MTSA’s latest issue of the Airways newsletter features a synopsis of the scholarly work of graduate and Acute Surgical Pain Management fellow Michelle Stotts (right), DNAP, CRNA. Future opportunities for Continuing Education focused on this and other topics will appear in upcoming issues of Airways upon CE credit approval from the AANA.

“I’ve developed a passion for education and am eager to share the knowledge obtained through MTSA with SRNAs and my CRNA colleagues.” —Michelle Stotts, Class of 2021

TITLE: Ultrasound-Guided Fascial Plane Blocks for Acute Rib Fracture Pain in a Level IV Trauma Center: A Literature Review and Introduction of an Evidence-based Analgesia Algorithm for Uncomplicated Rib Fractures

AUTHORS: Michelle Stotts, DNAP, CRNA; Hallie Evans, DNP, CRNA, APRN; Christian Falyar, DNAP, CRNA; Bill Johnson, DNAP, CRNA.

SYNOPSIS: Effective pain management reduces the incidence of respiratory complications in rib fracture patients. The incorporation of ultrasound into regional anesthesia has led to newer fascial plane blocks of the chest wall that can be used as part of a multimodal pain management plan. While current systematic reviews focus on indications and efficacy of fascial plane blocks compared to placebo, there is little research comparing them to traditional methods of regional analgesia for rib fracture pain. A literature review was conducted comparing ultrasound-guided erector spinae or serratus anterior fascial plane blocks to thoracic epidural or paravertebral blocks for the treatment of acute chest wall pain to support development of a rib fracture analgesia algorithm. Overall, studies comparing the fascial plane and traditional regional analgesia groups found comparable analgesia, opioid consumption and improved respiratory function in thoracic surgery and rib fracture patients. Development of an evidence-based multimodal analgesic algorithm incorporating ultrasound-guided fascial plane blocks to guide the management of acute rib fracture pain provides additional regional pain management options. This has implications for rural and small community facilities where traditional regional interventions may not be feasible.

ABOUT THE AUTHORS

Michelle Stotts, DNAP, CRNA, is a nurse anesthetist at Roane General Hospital, a Level IV Trauma Center and Critical Access Hospital (CAH), in Spencer, WV. She is a graduate of CAMC’s School of Nurse Anesthesia with a Masters in Healthcare Administration from Marshall University in 2002. The author was a student in the Doctorate of Nurse Anesthesia Practice Completion Program at Middle Tennessee School of Anesthesia at the time this article was written.

Hallie Evans, DNP, CRNA, APRN, is an Associate Professor at MTSA.

Christian Falyar, DNAP, CRNA, is an Assistant Professor and Assistant Director of the Duke University Nurse Anesthesia Program in Durham, NC.

Bill Johnson, DNAP, CRNA, is the Director of the Acute Surgical Pain Management Fellowship at MTSA.

MTSA has welcomed three new trustees to its Board.

Kenneth Holroyd, MD, MBA, is Medical Director for the Center for Technology Transfer and Commercialization at Vanderbilt University and Vanderbilt University Medical Center, and also holds appointments as Associate Professor of Anesthesiology and Medicine. Joining Vanderbilt University in 2005, Ken is on the Board of Directors of Cumberland Emerging Technologies and The Human Vaccines Project, while previously serving on the Board of Directors of the Tennessee Technology Development Corporation, Informatics Corporation of America (ICA), Acuitec, digiChart, and Friends in Global Health. He is past Co-Chair of the Public-Private Partnership Committee of the National Institutes of Health’s Clinical and Translational Science Award (CTSA) Program. At Vanderbilt, his clinical practice of medicine is in Anesthesiology. Ken was in the biopharmaceutical industry for seven years, at Magainin Pharmaceuticals and Genaera Corporation, where he was Executive Vice President and Chief Operating Officer. Previously he was a faculty member at the University of Pennsylvania and at Johns Hopkins University, where his research interests included the genetics and molecular biology of asthma. Ken received his residency training in internal medicine and in anesthesiology at Johns Hopkins Hospital and University, and in pulmonary medicine at the National Institutes of Health. Johns Hopkins University awarded him the M.D. degree in 1984.

