Erik Kramer CRNA FNP Mission Trips Mexico, Mosul and The Congo

Episode Transcript
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Mike MacKinnon (00:28):
Hello everybody and welcome back to anesthesia
deconstructed episode numbertwo.
My name is Mike MacKinnon.
I am your host.
On this episode we've got EricKramer and FNP and CRNA who has
done multiple medical missionsalong with disaster response
team.
Welcome to the show, Eric.
Awesome to have you here.

Eric Kramer (00:47):
Hey, thanks for having me man.

Yeah, it is great to have you here.
I'm really excited to hear aboutall the different stuff you've
been doing.
I know I I've been following youon Facebook and your trips both
to Mexico as well as otherplaces and, there's been some
amazing skillsets and reallyphenomenal medical care that
you're providing in places whereotherwise t here would be none.

Yeah, sure.
First of all, we go farther backthan Facebook.
I got to say real quick, back tothe old nurse-anesthesia.org
website.
So, I mean, we're talking anold,

I know it's been a long time.

As far as missions go.
Yeah.
I just moved back from Mexico.
I've lived there the past fiveyears.
I worked for a littleorganization called Mexico
medical missions and we workedwith an indigenous tribe called
the, Tarahumara Indian.
And I did anesthesia and a wholebunch of other stuff for the
admissions hospital down there.

Oh, that's amazing.
And how did you get hooked upwith that group?

So, I mean, I grew up kind of in Latin America.
My folks worked for habitat forhumanity for years.
So my sister was born in Peruand stuff like that.
And then I went to like aMexican public school for a few
years, and then we moved back tothe States.
I went to college but, myparents moved back and my mom
started linguistic work withRalámuli.
She's like one of the world'sleading experts on the

(02:02):
Tarahumara language(Ralámuli).
That's their, that's their wordfor themselves Tarahumara.
The people who run, they'refamous for their long distance
running.
Before I got into anesthesiaschool, I was just kinda trying
to figure out what I wanted todo with my life.
And I realized I, I went downand visited them and I realized
that there's a huge need foranesthesia down there.
They, this little missionhospital, h ad started i n,

(02:24):
there was no, anesthesia.
There was an orthopedic surgeonthat was just trying to do
everything under basically localor bier block.
Um, and that was kind of theKickstarter to get me going into
anesthesia.
So I went to anesthesia schoolfully intending to move down to
Mexico and we paid off our debt.
A couple of years after Igraduated, I sought out a job

(02:47):
that was specifically going togive me the skillset that I
needed to work independentlybecause I was by myself down
there.
I was the only anesthetist.
And so I got a job at a smalllittle rural hospital, which I
feel is the secret gem of theanesthesia world, right?
These small little places thatare all over the place, that are
run by nurse anesthesiologist.
And there I learned how to doregional anesthesia.

(03:09):
I learned it.
It was a great span from, fromvery simple cases, orthopedics,
all the way up to open hearts.
So I got a little taste ofeverything and it really
prepared me well for headingdown South to Mexico.

That's amazing.
And, and so when you went downto Mexico, you brought your
whole family with you.

That's correct.
Yeah.
I have a wife and two kids.
We immediately, after graduatingI took boards.
December, 2011.
Uh, no, I'm sorry.
December, 2010 I went and did myfirst mission trip down in
Mexico a few days later bymyself.
My first anesthetic as a CRNAwere delivered by myself.

(03:48):
And that's what I really kindadecided, Oh man, I really need
to start doing this long term.
So my wife and my kids and Istarted coming down with all our
vacation time.
Every time we had a vacation, wecome down and do a missions trip
down to Mexico.
And I just do the anesthesiathere at the little mission
hospital.
Kind of trying to figure outwhether or not it's what we were
supposed to do or not.
We're Christian.

(04:08):
So, you know, we spent a lot oftime praying about it and stuff
like that.
And finally, after a few yearswe decided we were supposed to
do that yet.
And I'm someone that I didn'twant to drag my wife along with
me.
You know what I mean?
That's never a good idea.
So she had to kind ofindependently come to the
decision, that's where we weresupposed to do.
So it took us a few years to getthere.

And is your wife a, is your wife medical as well?
Did she assist while she wasdown there?

My wife is a math and science teacher and so part
of her job, she had to, I mean,when you're down there in that
environment, you do a wholebunch of things.
But one of the things you didwas tutor kids, uh, other
missionaries.

Amazing.
So both of you basically wereinvolved in the service industry
, in servicing humanity,basically in Mexico and did,
your kids get involved as well?

My kids went to the Mexican public school down
there.
The Mexican public schoolsreally rural.
A lot of the kids when theyfirst entered the Mexican public
school system don't even speakSpanish.
They just speak that Ralámulithe language.
And um, my daughter started infirst grade and went up through
fifth grade and the Mexicanpublic school, my son's starting
kindergarten and I believe wentup to third grade and they just

(05:16):
kinda, they spent most of theirtime if they weren't at school,
we lived on the hospitalcompound so they would just run
around on the hospital compound,you know, outside our house and
play with other kids.

And you felt, uh , felt relatively safe down
there with your family?

It's safe.
I mean, this is a part thatoverdramatized a lot.
It was opium and marijuanagrowing territory for the
Sinaloa cartel that the Sinaloaguy open carried in our town.
They were the police of ourtown.
You just see them walking aroundwith their AKs, but they left us

(05:51):
alone.
At first.
It was pretty disconcerting.
I remember the first time Idrove into town with a team for
my church, we'd come down tohelp us, help us finish building
our house.
We drove into town and thecartel guy didn't know who we
were and didn't recognize theirtrucks.
So they all poured out of their,their house with their guns
aimed at us until I turned thattruck sideways to like show them

(06:14):
the Mexico medical sticker.
But once they got to know us, itwasn't a big deal.
Um, they tended to wave usthrough checkpoints and stuff
like that, you know, becauseanywhere associated with the
hospital and we're kind of aneutral party and all of that.

All right.
And so basically you'd be takingcare of them and their family
just as you would anyone else inthe town, right?

Yeah, absolutely.
I mean, part of it is becauseit's out of necessity.
It's the politics of the thing.
Right.
You know, um, it, because itprovides, you know, it allows us
to operate there and the otherpeople.
And then the other part ishonestly, because I think that's
what Christians are supposed todo.
One of my favorite verses.

(06:55):
This is one I found when I wasin Mosul in Iraq on a bomb
shelter with samaritan's pursethat inside the bomb shelter,
people that turned it into likea little devotion area and um,
someone had written on the wallpray for ISIS and they said a
diverse really struck me.
I'd heard it a lot of timesbefore, but it really hit me
there.
It said, you've heard it saidyou shall love your neighbor and

(07:18):
hate your enemy.
But I say to you, love yourenemies and pray for those who
persecute you.
And if I can just get on asoapbox for a second, I think
love is an active thing thatneeds to take action, right?
So if we just focus on servingand helping the people that we
think are easy to serve, like,you know, indigenous people or
something like that, then reallywe're no different than anyone

(07:40):
else.
But the way people really startto change a culture is by
serving and loving the peoplethat are hard to serve in love.
Therefore the cartel people thatare there, right?
Cause if we just treat them likebad people that they are, then
we're essentially reinforcingtheir own opinions and work.
We're contributing to the wholecycle of thing.
We're bandaging them up so theycan go out there and rape and

(08:02):
kill and hurt people all overand over again.
It's this vicious cycle.
But, um, I don't know if thatmakes any sense or not, but
that's one of the deep corereasons of why we were down
there.

