#127 – The use of TEG 6s in Trauma Resuscitation – Nathan Bowser

My guest today is Nathan Bowser, a 3rd Doctor of Nursing Practice resident in the University of Arizona‘s nurse anesthesia program. Nathan is the lead author on a paper published in the August 2026 edition of the AANA Journal titled “Use of Thromboelastography 6s in Trauma: An Integrative Review for Anesthesia Providers.” In this article Nathan and his co-authors outline the literature pertinent to Haemonetic’s new TEG 6s device, which presents substantial advances over their older TEG 5000 device. This new device is one of several in the market that bring thromboelastography to the point of care, which has significant implications for improving targeted transfusion during trauma resuscitation. Nathan and I walk through the clinical context of trauma resuscitation, in which up to 30% of severely injured patients arrive to the hospital in a trauma-induced coagulopathy (TIC). He then walks us through how having a cartridge-based point of care TEG device can speed time to transfusing the products your patient actually needs. The device is also useful for reducing the total number of blood products delivered and helping clinicians know when to slow down or even stop transfusion. At the end of the show, we talk a bit about Nathan’s process and motivation as a DNP resident to push his doctoral project through to submitting for publication and then producing this podcast. If you’re in to trauma resuscitation, blood product management or curious about how to find topics for and structure your DNP or residency project, this is a great show for you. Huge shout out to Nathan Bowser for putting the work in and to Dr Kristie Hoch, the program director at the University of Arizona’s nurse anesthesiology program for connecting Nathan and me. If you’re a critical care RN considering anesthesia training, definitely take a look at the University of Arizona’s program – Dr Hoch has been at the helm for years and has been working hard to develop the program and support her doctoral students. In other news, our CRNA team at MaineHealth just got back from the AANA Annual Congress in Boston a few weeks ago. We were thrilled to see a bunch of old friends and to meet the future of our profession in all of the nurse anesthesiology trainees and critical care nurses at the conference. I’m also looking forward to a seeing some of you at Encore Symposium’s fall conference in Bar Harbor, Maine in October and then in O’ahu, Hawaii in November. I’ve committed to join Encore again next October back at the Cliff House so if you’re looking for a 2027 conference to attend, scope out the scene with Encore Symposium’s conference at the Cliff House in Maine next October. And with that, let’s get to the show! Resources from Nathan: General review of Viscoelastic devices- https://pmc.ncbi.nlm.nih.gov/articles/PMC9903681 Thromboelastography on fixed wing- https://pmc.ncbi.nlm.nih.gov/articles/PMC11272443 Fibrinolytic shutdown- https://journals.lww.com/journalacs/abstract/2024/07000/differentiating_pathologic_from_physiologic.5.aspx https://journals.lww.com/journalacs/abstract/2017/04000/persistent_fibrinolysis_shutdown_is_associated.34.aspx https://pmc.ncbi.nlm.nih.gov/articles/PMC4443855 https://journals.lww.com/journalacs/abstract/2016/04000/acute_fibrinolysis_shutdown_after_injury_occurs.2.aspx Cell-based Model for Hemostasis The Cell-Based Model of Coagulation

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

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

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

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

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

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

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

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

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