Nicholas Howald is Chief Operating Officer at TriStar Skyline Medical Center. He came to TriStar Skyline from sister facility TriStar Hendersonville Medical Center in Hendersonville, where he served as COO for two years. He oversees operations at the 278-bed hospital and related care areas serving communities in and around Middle Tennessee and Southern Kentucky. Nick has seven years of increasing responsibility with HCA, starting as an administrative intern at TriStar StoneCrest Medical Center, then as an administrative resident and later as associate administrator at TriStar Centennial Medical Center. He also spent a period of time serving as the interim executive for the TriStar Transfer Center. Nick is originally from Iowa and earned his Bachelors of Arts, Masters in Health Administration and Policy, and Masters in Business Administration from the University of Iowa. In Hendersonville, he has served on the board of the Chamber of Commerce in Hendersonville and graduated from Leadership Sumner. Nick and his wife, Rachel, live in Hendersonville.

Paul Mazzoni, MD, is Managing Partner at Cardiovascular Anesthesiologists (CVA). Originally from New York City, he attended Tulane University for both undergrad and medical school. His anesthesiology residency and cardiac fellowship were done at Maine Medical Center in Portland. He began his career at Cardiovascular Anesthesiology PC at Saint Thomas Hospital in Nashville in 1984 and has been practicing there ever since. In his current practice he performs anesthesia for cardiac, neurosurgical and general cases about one third of the time each. He continues to keep a full clinical load and has been the managing partner of the group for the past 17 years, responsible for business operations.

MTSA is offering an Advanced Cadaveric Ultrasound-Guided Regional Anesthesia workshop for CRNAs on Oct. 17. Participants receive the benefits of small-group “live” scanning and needling stations, low faculty-to-attendee ratios, and an individualized learning plan that suits the attendee’s needs in regional anesthesia, according to Bill Johnson, DNAP, CRNA, Director of the MTSA Acute Surgical Pain Management Fellowship and DNAP Completion program. Information presented is highly practical and immediately useful to the attendee’s daily clinical practice.

Johnson said that the following blocks will be taught and demonstrated: PECs I/II, erector spinae, infraclavicular, serratus anterior, costoclavicular, RAPTIR, quadratus lumborum, TAP (iliohypogastric/ilioinguinal, transversalis, and posterior TAP), suprascapular (anterior and posterior approaches), and paravertebral nerve blocks. Advanced approaches to upper and lower extremity will also be taught, to include axillary at the circumflex artery, distal upper/lower USGRA blocks, and anterior sciatic.

Instructors for the daylong workshop include Johnson; Stace Dollar, MS, CRNA; John M. Edwards, III, MS, CRNA; Kelly Martin, MS, CRNA; and MTSA Acute Surgical Pain Management Fellows.

Participants can earn up to 16 Class A CE credits by completing the pre-course content and the course content combined. In addition, the AANA designates this program as meeting the criteria for up to 2 CE Credits in pharmacology/therapeutics.

Registration is available at www.mtsa.edu/workshops. For more information contact Bill Johnson at (615) 732-7846, bill.johnson@mtsa.edu.

Participants in MTSA’s Acute Surgical Pain Management (ASPM) Fellowship will soon have access to a new state-of-the-art clinical site in Mt. Shasta, Calif., focused on transitional pain services, according to Bill Johnson, CRNA, DNAP, Director, ASPM Fellowship and Doctorate Completion Program.

MTSA graduate Jon Wilton (right) is director of anesthesia and chronic pain at Mercy Medical Center Mt. Shasta. His practice focuses on opioid-free interventions for chronic pain management. Wilton has joined MTSA in a special role as a clinical mentor and will help develop curriculum based on the growing area known as “transitional pain,” which includes a wide variety of preoperative interventions to minimize pain while a patient awaits surgery. It also includes caring for patients who transition to chronic pain.

“Jon operates one of the most cutting-edge anesthesia departments anywhere in the country,” Johnson said. “They’ve moved to a transitional pain service model where patients come in up to six weeks before their surgery, and they are able to provide long-acting regional blocks, which allow the patient to manage their pain without using narcotics. Then during surgery, they perform the conventional blocks that we teach in the Fellowship, followed by post-operative pain management.”