No, it totally makes sense.
I mean I think that's an, anamazing sentiment that a lot of
people can learn from.
The fact of the matter is, is ifyou continue to treat people as
if they're evil, they willcontinue to be evil.
You'll push the more down thatpath.
And, um, by accepting them andtaking care of them and trying
to show them a better way, youknow, whatever religious beliefs
you have or however you youidentify with faith or, or

(08:36):
morals and ethics, I think, Ithink that only pushes them in
the right direction, don't youthink?

Yeah, absolutely.
It's kind of, it's a fundamentalhuman idea.
I think that extends beyond,like you said, religious
boundaries in the sense that,you know, like violence begets
more violence.
But when you confront violencewith love or something different
that's really radical andthey've never seen before, and
that often causes people topause and think and go, wait,

(09:03):
what is going on here?
Why is this so different thananything I've ever experienced
in my life?
You know, because you see in thetowns there, those little
villages, it's superimpoverished.
Everybody's just completelydestitute.
You know, everyone's living juston what they can grow and the,
the ultimate occupation outthere, the occupation with all
the money, glory, fame, four byfour trucks, everything is to be

(09:27):
a cartel foot soldier.
sicario, you know, so like theydon't have anything else to live
for out there.
And it makes it tough becauselike there's no other
alternative.
And when, when this, the sicariolifestyle is promoted as like
this awesome thing, you end upgetting into this whole horrible
cycle of violence and peoplegrowing up and perpetuating the

(09:48):
same violence that they stoppedperpetuated on their own
families and stuff like that.
It just really kind of adifficult thing but yet the same
just solution in my mind hasnever been more violent.
You know, the solution is toinject something different into
that whole, uh, dynamic to tryto change it.
Uh, not through hurting people,but trying to help them, if that

(10:11):
makes any sense.

I think that's a phenomenal insight.
I also think that just what yousaid there echoes in America.
I mean, you know, in areas thatare economically impoverished,
you know, people wonder whysomeone ends up selling drugs.
Well, it's because all that'sall they ever know is the only
opportunity they have.
It's their future whetherthey've decided on it or not.
Sure.
And unless you show themsomething else and help them

(10:33):
along the way, they're nevergoing to get into that vicious
cycle.
Totally accurate.
I mean, totally agree.
Yeah, I totally believe it.
And so when you're down thereand bring in your family and you
go down, did you feel like, so Iwent on a mission trip with Juan
Quintana to Columbia, and when Iwas down there, there was an
absolute feeling of gratitude,uh, from the town.

(10:55):
And they were clearly not onlyhappy but elated that people
would come from somewhere elseto assist them, which would be
cared they would otherwise notreceive, couldn't afford to
receive, or had no ability toreceive.
Did you feel that as well?

Uh, I'm going to be totally honest.
No.
And that has part to do with theparticular people group.
We were serving the Tarahumara.
They're super reserved anddistrusting and isolated,
isolated from Mexico, from evenother, uh, communities with
their own people group.

(11:30):
And that for a lot of reasons,they're one of the only
indigenous tribe that, uh, wasnot conquered by the Aztecs.
They just fled to the mountainsand Hid.
Um, it's one of the reasons why,even though they're like only
eight hours from El Paso, barelyanyone speaks Spanish in their
tribe or, um, not many peoplefrom the outside are able to

(11:52):
speak the language.
They're just incredibly isolatedand they don't trust outsiders.
They don't trust, um, they don'ttrust Americans.
They have this story in theirbelief system where they say
that God and Satan ran a footrace and, uh, whoever won the
foot race, uh, was gonna win aprize.

(12:15):
And I'm butchering this storycause it's been a couple of
years since I've heard it, butbasically the white man won the
foot race.
So their prize was to dominatethe Tarahumara and, and, and the
Tarahumara, w ere going to besubjugated.
So long story short, there'sbeen this long history, i t w
ith the Tarahumara people ofbeing abused and taken advantage

(12:36):
of.
And, and part of that is becausethe cartel thing, b ut it goes
way back beyond that.
And so when we went out there, uh, they don't trust us.
They don't trust the medicinewe're providing.
They don't trust anything aboutus.
So it's really a l ongtermrelationship building thing.
I never really saw much of thegratitude that I would see, say
I went on a Guatemala missionstrip or something like that

(12:58):
where people are more open andbasically used to seeing
outsiders.

Yeah.
So even after five years ofservice, you really didn't,
didn't feel that.
I mean you obviously know their,you know, they have gratitude
for the fact that you're doingthese things for their kids,
their family.
But it didn't come across inthat same way.

Yeah.
Not generally.
I mean there's individualinstances, you know, but
generally speaking, they're justa very reserved people group and
in front of the things thatactually respect about them.
The other thing I'll say is, uh,that about like feeling, um,
gratitude or whatever is thatthere's a difference between a
short term trip and what we didfor five years.

(13:35):
You just, it ends up being along grind.
And one of the reasons weactually left was because I was
working 120 hours a week invarious different capacities
that was running thetuberculosis clinic.
At some point I was the stand inmedical director, I was the head
of nursing, I was doing thecritical care flight stuff.
I was doing emergency room andhospitalist coverage as the
nurse practitioner, you know, onand on and on.

(13:57):
And there's no imagine doing allthose jobs in the state, you
know, and for a hospital andworking 120 140 hours a week and
it's not that gratifying.
And so it was not thatgratifying in Mexico either, if
that makes any sense, like it'stough.
You have to find that work lifebalance.
So it's probably not what youwant to hear when you're talking

(14:19):
to someone about missions andthat kind of thing.
But it's the honest truth it,you know, whether you're in
Mexico or in the United States,finding that work life balance
and being able to figure outwhat your boundaries are.
Super important.

Well, I think you made a very important point
there in that it's not likegoing for two weeks to Columbia
like I did or to Guatemala or toany other place.
This is, this is moving there.
This is your whole life isthere.
It then becomes your job.
It's very different.
I, I can definitely see how thatwould, would differ, especially
over time because the grindwould get to you.

Yeah.
Five years.
Yeah, you can, you can, you canhold up, you know, with the
intense pace of a short termcondition, super intense pace,
working all day.
You can do that for a couple ofweeks, you know, but if that was
what you did for 24, seven, it,it does get, you know, they'll
get pretty tough after awhile.

And while you were there, was there, were you
compensated in any way for allthis, all these hours?
All this time?

No, no, no.
Yeah, no.
We, uh, we took donations, butyou know, to be really, uh, as
diligent as we could witheveryone's donations, we didn't
use it as a, to pay for our ownexpenses outside of like a gas.
And, electricity.
We would, uh, use that to buymedications and upgrade stuff at

(15:39):
the hospital.
What I would do is every, everynine, 10 months or so, I come
back to the U S and I'd would dolocums anesthesia for a couple
months to earn our, our, uh,money so we could live down
there for the next year.

So, you know, at the risk of embarrassing you
basically, you did it in anentirely altruistic manner to
help people for the rightreasons.

