John Shields, DNP, CRNA: How “Milligram Per Kilogram” Learned to Embrace the Art and Science of Anesthesia Equally

Giving anesthesia is described as both an art and a science. The best CRNAs embrace both aspects fully and equally; but truth be told, it doesn’t always occur simultaneously.

John Shields, DNP, CRNA, who became a CRNA nearly 40 years ago and currently specializes in cardiovascular anesthesia, understands the concept well. Reflecting on his long career as a clinician, educator, mentor, and innovator, he’d be the first to tell you it was the science that captured his imagination and wooed him into the profession, but it took a sharp-eyed (and sharp-tongued!) mentor to inspire his appreciation of the art.

Becoming a CRNA wasn’t even a blip on John’s radar when he graduated early from high school at the age of 16. He wound up taking classes at a junior college in Alabama while earning some money working on a cotton farm and at a nursing home. Two years later he moved to Nashville to attend night school and look for work. It was there that his father got him a job as surgical support staff while he tried to figure out what to do with his life.

“I had just started my shift at the hospital when there was an emergency appendectomy,” John recalls. “I met the nurse anesthetist waiting to go back with the patient. He saw the look on my face and said, ‘Hey, man, want to come watch?’” So he did.

The next day John started asking around about anesthesia (he had to write “anesthesia” down on a piece of paper to remember the spelling) and was introduced to a married couple who were CRNAs. They explained to him what they did, the history of nurse anesthesia, and the time, money, and effort it takes to earn the degree. Not long after, in 1980, he enrolled in the nursing program at Austin Peay State University in Clarksville and began his journey to become a CRNA.

“Nurse anesthesia training during the 1980s was very different than it is now for any number of reasons,” John recalls. “Except for the program dean, the faculty was all just practicing CRNAs/clinicians, or the ‘occasional faculty.’ While I did not appreciate it at the time, this made them even more special since any didactic training or lectures took away from their own time. They were not paid to teach us…it was just them passing along the same skills that were passed along to them by the previous generation of providers.”

John admits that early on in his training he “became very caught up” in the science of anesthesia. “I worked with several experienced CRNAs who contributed to my education in different ways, either passively or actively,” he says. “They worked with me despite my overzealous and less than humble approach to what is actually a practice profession.” Paradoxically, John met the CRNA who would have the most influence on him near the end of his training, immediately prior to graduation.

“He was well known as gifted clinically, but he was very direct, if not gruff,” John remembers with a considerable degree of admiration. “He recognized my compulsions and overthinking, so one day he told me, ‘Your new name is Milligram Per Kilogram. That kind of stuff is going to get you in trouble someday. Anesthesia is simple…half the big syringe and all of the little syringe. This is a patient, not a science project.’” John recalls that the CRNA forced him to do cases using simpler techniques, and vastly improved his efficiency and focus on the operation itself. “I became much better at communicating with the surgeon and being a member of the surgical team instead of practicing in a silo,” he says. “While I still wound up embracing the science, I became a better CRNA by putting the care of the patient first.” In other words, he learned to embrace the art.

He received his nurse anesthesia diploma from Middle Tennessee School of Anesthesia in Nashville in 1985, then went on to earn his Master of Science in Anesthesia from Middle Tennessee in 2005 and Doctor of Nursing Practice from Vanderbilt in 2013.

John’s experiences with his own CRNA mentors led him to become a respected educator/mentor in his own right. He credits his former chief CRNA at St. Thomas, where he later became the chief CRNA himself, for getting him involved in training new CRNAs. “Heart surgery is extremely challenging, so getting new staff up to speed quickly and without any knowledge deficits is a major endeavor,” he says. “Again, I am often fascinated by the science of anesthesia but not everyone is, so teaching and learning have to be paired with the individual learner. I’ve found that anesthesia providers learn best by hands-on learning. In this regard, I try to never touch the patient when I’m paired with a CRNA, SRNA, or resident, similar to the manner in which I trained. Nothing is more frustrating or detrimental to a young mind than being forced to follow someone else’s plan of care.”

John later became an instructor at several nurse anesthesia educational programs and began doing speaking engagements at conferences. Today he trains SRNAs and CRNAs, as well as helicopter pilots and military personnel, in the use of ultrasound in the field.

“Stethoscopes are not very useful with the noise in the helicopters,” he explains. “Both nonphysicians and medics are extremely aggressive clinically. The work I do with helicopter pilots, Lifeflight, emergency crews, emergency room physicians, and the military is free; I consider it my way of paying back the profession.”

John also works with POCUSLab based out of Kentucky, training CRNAs in the use of ultrasound including transesophageal echo. “To my knowledge, we are the only group offering this to CRNAs,” he says. “Intelligent Ultrasound builds the simulators we use and supports us in facilitating this education by sending them to the workshops free of charge. They came on board with us in 2016 when no one else would support CRNA education in this field. We also helped them develop some of their applications, such as gastric ultrasound and the 3D transesophageal echo upgrade. So it really has been an extremely good partnership for cardiac anesthesia and CRNAs.”

In his clinical practice, John’s life couldn’t be better. “I work in an anesthesia care team at Vanderbilt Heart and Vascular Institute with some of the finest physicians in the region,” he proclaims. “The CRNAs and physicians in my group have an amazing culture of trust and ownership of each other, and I feel we are family. We are the busiest heart transplant center in the world the last two years, and one of the busiest lung transplant centers.” He says that along with a very busy and exotic caseload including coronary artery bypass and heart valve surgery, the team manages care for patients undergoing interventional cardiology such as transcatheter aortic valve and mitral valve repairs. “These procedures are not surgical cases but rather noninvasive repairs that are very challenging. We do a lot of ‘firsts’ here with cutting edge technology, and we are all proud to function at this level.”

There’s no doubt that John’s passion for the science of anesthesia remains great. “Since I became a CRNA, anesthesia has gone from watching chest movement to measuring expired gases to measuring hemodynamics and heart pressures to looking at the heart with ultrasound during surgery. This is an amazing time in the history of healthcare, where we not only are being offered better ways to take care of our patients but in a more cost-effective manner,” John explains zealously. “I believe ultrasound in particular offers a more efficient way to place pain-reducing nerve blocks and heart monitors as well as diagnose causes of breathing and circulation issues.”

John’s passion for the art of anesthesia is equally great.

“I wrote an article on Civil War anesthesia with a colleague which we presented at the Anesthesia Historical Society at Vanderbilt University in 2007,” he recalls. “There have been tremendous advances over the last 160 years in nurse anesthesia education, and technology especially over the last 40 years. But in the middle of all of this technology, anesthesia remains a simple relationship between provider and patient. At the core of anesthesia are its humble beginnings including the administration of chloroform and ether by anyone, such as during the Civil War by orderlies and support staff…like me.”

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