can do. And again, the beauty of like being a CRNA is like You can go to any of those practices and excel, you know what I mean? And so you just have to be given the opportunity. When I talk, I want to, I want them to understand that they can do it. And I, I really truly believe in mentorship, you know what I'm saying? Like, in order for somebody to think they could be that, they have to see that person. You mentioned about the, uh, Filipino Nurse Anesthesiology Society. I'll just say FANES, right? There are not a lot of Filipino CRNAs. There are a lot of Filipino nurses out there, right? Like, but yet the proportion of people Filipinos that are actually going to anesthesia school is actually very, very small. And so it's just one of those things, we really just increase exposure.

Poncho, what, what do you hope aspiring CRNAs learn when they hear about your story at Shock Trauma, the GO Team, all these things that you're involved with?

What I want them to know is that you could do anything. More than anything else, I think that you could do anything. Again, I think we get ourselves in silos where we can't do this, we can't do that. I don't want to go outside of this experience. And again, you know, I've been in this scenery for 20 years. I still learn every day. I still love learning. You know what I mean? I still love teaching, you know what I'm saying? And there's something that I don't know, I love to figure it out. But you have to surround yourself with people that are going to make you push yourself. And I think our colleagues are pretty amazing, do so many different things. And again, there's no limit to what you can do. You just have to put yourself in a situation or in the circles that get you there. Like I said, I always think about the AANA Congress and how many people I met, or in the different conferences that I've been to where I heard somebody speak and I was like, that's pretty cool. Even for myself, I still get inspired when I go see people, you know, talk and talk about their expertise. I think we all should have something that we're really, really good at that we can teach and pass along to the next generation. My niche obviously has to be trauma anesthesia, right? I love regional anesthesia. I love austere stuff. So that, you know, that critical care, that's all my niche. But at the same time, you know, they got some great pediatric CRNA specialists out there. They got some great OB people out there. They got so many great people.

And I think, uh, Bonjo, one of the things that has been kind of coursing through my mind here throughout, you know, this episode, preparing for this episode, uh, is, is a piece of advice that I got from my, my friend and mentor, uh, Daniel King. We were talking at one of the conferences and he's like, Tyler, he's like, you know, clearly mentorship is your thing. You know, you have to find all these different avenues that go in line with that, you know? And for you, it's, you know, shock trauma and it's also ultrasound. Like all of these things work together. And when you have this kind of, when you identify what your thing is, you can supplement it in all these different ways, but that are working kind of cohesively. And I think that's something that you've certainly done within your entire career. I really genuinely appreciate you for joining us this conversation. And I really think that your career represents something that's really incredibly important for all of our aspiring CRNAs to see, in that, you know, our profession has become something bigger than what most people even imagine. Your story really shows nurse anesthetists that it isn't just about being in the operating room, but it's about your identity, about leadership, about service, and, and finding this skill set that we talked about, that, that you can really make this great impact on this profession. All right. And I really believe that this episode is gonna inspire a lot of people, especially our pre-hospital folks, our flight nurses, maybe some people that have been in the military and want that feel again. But I can't thank you for everything that you've done for our profession and continuing to mentor and show people all these different parts of anesthesia. So thank you very much for joining us here today, Bonjo, and keep teaching. Because you're, you're doing a great job out there. And I've talked to many mentees that are part of that Filipino Association. They, you know, they absolutely love it. So keep doing what you're doing, my friend.

I appreciate you, Tyler. Thanks for— and again, thank you for your platform. Again, I think it's amazing, you know, you know, introducing a whole new group of people to becoming a CRNA and all the wonderful things that are associated with it. So can't thank you enough.

Likewise. Take care, Bonjo. Take care.

Thank you, Tyler.