Johnson said that the Fellowship curriculum will begin to reflect the growing shift into transitional pain management, led by Wilton’s expertise. A few examples include preoperative cryoanalgesia for shoulders, knees, and intercostal nerves; pulsed or continuous radiofrequency neuromodulation for the shoulder, hip, and knees; and greater and third occipital nerve blocks and musculoskeletal injections, among other therapies.

“When we examine acute versus chronic pain, it’s really more of a continuum,” Wilton said. “There are plenty of patients, up to 85 percent depending on the procedure, who have surgery and end up with chronic pain. A transitional pain service helps remove the divide between chronic and acute. We’re identifying patients who are at risk before surgery and taking special precautions to make sure that their pain is treated adequately.”

According to Johnson, Wilton’s role as a clinical mentor for MTSA places him at the highest tier of knowledge and experience in nurse anesthesia, as evidenced by his use of innovative techniques and publishing original research articles. In addition, he has developed one of the largest online groups for ultrasound-guided regional anesthesia, with more than 6,000 global members sharing information and best practices.

“Because state regulations don’t allow the use of fluoroscopy, Jon employs an extremely innovative procedures for chronic pain management using ultrasound exclusively, which is practically unheard of. In addition, he has expanded the utilization of certain equipment which has pushed manufacturers such as Avanos and Iovera to recognize the application of their products in nurse anesthesia, adding CRNAs to their provider list. This includes both freezing and applying heat to nerves to prevent them from transmitting pain for a long period of time,” Johnson said.

According to Johnson, as the transitional pain curriculum is added to the Fellowship, the initial focus will be on long-term pain management for shoulder and knee patients, then expanded into other specialties.

“Jon’s involvement at MTSA will have huge benefits to our Fellows and, by extension, patient care in a variety of settings. It will boost the innovation and clinical experiences of our Fellows and provide exciting new opportunities for our profession,” Johnson added.

JOIN THE FELLOWSHIP
Now Enrolling

From medical management approaches, such as multimodal therapies and opioid sparing strategies, to advanced interventional techniques, including continuous catheter utilization, the ASPM Fellowship enables CRNAs to acquire the knowledge to treat patients with confidence and skill.

The Fellowship curriculum includes special focus on perioperative point-of-care ultrasound (PoCUS), which is the use of portable ultrasonography at a patient’s bedside for diagnostic and therapeutic purposes. Along with its use for pain management, heart, lung and abdominal ultrasound scanning may reveal sources of hypotension, hypoxemia and other presentations of cardiopulmonary instability.

In addition, fees for the basic and advanced Regional Cadaveric Workshops are waived during the Fellowship enrollment period for any applicants who have met all the admission requirements.

Application period closes Nov. 1. For more information about the ASPM Fellowship, visit www.mtsa.edu/fellowship.

MTSA has begun the process of upgrading its online modules for the Acute Surgical Pain Management (ASPM) Fellowship, making two strategic hires to help manage the improvements.

Michael Morgan, MA, Instructional Design Specialist

Deirdre Williams, BS, LMS & IT Support Specialist

Michael Morgan, MA, Instructional Design Specialist, and Deirdre Williams, BS, LMS & IT Support Specialist, are coordinating the efforts under the direction of Bill Johnson, DNAP, CRNA, Director of the Fellowship and DNAP Completion program.

“We originally built the Fellowship using content from 31 different faculty who had their own way of presenting the material,” Johnson said. “In order to provide more consistency, we’re overhauling our online modules to conform to a single template. All the content will be packaged into SCORMs (shareable content object reference models), which allow learners to navigate along a fixed set of paths through the material.”

“I’m taking existing course content and making it more interactive. So instead of clicking through a PowerPoint slide, there will be widgets and graphics that display animated information and clickable tabs to display text and images,” said Morgan, whose background includes instructional design and teaching experience at the University of Tennessee and Georgia State University, as well developing courses for corporations such as Verizon.

According to Johnson, other Fellowship content will be streamlined into smaller segments. For example, instead of watching an hour-long video, modules will allow students to navigate through different sections of the lessons at their own pace. In addition, students will have access to written transcripts of the lectures, and all the videos will have closed captioning so viewers can mute the audio and read the closed captioning as it’s being presented.