I, yeah, I, yeah, I guess

you're like a one percenter.

Yeah Dude, I know we're coming from different
backgrounds religiously, but Ideeply believe that Jesus taught
some hard things, and not a lotof people want to do those
things, you know what I mean?
Like serve people.

Absolutely.
You're trying to walk in hisfootsteps, basically.

Yeah.
Yeah.
And, and it's, it's hard, man.
You know, I believe that whenwe're talking about who is your
neighbor?
I believe in the 21st century,our neighbors can be
international neighbors, youknow?
Right.

It's a global community at this point.
Yeah.

Yeah.
It's a global community.
Yeah.

That's amazing.
So, moving back to where, whereyou were in the hospital, about
how large was this facility andhow many beds, like what kind of
services did they provide andwhat kind of providers were
available?

Sure.
So there was 27 beds ish.
I'm ballparking that number.
We had a men's ward, a women'sward, and a pediatric ward.
Additionally, while I was downthere, like in the first year
two, we opened up in ICU, just asingle bed ICU.
But basically all that was, wasa separate room where we put
either really sick CD patientsor, uh, we would roll in one of

(17:14):
my anesthesia machines orsomething, early on as a
ventilator if we needed to.
We have just a single bed, ER,um, but you know, how many to
receive anything from very minorstuff to catastrophic trauma.
So it just depended, uh, beforethe year before I moved down, a

(17:34):
bus went down, went off of acliff and all 40 survivors came
to that one bed.
ER, I mean, so you just neverknew what you were going to get.
x-ray laboratory, there is a,there's a growing tuberculosis
program.
Tuberculosis is estimated to beabout 50% in the area I was in.

(17:55):
Um, and aside from that, soaside from those inpatient
services, there's an outpatientclinic pretty robust.
Uh, and then from there there'swell drilling projects.
My parents are doing a literacyprogram where they're in there
with the hospital and my parentsand my dad started a printing
press kind of thing and he isteaching Tarahumara how to read

(18:19):
their own language cause uh,their, their language wasn't
really in written form that waseasily available.
So they do literacy classes inboth Spanish and Tarahumara
people.
So that's one of the otherthings as far as the medical
staff goes, it's mostly staffedby their, I can't say now

(18:40):
because we've been gone sinceApril, but I'd say three Mexican
family physicians.
There is an orthopedic surgeonwho founded the hospital.
Um, my sister who just moveddown there last year, she's a
pediatrician.
She's there for two yearsthrough Samaritan's purse.
And then her husband is ageneral surgeon and he's also

(19:01):
there for two years.

And you were the only anesthesia there at the
time,

correct?
Yes.
Yeah, I was, when I was there,there was another general
surgeon who has since retired,an American general surgeon.
Yeah.
But I was the only enough.

So is it mostly staffed by Mexican nationals or
is there a lot of internationalpeople coming and going?

No, it was mostly staffed by national.
That was a tough area to, uh,recruit, um, non-indigenous gap
too because of the violence inthe area.
We used to have a couple ofmidwife, American midwives who
were excellent, but they justburned out to being 24, seven.
So just working hard.

(19:44):
So yeah, it was mostly Mexicannational staff.

And you went down there originally, uh, just,
just as a finishing your CRNAprogram, how did you find the
difference after being a CRNAand then obtaining the family
nurse practitioner and thengoing back, how did you see that
expand your scope, your ability,your capability?

So that's an excellent question.
And I know you're a family nursepractitioner as well, so you can
appreciate this.
I think while I was down there,I tried to do hospitalists and
ER work as a nurseanesthesiologist and I quickly
realized how limited my scopeis.
I have a very deep but verynarrow scope as a nurse
anesthesiologist.

(20:27):
So when I went back to school asa family nurse to get my family
nurse practitioner, theintention with that was to be
able to not be winging it somuch and be out of the ORs
situations.
And I would say it wasincredible.
It was, it was extremely useful.
Uh, when I walked back into thehospital after, after I got back

(20:50):
with my FNP, I was immediatelyable to do a hundred things that
I wasn't able to do before.
Some of them super simple likeknow which antibiotic to
prescribe someone, you know.
Um, but also I think what wassuper important was the ability
to have a differential diagnosisprocess when faced with a
patient that didn't have aneatly typed up history and labs

(21:14):
and all the rest.
And all you had was yourphysical exam skills and you
know, the question and so,

and limited diagnostics too!

limited diagnostics.
Yeah.
I mean we had basic lab stuffand I got really into
ultrasound, you know, um, I am ahuge advocate of point of care
ultrasound and the anesthesia Iraised money for and bought a
Lumify phased array probe.
It was about$8,000, but it wasworth every penny.
I still use it every day, evenhere in the States doing

(21:46):
anesthesia.
But yeah, it's limited.
And that's one of the thingsabout I think family practice or
internal medicine versusanesthesia in general is there's
a greater reliance on yourphysical exam.
And I think that's somethingthat in general and anesthesia
is missing a little bit as theability to perform a physical

(22:07):
exam and then draw data out ofthat to be able to, you know,
change your treatment orwhatever.

Well, I agree with you.
I think, that that full focusassessment, physical exam though
CRNA programs teach it andphysician anesthesiologists get
it in their medical school.
I don't think it's honed untilyou get the experience
constantly doing it aftergraduation in anesthesia.
Frankly, we do limited exams.
I mean they're limited examsfocused on anesthesia with a

(22:34):
history that they come with,whereas in the emergency room
it's, it's an investigative it'sa forensic files in the
emergency room of what's wrongwith this person and that
requires a large, a largerperspective.
And I totally agree with yourstatement that anesthesia is
narrow but extraordinarily deepor family practice may not be as
deep, but it's extraordinarilywide and so you learn so much.

I really liked it that, that phrase you used
forensics, that is super truewhere you just have these clues
and you've got to figure it out.
That is, that's something Ididn't really understand until I
started doing internal medicineand all that stuff as to how
difficult that can be if youdon't have that structure and

(23:18):
background to be able toapproach the problem, you know?

Absolutely.
You just can't Googleeverything.

No, you can't.
No.
Yeah, exactly.

And so now you brought down there not just
being a CRNA and an FNP, but youbrought down a whole skill set
that never existed in that placebefore.
The utilization of just basicultrasound with blocks but also
POCUS.
Talk to me a little bit moreabout the ultrasound guided
blocks that you were doing downthere and, and then after that

(23:49):
your utilization of POCUS and ifyou have any particular stories
where it really made thedifference, I think the
listeners would love to hearthem.

Yeah, sure.
So, blocks are crucial and likeit's here in the States too.
It stuns me now doing locumsanesthesia all over the place.
How many large institutionsdon't use them routinely for
pretty much every singlesurgery, you know, out of
inconvenience more than anythingelse.

(24:18):
And awkwardness with staffing.
When I was down there, uh, Istarted with your basic
peripheral nerve blocks, yourISBs, Pop blocks all this stuff
I learned when, uh, I was in theStates right after graduation.
But the nice thing about workingon my own and being able to
define my own program is I wasable to be pretty aggressive
with growing my, my blockskillset.