Further enhancements include knowledge checks and interactive learning assessments that students will do throughout the module, which also helps to break up the lecture. This helps reiterate what they’re learning with a series of questions, improving their knowledge retention, Johnson said.

“This process will take at least a year to fully complete, but we’re aiming to launch some of the new modules this fall with the new Fellowship cohort,” Johnson said, adding that MTSA’s goal is to transition all of its continuing education offerings to this interactive online approach, followed by the DNAP Completion program.

“I really enjoy this content because I know it’s meaningful, and it helps CRNAs become better at their profession, which helps patients with pain management. And the process of working with Bill and the team has been very constructive,” Morgan said.

Many dedicated, hard-working individuals leave their imprint on a profession, but few are deserving enough to have both a scholarship and an award established in their honor. MTSA alumna Patty Cornwell (’72) is one of the deserving ones.

Cornwell, a retired CRNA, devoted her professional career to providing exceptional anesthesia care to patients for surgery, labor and delivery, and other surgical procedures, and she devoted her spare time to serving the nurse anesthesia profession she loved. After graduating from MTSA, she joined the AANA in 1972 and the Tennessee Association of Nurse Anesthetists (TANA) in 1976. Throughout her decades of membership, she served on dozens of committees and became passionate about advocating for her profession at the local, state and national levels.

In return, Cornwell is being honored by TANA and AANA with the creation of the Patty Cornwell Stewardship and Advocacy Scholarship, to be awarded annually to a student nurse anesthetist enrolled in one of Tennessee’s nurse anesthesia educational programs. The first scholarship will be awarded this spring. This follows the establishment in 2015 of the Patty Cornwell Practitioner of the Year Award, given annually by TANA to a Tennessee CRNA in recognition of Cornwell’s exemplary career as a clinician.

“Throughout her career, Patty was a shining example for all nurse anesthetists on how to provide high-quality, compassionate, patient-centered care,” said MTSA Chairman of the Board of Trustees and TANA President Vic Martin, MBA, CRNA. “As a dedicated association member, Patty worked tirelessly to strengthen TANA and to advance and protect nurse anesthesia practice. She truly has been a difference-maker for our profession.”

“When I was pursuing my degree, my focus was always to just get through school and get a job,” said Cornwell. “I knew nothing about the work of the AANA or state associations at the time. After graduation, I went to work in Florida. That’s where two of my colleagues took me to a state meeting for the first time and got me interested in becoming an active member.”

After returning home to Tennessee, Cornwell went on to serve on every single TANA committee – including as president three times – and was the organization’s executive director, lobbyist, and federal political director at various points during her career. She also served in various capacities for the AANA, the national association representing the nation’s nearly 60,000 nurse anesthetists. Much of Cornwell’s work focused on ensuring CRNAs’ ability to practice to the full scope of their education, training, certification and licensure.

Cornwell emphasizes to new CRNAs that how they introduce themselves to their patients can help raise awareness of the profession.

“Make sure your patients know exactly who you are,” she advises. “I always told my patients: ‘I am a Certified Registered Nurse Anesthetist, and I will be providing your anesthesia today.’ I left no question or doubt.”

“I always encourage CRNAs and students to get involved in their state association and be as knowledgeable as possible about what is going on around them that can impact their profession and career,” she continued. “It’s important to pay attention and keep your eyes and ears open at all times.”

Source: Tennessee Association of Nurse Anesthetists

MTSA has launched Neuraxiom.com, a revamped website of practical resources to help anesthesia providers learn ultrasound for regional nerve blocks, announced Bill Johnson, DNAP, CRNA, Director of the MTSA Acute Surgical Pain Management Fellowship and DNAP Completion program.

Originally created by Jack Vander Beek, Neuraxiom.com is now owned and authored by MTSA and includes free content as well as opportunities for special access to fee-based continuing education modules. The site also features interactive anatomy illustrations and a range of content on subjects such as ultrasound, pharmacologic agents and local anesthetics.

In addition, Neuraxiom.com enables CRNAs to participate in continuing education, including current information on acute pain management with options to take a quiz and receive AANA credit.

Vander Beek developed the Neuraxiom textbook and website by documenting and illustrating a compendium of Ultrasound-Guided Regional Anesthesia (USGRA) techniques that have been successfully adopted by a countless number of regionalists over the years. It applies an evidence-based approach in updating the vast amount of knowledge that has been published in USGRA in the last decade.

For more information, visit neuraxiom.com.

U.S. Army Major Robert Fabich, DNP, CRNA, was the 2020 recipient of the Acute Surgical Pain Management (ASPM) Fellowship “Outstanding Achievement Award,” presented at Middle Tennessee School of Anesthesia’s Commencement ceremony in December.

Fabich currently serves as the Chief of Anesthesia at Bassett Army Community Hospital at Fort Wainwright in Fairbanks, Alaska. Prior to that, he was part of 102nd Forward Surgical Team deployed to Syria, supporting U.S. troops on their final push against ISIS.

“Robert has done some outstanding work in the field of acute surgical pain management,” said Bill Johnson, DNAP, CRNA, Director of the Fellowship and DNAP Completion program, during the award presentation. “During his deployment, he participated in more than 600 trauma cases, making him the busiest deployed anesthesia provider in the combat theater.”

Fabich began the MTSA Fellowship in 2018 but had to leave the program for his deployment. After returning to the U.S., he re-enrolled in the Fellowship and completed the program in 2020.

“Robert has presented internationally on topics of acute pain management. He most recently presented at the World Congress of Nurse Anesthetists in Glasgow, Scotland, while enrolled in the Fellowship. His military decorations include the Meritorious Service Medal, Army Commendation Medal with a Combat Device, and Expert Field Medical Badge. He supports the local community in Fairbanks by volunteering with the local fire department as an EMT and a firefighter,” Johnson said.

Fabich used his war-time experience to publish three case studies, with the help of several colleagues, that were circulated in the journal Military Medicine:

• A Novel Use of the Erector Spinae Block in the Austere Environment (co-authors: Sharrod Greene, DNP, CRNA; Currie Tighe, BSN, RN; Rebekah Devasahayam, MD; and Tyson Becker, MD, FACS)
• Definitive Management of a Traumatic Airway: Case Report (co-authors: Benjamin T. Franklin, MD, and Nicholas Langan, MD)
• Rare Use of Posterolateral Thoracotomy in an Austere Environment (co-authors: Rebekah J. Devasahayam, MD; Currie A Tighe, BSN; and Tyson E. Becker, MD)

“There’s no other program that’s as cutting-edge when it comes to acute surgical pain management and ultrasound-guided regional anesthesia as MTSA’s program. It’s above and beyond anything I experienced in my initial CRNA education. Dr. Bill Johnson does an amazing job with the amount of content that has gone into the program. As a bonus you have the opportunity to learn and interact with some of the heavyweights of regional anesthesia in our profession,” Fabich said.

“I’d like to thank Fellowship faculty such as Bill Johnson, John Edwards, Dan Nash, Stace Dollar, Patrick Myer and others. Each one of them taught me something that I’ve been able to apply in my practice or teach to another colleague. Because of the instruction they gave me, they’ve affected the lives of service members across the United States and the world,” Fabich added.

Prior to joining the Army, Fabich received his BSN from the Military College of Vermont Norwich University, He was accepted into the United States Army Graduate Program in Anesthesia Nursing (USAGPAN), and earned his DNP from Northeastern University. A native of Bedford, N.H., he is married to his wife Rebecca of 11 years.

About the Outstanding Achievement Award

Recipients are selected by MTSA and the American Association of Nurse Anesthetists (AANA) to receive the Outstanding Achievement Award, which includes a $1,000 cash prize. The award is based on a Fellow’s ability to:

• contribute to the clinical expertise and scholarship in acute pain management;
• advance the scope of nurse anesthesia practice;
• develop innovative acute surgical pain management approaches that contribute to safe and effective patient care;
• inspire other nurse anesthesia providers in the profession;
• interact collegially with all health care providers to positively impact the image of nurse anesthesia; and
• participate in community affairs, legislation and organizations that affect and advance nurse anesthesia practice.