(24:38):
So, um, I was, I, by the end, bythe time I left, I was, I was, I
was starting to do Peng blocks,which are, you know, those
periarticular nerve group blocksthat block the, the hip capsul
joint, which are prettyfantastic for hip fracture.
Um, and, uh, I did a bunch oferector spinae blocks.
We had a on that as an examplefor that.

(25:00):
We had a bunch of, um,intestinal TB patients, uh,
where you get this Miliary TB,all everything testing that
causes huge fluid shifts andkind of like an ascites, a
lymphocites almost into theperitoneum.
And so these people were inexcruciating pain.

(25:21):
We do these laparotomies onthem.
But one of the problems inMexico was, and this is what
pushed my block program so hard,was narcotics were extremely
hard to come by.
One of the issues in Mexico,they were trying to combat
cartels and the drug trade.
And the way they did that was bymaking it pretty hard for normal
hospitals to get narcotic likefentanyl and so on.

(25:44):
So it was out of necessity, theystarted doing that.
But when I'd have like these biglaparotomy patients, I didn't
like putting catheters in likeepidurals, uh, for most
procedures because of the riskof infection out in a place like
that.
So I would do a bunch of singleshot, uh, erector spinae blocks,
which honestly, once you get OKwith them, they take like 30

(26:05):
seconds each.
They're not that long of a blockand you would get a, a solid day
of relief out of them and youknow, and then the other blocks
that are, I mean, towards thetail end, I was starting to do
quadratus, lumborum and otherdifferent blocks.
But the point is that I did thisbecause I didn't have access to
narcotics.
And through that process Idiscovered that narcotics aren't

(26:28):
even really necessary to havereally authoritative pain
control.
Uh, they're, they're necessaryin some instances, but with most
routine cases you can managethem without them, especially if
you can do a nerve block ifyou're working in the ER or
something, there's, there'sdefinitely a role them or
certain postoperative cases.
But, nerve blocks are huge inmitigating all kinds of

(26:50):
postoperative complications.
And then as far as the Pocusgoes, that really started
becoming super important to meafter I came back to the nurse
practitioner and I startedworking in the ER, for all kinds
of things, from checking to seewhat was going on.
If someone had a sclerosis ofthe aortic valve or something,

(27:11):
you know, cause if someone had acardiac Tamponade I remember
there was one night I wassleeping, I was on call, it was
two in the morning.
We live about 20 seconds walkingfrom the hospital itself on the
campus.
And, uh, I heard a bang on mydoor.
Normally people ring thedoorbell.
But I heard a banging and Ithought, wow, that's weird.

(27:31):
Something must be really goingon.
Someone's freaking, they forgotto ring my doorbell.
So I went down and there was twocartel guys at the door armed
and they said, you need to comewith us right now.
Two in the morning.
I was like, why?
What's going on?
They were like, one of us hurts.
I said, hang on a second.
Usually when they say that andyou say, we're either run over
because they're drunk andthey're driving all over the

(27:51):
place or they weren't some kindof firefights.
So I went and grabbed my Lumifyand I went down.
I was the only one at thehospital.
There was no physician and nosurgeon.
So whatever was going to happen,I was going to have to deal with
it myself.
And, I went, I grabbed my Lumifythe phased array ultrasound

(28:12):
probe when I went down and Ifound a guy that was in the back
of a truck when, uh, one of themhe'd been shot and then stabbed
and the shot had gone throughhis, right underneath his left
rib, right about where thespleen might be.
I told them there's nothing wecan really do for this here.

(28:33):
He needs to get to a place thatcan operate on him.
But let me check real quick tomake sure that there's nothing I
can do.
Like if he's developing acardiac tamponade or maybe he
dropping a lung or something.
So I'm there in the back ofthat, that truck, I scanned
them, did a fast exam on himreal quick.
He was negative for that.
I didn't see any kind of bloodin his abdomen or anything like

(28:55):
that looked like it missedeverything major even though he,
he was really pale looking, Icouldn't find any obvious
obvious bleeding and then Istarted a bunch of fluids on him
with some fluids and set themdown the road, you know, so
that's when I realized, wow,this is super handy.
And then, I started getting,kids with, cardiac

(29:18):
abnormalities.
And this is super out of myrealm, you know, but it's one of
those things where there's noone else to check it out.
So I started trying to tease outreasons why a kid would come
into the ER with a shortness ofbreath, kind of like a funny
looking kid syndrome thing.
And as part of my exam, I pullout the phased-array probe and
do a cardiac exam to see ifthere was any cardiac

(29:40):
abnormalities, you know.
And at that stage, all I coulddo was basically go, this is a
normal looking heart or there'ssomething weird here and it's
worth this indigenous familyflying out of the mountains to
the capital city and goingthrough the trouble of getting a
consultation with one of thegovernment hospitals,

(30:01):
physicians, which is a hugeprocess.
And most of them don't want todo it.
So we don't, we try to avoiddoing that unless it's a really
big deal.
So those are a few examples oflike Pocus and how it kind of
started growing on me and how Istart realizing was an important
thing.
One last example of Pocus, itstill applies here in the States

(30:21):
is just checking to see ifsomeone's NPO, you know, people
can tell you they're NPO foreight hours and it may be true,
but they may have gastro-paresisfor some reason and then it
takes literally like 30 secondsto put your probe on someone and
see whether or not they actuallyhave an empty gap.
And that was something I wouldemploy routinely.

Well, I can see that being incredibly important
down there, particularly whenyou know they're not trusting of
you from the beginning.

Yeah.
Right.

Once you're doing all this stuff in the
hospital, did, what was thefeeling, the general feeling
within the medical staff withyou?
And I mean, as you know, there'slots of politics in the USA when
it comes to APRNs CRNAs did youfeel any of that there or did,
did that all just get put aside?
How were you, how were youlooked at?

I had to prove myself to the American
physicians.
They were older in their sixtiesand um, so I had to kind of like
prove that I was capable ofhandling the pace kind of
patients we were getting, youknow, and we're not taking ASA 1
and 2s, you know, sometimes wewere talking people that would
die an hour after they got offthe table because they were so

(31:30):
sick from sepsis or something.
So, and that suspicion was invery concrete ways.
When I first came down, I wasn'tallowed to do any pediatrics.
They would bring in a Mexicananesthesiologist to do all the
pediatric cases unless it was alife or death emergency.
And the general surgeon justgenerally would be very
restrictive with allowing me todo nerve blocks and those kinds

(31:52):
of things.
Cause he just thought I, Ididn't quite know what I was
doing.
But after about a year of beingdown there, I was doing the full
spectrum, they'd gotten tounderstand my capabilities and
my training and I was doinganything from, you know, newborn
babies all the way up towhatever with no real
restrictions on the kinds ofcases I was capable of handling

(32:16):
the general surgeon.
And I got really close,especially the older general
surgeon.
he and started teaching me allkinds of stuff that had nothing
to do with anesthesia, likesurgical techniques, putting in
chest tubes and stuff like thatbecause I think he really grew
to respect the skill set that Ihad and wanted to improve on
that in ways that he could.

And so additionally, once you started
to get respected you and theysaw that you were capable of
these things, did that translateinto a different relationship
with the Mexican nationals thereas well?
Cause I'm sure that, you know,they, there's only so many
people that were in the hospitalthat were foreign, like you
said.
So were they just as standoffishinitially the staff at the

(32:58):
hospital and then come tounderstand that you were
capable?

No, the Mexican staff, was always pretty
approachable.
they didn't come from thatcontext.
They're the, the Mexicananesthesiologist who came, had
no concept of nurseanesthesiologist.
He, in Mexico, there was nonurse anesthesiologists, it's
pure physician anesthesiologist.
So he always half believed thatI was from kind of like

(33:25):
anesthesia tech with delusionsof grandeur, I think.
Although it really chafed himwhen he, cause he didn't know
how to do nerve b lock.
It really Chafed him when the,the surgeons would request
blocks from him that I routinelydid.
C ause he would come up everyonce in a w hile, either while I
was gone out or sometimes,Mexican, plastic surgery came

(33:49):
that he knew a nd he would comeand do like an outreach with
them.
U m, but he wasn't able to dothe blocks and I was told that
that kind of bothered him, that,that someone that was lesser
than was able to do those kindsof things, you know.

Was there any other APRN type roles in Mexico
at all?

Uh, you know, that's a good question.
Uh, not that I'm aware of.

So basically it's entirely physician driven
as far as you could tell.

Yes.
Yes.

And so now you did five years at that facility
with intermittent periods ofcoming back to the US to work
locums to help generate therevenue to keep keep afloat.
Correct.
And while you were there, Ithink I remember you said you
had built a house while you werethere.

Well, kind of.
We finished it, my parentsstarted it and then we just did
the finishing work.
My parents were planning to movethere.
Uh, anyways.
And uh, once they found outwe're moving down, they just
gave us a house.
And so we finished it.

And during the process of living there, what
was the kind of expense that yougenerated for a family?
Just to, you know, subsist.
And have, you know, have generalthings, just the basic basic
living arrangements.

That's a great question.
everyone seems to assume thatlife is cheaper, you know, when
you live overseas.
But, uh, the rule of thumb is ifyou want to live with some sense
of comfort, which I think isimportant if you're living
somewhere overseas, longterm,not decadence but just comfort.
So you're able to come home andrelax.

(35:18):
That costs more or less thesame.
So our grocery expenses would beabout the same.
We'd pay the same on electricityand gas, you know, um, internet,
the hospitals started withsingle satellites connection one
megabyte per second downloadthat was$900 a month.
And then the last year and ahalf that I was there, we got a

(35:40):
new satellite system from hughessatellite.
And so my dad and I split thecost of the$450 a month
connection.
That was 10 megabytes persecond.
So there's expenses for sure.
Dollar amount.
I couldn't tell you, but, Ithink we were averaging about
2000, maybe a month in totalexpenses.

(36:02):
And that's just a guess.
I'm not exactly sure.

Wow.
Now I think that's an importantpoint.
Yeah.
I think you're absolutely right.
People just assume you go toMexico and you know, you get
$1.50 Cerveza and everything'slike that in the whole country.
But clearly when you're there,especially in an isolated area
that's very rural, you're goingto have a whole lot more costs
to get anything.

Yeah.
So yeah, we lived in the middleof, we were really rural, but my
wife is like a logistics expert.
So she would plan like a month'sworth of meals and then we would
drive to the Capitol, maybe sixhours away and there's a Costco
there.
Um, and so we'd picked up allthe groceries and needed, you
could get local stuff like fruitand some, some fruit, not a lot

(36:44):
of fruit, but milk, stuff likethat locally at a place that was
45 minutes away.
But, you know, it, one of, oneof the things about living long
term overseas is that a lot ofpeople come down thinking
they're going to live exactlylike the indigenous people too.
If they poop in a ditch, I'mgoing to poop in a ditch.
If they live in a stick hut andit's dripping and rain, then

(37:04):
that's what I'm going to do.
And those people end up burningout after six months because
there was no rest from that.
That's something that's superimportant for me.
It's still important for me herein the States, I think, and it's
part of the message that I wantto tell people that just want to
work 24 seven it's important tohave a place of rest where you
can just chill out and relax.
It certainly was important therefor us in Mexico and so we felt

(37:27):
okay ethically okay, having likeindoor plumbing, having
internet, having running water,you know, all those kinds of
things.

Right.
Well it gives you a reprievefrom the 120 hour work weeks you
are doing while you're there.

Yeah.
Well a brief reprieve becauseyeah, it ended up getting to me
anyways.
But yeah,

that's a lot.
And so you were there five yearsand then you came, did you come
back to the States before youwent on?
Some of the other missions youdid afterwards?

I did.
I did those things when like,well, I did Mosul while I was in
NP school.
I actually finished my OBrotation early so that I could
head to Mosul.
That was in 2017 we were in thestate for that.
Uh, and then I was at and ebolatreatment center in the Congo
just in February for a month.

So let's talk, let's talk about Mosul.
When you went there, what wasthe primary goal?
What were you doing?

That was with Samaritan's purse.
It's a Christian organization,pretty large, but they have
something called a DART, whichis a disaster systems response
team this a paid position, there, they have hundreds of people
that are in their network andbasically at the drop of a hat
you have to be ready to go onsome kind of disaster response
wherever might be needed.

(38:38):
Right now they have an emergencyhospital set up in The Bahamas
and they're doing surgeries overthere.
There'd be these big inflatabletent kind of things that's
modular and they can add, do allkinds of different stuff with
it.
It's pretty cool.
So what they did in 2017 waswhen the Iraqis and the Kurds
were taking back Mosul fromISIS.

(38:59):
Um, they set up a trauma fieldhospital right outside of Mosul
and started accepting all thebattlefield casualties and even
ISIS prisoners.
Um, they were pouring out ofthat city and I went there.
It was my first response, withSamaritan's purse.
I went there in July for amonth.

And what was that like?
I mean, what did you feel that'sgotta be a lot less safe than
when you were in Mexico?
So I'd imagine there was danger.

Yeah, I definitely, yeah, I definitely felt
uncomfortable there.
Um, but for the most part wewere within like this compound
that had blast walls and thenthere was a Kurdish security
force and like a trench that wassupposed to stop, you know, IEDs
and stuff like that truck withexplosives on it from slamming

(39:50):
into the hospital, that kind ofthing.
So it was fairly well defended.
And actually, so Mosul is just afew hours away from Erbil, which
is the Kurdish capital of theKurdish people.
Erbil is amazing.
It's a very American friendlyplace.
I was able to walk around with abuddy of mine for a couple hours
and just the streets of Erbiland people would come up, shake

(40:13):
our hands, say hi, they lovetalking with us.
So it was a different animalthan when you left that Kurdish
zone and all of a sudden there'sjust this different vibe.
And definitely people were notthe fans of you that they were
in Erbil.

And so was there any US or allied forces
protecting you in that time?

No.
No.
We had, we had some, some Iraqimilitary, but it was mostly
Kurdish private contractors.

And was that supplied by, by that group, the
group that you were there withor by some other group?

Yes, Samaritan's purse hired them.
Yep.

So basically they're mercenaries for hire to
cover and protect the hospitalwhile you're there doing,

I wouldn't call them mercenaries per se, that I
would call them a privatesecurity group, but I don't
know, maybe that's justsemantics

could be, I dunno.

Yeah.
Yeah.

So what kind of surgeries, what were you doing
there when you were there?

Uh, so I, I was there, during my FNP training.
My school was gracious enough togive me the time off to be able
to go there and we would dowhatever role and I was coming
down, I came in towards the endof the response, uh, but there
was still, there was a lot oftrauma, a lot of burn injuries,

(41:32):
um, a lot of broken bones andorthopedic kind of stuff.
But some of the most ethicallycomplex situations I've ever
been in.
I was in there, the second day Iwas there, there was this kid
that had been blown up on IEDthat had been there a month

(41:53):
initially.
Uh, this was the, the hospitalwas supposed to be a quick
turnaround.
We do stabilizing surgery andthen we transfer everyone to
Erbil for definitive care.
But as time wore on Erbil gotoverwhelmed with everything and
they stopped accepting people.
So this kid who should have hadbetter treatment, better care

(42:13):
was stuck at our hospital, endedup being trached and this kind
of thing.
And by the time I got there wasseptic had ARDS from black lung,
all these other things, andthere was no real pediatric
intensivist or anything there,there was just a bunch of people
doing the best they could helpthis kid, but they'd run out of
options.
He'd gone through everyantibiotic on the, you know,

(42:36):
that they had available and, andhe wasn't responding to the
antibiotics and they came to meand said, is there anything we
can do to help him?
Uh, because he was, he wasstarting to go into respiratory
failure.
The vent wasn't doing a goodjob.
He'd been on vent without ahumidifier for a month because
the portable Vents we had didn'thave humidifiers.

(42:58):
Um, so I don't know.
So I found myself in a situationof trying to help manage a
critically ill pediatric traumacase, with sepsis and all these
superimposed problems.
And you know, there's, there'sintense emotions on every side
from people that have beentaking care of this kid for a
month.
Um, and it, it was superdifficult in contrast to that,

(43:24):
we also were taking care of like, ISIS prisoners that were
captured.
And then we, you know, operatedon them for gunshot wounds or
whatever.
And that was relatively simple.
I mean, for me it went back andfor all of us there went back to
that same philosophy of, youknow, we need to show these
people some love and somethingthat they've never seen before
in their lives as far as, uh,other types of cases we did.

(43:52):
by the time I got there, it wasjust, it was just a very complex
situation.
we would have women who wouldcome in with these third degree
burns that they said were causedby a fire.
like stove fires, but they werethese uniform burns that look
like they, uh, look like they,they had been doused with

(44:17):
gasoline and then set on fire.
Um, and the ethically complexpart of that was that any one
that we sent to Erbil has tosurvive in the back of the
ambulance without anyone in theback of the ambulance with them
because of security risks.

(44:37):
So we weren't able to send thosekind of patients to Erbil, but
we had difficulty managing themthere.
Their mortality rate was superhigh and so often all we could
do was sit with them, give themdrugs like ketamine and pray for
them and just be with them, youknow, until they passed.

Wow.
That is a tough situation to bein.

Yeah.
Yeah.
For especially for the ER peoplethat were there.
Same thing with kids.
There was one other case thatI'll tell you, I don't know.
I don't know how many, I don'tknow how much time you have
here, but there was one othercase that really, really got to
me deep there.
So ISIS in Mosul, took controlof a hospital that was later

(45:19):
liberated and all the patientsthat had been at that hospital
started coming to us.
One 14 year old kid came in witha mangled leg and seemed like a
normal 14 year old kid when Iinterviewed him.
But when I, when I brought himinto the, or, he flipped a brick
and I was trying to figure outwhat was going on.
Um, and later on, one of theIraqi surgeons we were working

(45:39):
with from Mosul, and he was thesurgeon from Mosul who fled,
told me that ISIS had ran out of, um, any kind of anesthetics.
And so they were just paralyzingpeople with rock or vecuronium
intubating them and then doingthe surgery they had to do.
And this kid had had severalawake surgeries like that.
Um, other people had limbsamputated with no anesthesia,

(46:00):
that kind of thing.
Another kid that I got.
Uh, and this was the one thatkind of stick with me even
today, even after everything inMexico was a kid that had been
in that ISIS hospital formonths.
He'd been playing with an IEDand that blew up and it blew his
abdomen open and blew one ofhis, his, his legs off.
And I remember I was on callthat night, so I went to the ER,

(46:22):
they told it was a little kidwith an IED, injury went in and
I, I looked in with a kid witha, or like a sheet pulled up to
his neck and I thought it lookedpretty normal when I pulled down
the sheet, his abdomen was openand his intestines were up, but
it wasn't an acute injury.
His abdomen had been open for amonth and his leg has no
dressing on it.
And the femur just kind of stuckout a little bit.

(46:42):
But it's been so long that thefemoral artery had just kind of
like atrophied up, you know, andthey'd never done anything about
it and they just waited for himto die.
But the little guy who just hungon for a month, um, and he was
one that Erbil wouldn't accept.
So we ended up with him for twoweeks until he passed.

I mean, these are these, these are things that
people in the US are rarely ifever going to see providers,
patients, anybody.
And so how do you, you know,coming from, from this place of
wanting to help people comingfrom the US where there's so
much available, you know, whenyou're there and you see that
kind of level of suffering, howdo you take that back with you?

(47:22):
Right?
Are you dreaming about that orare you having nightmares?
Are you having difficulty?
like to me it soundsunbelievable.

Not at all.
I feel like I've always beenable to compartmentalize really
well.
And, I think a lot of people inour jobs can do that.
You know, it's just focused onthe task at hand and you don't,
I don't know.
It's something that I guessmaybe it's a gift that I've had,
but also in Mexico, you know,you just kind of focus on the

(47:51):
work you have to do, you do thebest you can with what you got
basically and well at least thenyou're, you're solid in the
knowledge that you've done allyou can.
\.

And anything that happens from that point is
fate.
Right?

For the most part.
I mean there are times when youjust think back and you second
guess yourself, but I meanthat's part of the career,
right?
There's always going to be thosetimes when you look back and you
know, I should have done thisdifferent or something like that
and definitely IN IRAQ there arethings like that too.
And in Mexico, but it's part oflife and part of growing as a,
as a health care professional.

Absolutely agree.
And so now you also mentionedthat you went and did an Ebola
clinic that was in February.
What was the circumstancessurrounding that?
Was that still with the samegroup?

Same group?
Yup.
Once again, they sent me out.
They asked for volunteers to gostaff and run an Ebola treatment
center and the democraticRepublic of Congo, which that
outbreak is still ongoing.
It's the second largest afterwhat happened, in 2014 or
whenever that was.
So I went there for a month andit ended up being me and another

(48:55):
family nurse practitioner beingthe only medical providers at
the, at the facility.
Um, kind of supervising thetreatment of all the, all the,
all the potential Ebola cases.
It's mostly protocol driven.
Um, and it's, it's a lot of,it's actually nursing driven,

(49:16):
but him and I were the only ones, uh, only medical providers
there.
You kind of make all of them themajor medical decisions

and you guys manage the treatment based on
those protocols.
Did you feel safe while you werethere?
I mean, Ebola terrifies peoplewhen they hear it, you know.
So when you're there and you're,you're dealing with those
patients, how was that?

I felt I felt pretty safe.
Samaritan purse training ispretty thorough before you go on
the field.
Uh, and they're very wellequipped.
Additionally, actually got theEbola vaccine.
While I was down there.
So yeah.
So I'm, I'm ready for theapocalypse that it comes to the
states.
I'll be one of the survivors.

What kind of treatment were you doing?
What exactly was happening?

um, yeah, so, so, so first of all the, in the GRC
they cast a very wide net as faras symptoms.
Um, so we had, we had so wide infact that we had something
called SHE-bola where a womanwith, uh, abnormal bleeding

(50:17):
would come in and that would beenough of a criteria,
unexplained bleeding with thecriteria for admission, for, to
check to see if the patient hadEbola.
And that meant full isolation,the hot zone, you know, where
people with all the workerscoming in, in the full on Ebola
looking gear with aprons andeverything.
Um, we had guys coming in withall kinds of stuff that wasn't

(50:38):
Ebola but met the criteria ofthis huge net they have.
And we ended up catching somepretty serious things.
And once again, it was somethingthat was just super ethically
challenging that you can onlyappreciate in those situations
where you have someone, you knowfor certain, does not have ebola
who is desperately sick, butthey're in the hot zone and they

(50:59):
have to get two negative tests48 hours apart before they can
be released for othertreatments.
You know, I had a boy withrabies that died there who came
in it looked exactly like ebola.
I would actually go so far tosay if one of the most horrific
deaths I've ever seen in mylife.
Um, who came in, we knew itwasn't ebola, but we couldn't

(51:21):
transfer him out of therebecause the risk was just too
high.
We had a couple kids withcerebral malaria, but that's
pretty easy to treat.
Um, there's a drug calledArtesunate and you can get a kid
with a glasgow seven or eight.
You give them a dose ofArtesunate, and a few hours
later they are walking andtalking.
It's a miracle drug.

(51:43):
So there was interventions wewere able to do, aside from
treat ebola.
But it's tricky when you have togown up, you have to take
everything in there with you.
Once something goes into the hotzone, it does not come out.
Um, the medications we have totreat these things because of a
various various reasons are verylimited.

(52:03):
When you're trying to treatebola, you can't run a full
fledged clinic that treats awhole host of diseases.
You have to focus on triagingand finding ebola cases.
And that meant a lot of otherthings were left untreated.
But everyone that came in wouldget a regimen, uh, uh, an
antibiotic oral cephalosporins,oral, I believe it was a proton

(52:25):
pump inhibitor, um, malariadrugs and uh, Tylenol I believe
or some kind of pain reliever tohelp control some of the
symptoms.
And they would be in that lockeddown hot zone ebola zone for at
least a couple days.
Um, each one in an individualisolated room, they weren't

(52:48):
allowed to leave their room theentire time.
And then staff would make rounds, uh, groups of people.
You were never allowed to gointo hot zone by yourself.
You had to go in with a partner,we'd go in at scheduled times
to, you know, deliver meds, uh,do physical assessments, um, all
that kind of stuff.

(53:09):
So, and, and once you were done,it took about 45 minutes to do
the whole decontaminationprocedure, which when you first
start that, you don't realizethat that has much of a big
deal.
But when you're in the fullebola outfit and it's like 120,
130 degrees, you may be, havehalf an hour to do everything

(53:30):
you need to do with up to 20potential Ebola patients before
you have to get out of there.
Because passing out inside thehot zone is a pretty difficult
thing to deal with,

I can imagine.
And did you have, obviously youhad a lot of positive patients
there too.
And once you, once you found inthe very positive, what was the
process?
What was the treatment for them?
What ended up happening?

There's a, there's a process.
Uh, it's all laid out.
The world health organizationhas this neat way of doing this.
But, uh, you have a suspectedzones.
So ambulances come in orsometimes people would walk in
and they would met by a triagenurse.
There's always like at leastthree feet and two fences in
between the triage nurse and thepotential patient.

(54:17):
They're ask screening questionsif they meet the criteria gowned
in people that have that fullebola garb with a mask will come
in and take them to their roomwhere they'll, they'll, they'll,
uh, get initial lab work, getthem oriented to the room, give
them some food and some water.
And then if they're confirmedpositive, they move from the

(54:41):
suspect ward to the confirmedward.
And on that side, there's eithera wet or a dry side, so the wet
or dry side basically, refers tobody fluids, right.
The thing about ebola is it'sfamous for being a hemorrhagic
disease, but actually it's moreof a water loss disease.
They found that the biggest waythat people can decrease

(55:02):
mortality rate for ebola is topump them with IV fluids.
So if so, people will startthrowing up diarrhea.
All this kind of stuff.
And also hemorrhaging if it's areally advanced case.
And um, so they're on one sideand then the dry side, which is
the patients that are positivebut don't have all the symptoms

(55:25):
yet, they're on the other side.
They stay there and then after acouple weeks, if, if they
survived it a couple of weeks,they're prognosis is pretty good
for at least survival.
Um, and so after I, you know,I'm reaching back out cause I
haven't thought about this stuffin February, but I believe that
after five days being symptomfree, they take a test and if it

(55:50):
comes up negative, then they'reallowed to leave cured of ebola
and they actually have theantibodies now in their system
so that they can go back in assupporters without the
protective garb to be able tohelp other people that are in
there with Ebola and a lot ofpeople who, yeah, yeah.
A lot of people who survivedebola would come back as kind of

(56:11):
support staff to help people whoare going through it.

That is amazing.
What an amazing list ofexperiences you've had,

I guess.

I mean, that is really amazing.
You know, I know from yourperspective doing these things
because you feel your calling,you feel it's the right thing to
do for people.
It's about love.
But you know, from the outsidelooking in, how many people are
willing to put themselves in aplace where it's basically a
third world country in a ruralarea for five years.
How many people are willing to,you know, go into Mosul or into

(56:42):
a war zone and then into anEbola zone?
I mean, you've done three thingsthat probably 99% of people will
not do one of, or anything closeto one of, in their whole lives.
You know, I mean, they're gonnawatch the hot zone movie and
that's going to be the last timethey think of ebola that they
don't want to be around it.
That's what's going to happen.
And yet you've done all theseamazing things.

(57:03):
So I guess then the question is,when you come back from all of
this, what are the three bigtakeaways?
And it doesn't have to bemedical.
Just the three big takeawayswhen you come back to the U S uh
, from all of these experiences.

Number one is that nurse, anesthesiologist, and
physician, anesthesiologist havean amazing gift and skillset
that they can offer the world.
And most people don't capitalizeon that nearly enough.
There's a reason why doctorswithout borders only asks eight
weeks of anesthesia providersversus a year from every other

(57:41):
specialty.
And that's because no one fromanesthesia volunteers for
missions.
So there's a huge demand.
No one wants to go do it.
That's the first thing.
Number two for me is this is,this is something that's taken
me years to learn and I thinkit's important here in the
states too, is to balance workand life.
Be a complete human being.

(58:02):
You know, um, don't overwhelmyourself with so much work
pursuing money or pursuing sameor whatever the heck it is.
Make sure you have enough timejust to relax and enjoy all the
hard work, you know, don'tthink, Oh, I'll enjoy myself
later on or something like that.
Mental health and um, stabilityand just being able to live in

(58:27):
the present is super importantin our career.
And I think sometimes we take itto the extreme and end up
pushing ourselves a lot harderthan we should.
And the third, uh, takeawaypoint I think is to love people
and to uh, extend across linesthat other people will not cross

(58:49):
in order to love those people.

So one additional question, Eric.
When you were working both in,you know, other countries
overseas, all of these differentexperiences and then coming back
to the States, what are some ofthe differences you saw?
Was there a similar scope ofpractice?
Did you feel things were unusualafter all that work and
basically being a primarypractitioner in every, both
anesthesia in the, in the ICU,in the ER?

(59:15):
What was the difference when youcame back?

That's an excellent question.
So it's actually one the reasonswhy when I came back to live
here in Ohio and become somewhatpolitically active because in
Mexico, I was able to practiceto the full extent of my
training as a nurseanesthesiologist.
I went to case Western, which isa really good school and they
taught me a lot.

(59:38):
And then when I went intopractice, depending on where I
was working, some of thosethings I wasn't able to do that
i was trained in school.
So when I went down to Mexico,um, it truly was a full
practice.
If I was taught it in school, Iwas able to do it on the field.
What started to become a littleodd to me was when I would come

(01:00:01):
back to these locums work in theUnited States, especially in
Ohio.
And this varies by state.
Every nurse practice act as youwell know that, um, that
dictates what CRNAs can andcannot do.
And for me, in Ohio, there's noprescriptive authority even
during the perioperative periodfor nurse anesthesiologist.

(01:00:22):
So I couldn't get a, an RN topush my mind local anesthetics
for a nerve block, I had to haveanother CRNA do it.
I couldn't in PACU ask a nurseto put oxygen on legally onto a
patient.
I couldn't ask them to put on anasal cannula because that's
giving a verbal order to an RNand then I would go back to

(01:00:44):
Mexico and all of a sudden I wasputting in chest tubes and
central lines, you know?
Um, and so it was this reallybizarre thing.
And the more I thought, the moreI realized that this was kind of
an artificial line for whateverreason.
So when I came back to theStates in Ohio, I've gotten
involved with my stateassociation and I encouraged

(01:01:06):
nurse anesthesiologists all overto kind of look into CRNA to
support their state boardsbecause they really do promote
some of these important practicethings that can be game changing
sometimes in our state in Ohiocurrently there's a bill where
we're just trying to getperi-operative ordering
authority.
We're not trying to do somethingcrazy like go outside and be

(01:01:27):
able to prescribe opiatesoutside of the hospital setting.
We're just trying to match whathas always been happening with
the law so that what we're ableto do in the OR as experts.
We can also do pre and postoperative in Ohio.
As soon as you take your patientfrom the operating room into the
recovery room, you go fromsomeone who is able to do

(01:01:50):
anesthesia and handle dangerousdrugs to apparently a buffoon
that can't even tell an RN toput oxygen on a patient.
You know, you can't even writean order for an RN to get Zofran
for your nauseous patient.
Something you did maybe did 10minutes earlier in the operating
room.
So it's something I'm actuallypretty passionate about.

(01:02:12):
Uh, I, you know, I'm not thismegalomaniac that wants total of
authority to do whatever theheck I want, you know, but I do
want reasonable abilities topractice with the tools that I
was trained with and thatfrankly, I use every day in the
OR,

Mike MacKinnon (01:02:30):
absolutely.
Well it would be veryfrustrating to go from a place
where you're treating ebola,taking care as the primary, um,
primary care provider plus theemergency room plus the ICU
intensivist plus the anesthesiawith absolutely no restriction
and having great outcomes andpatients doing very well to not
being able to ask a nurse to putoxygen on a patient in PACU.
That is a unusual juxtapositionand I think it speaks a lot to

(01:02:53):
the, you know, the politicalconstraints related to trade
protectionism.

Eric Kramer (01:02:57):
I agree

man, you are an amazing human and I don't know
if you ever get to hear it, butyou know, the fact of the matter
is is that is true.
And for those that listen tothis and they think, you know, I
want to do some of these things,I want to give back to humanity
the way Eric has, where shouldthey go besides obviously

(01:03:24):
contacting you to get moreinformation about getting
involved and you know, jumpingin and actually doing some of
these things, promoting love,promoting service, you know,
promoting humanity.
How do they get, look, what kindof places can they go?

That is such a broad thing.
I would say, you know, first ofall start investigating.
You know, what can be done.
It doesn't have to beinternational.
You know, it can be local andit's not just a checkoff I did
my good deed for this thing.
There's something intrinsicallysatisfying about going in

(01:04:00):
serving other people, you know?
Um, so, so that can be, if youdon't have enough time to go on
a missions trip, then just goand see if you can do something
locally.
Um, the other thing is I'mstarting a nonprofit, that, i s
g oing t o do two things.
It's g oing t o number one, I'mcreating an online database of

(01:04:21):
3D printable medical devices.
And then I'm going to go a nd set u p 3D printers at hospitals
overseas so they can print theirown medical equipment.
But the second part of thatmission is I want to teach, u m,
mission hospitals that don'thave anesthesia.
And I think tons of those kindsof hospitals how to do
anesthesia.

(01:04:41):
I'm a firm believer that youdon't have to have a certain
degree to do, especially whenthere's no other option.
I think it's cruel to say, well,there's no anesthesia here, so
we're going to do this surgeryon you awake because we don't
have anyone that can even offerbasic services.
So, something that I think a lotof anesthetist can do not just

(01:05:03):
through my organization.
I'm going to start, what I'mgoing to do is I'm going to go
and offer to ultrasound guidedregional anesthesia and basic
anesthesia techniques to nonanesthetist at mission
hospitals.
Um, but there are CRNA schoolsin Africa and I believe in
Somalia or other places, wherenational nurses are learning how

(01:05:30):
to become a CRNAs and needqualified people to teach them
different techniques.
And from the United States,anyone that's come from the
United States has a greatbackground to be able to go and
do that over there.
So that's the other thing Iwould recommend, not just go and
do surgeries, but maybe pay itforward by teaching people who
will be working in a countrythat doesn't have any,

Oh, right.
Well that falls in line.
It falls in line with thegeneral belief set that, you
know, you can give, givesomebody bread, but if you teach
them how to make it, that's 10times better ultimately.

Oh yeah, absolutely.
Yeah, yeah.
Then just doing it yourself.

Absolutely.
Eric, this has been amazing.
I mean, I've learned so much.
I already had a ton of respectfor you before this.
I, I've read all your stuff.
I followed you, but you knowyou're like a CRNA hero and I
appreciate that you're part ofmy profession.

Yeah.
Dude, I'm so glad to finallytalk to you.
After all these years of knowingand interacting with you, it's
actually pretty exciting.

This has been amazing.
This is a great interview.
I appreciate you, being on

all right.
Yeah.
Thanks for having me, man.

Speaker 2 (01:06:38):
That's all for this episode of anesthesia
deconstructed.
For more information based ontoday's discussion, be sure to
visit uswww.anesthesia-deconstructed.com
you'll also gain access to ourblogs, editorials, and more
resources to keep you updated onthe science, politics, and
realities of today's medicalindustry.
That'sanesthesia-deconstructed.com.

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