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ALANA

NewsBulletin advancing quality anesthesia care, serving our members, promoting the nurse anesthesia profession

ALANA NewsBulletin • Fall 2015 • www.alabamacrna.org

2015 ALANA Fall Meeting Friday, October 16 – 8 CE Credits. 3 Pharm1130-1200 Registration1200-1600 Adult Cardiovascular Seminar, Michael Humber & Scott Karr1600-1700 Dinner on Your Own1700-2100 Pediatric Cardiovascular Seminar, Michael Humber & Scott Karr1700-1900 Exhibitor Set Up (Tables First Come, First Served)

Saturday, October 17 – 7 CE Credits, 2 Pharm0630-0700 Registration & Exhibits Open0700-0800 Student Breakfast for New SRNA Students0700-0800 Non-Opiod & Non-Gas Anesthesia Technique: Implications, Garry Brydges0800-0900 Funderburg Lecture - Fluoroscopy and Radiation Safety, Jackie Rowles 0900-1000 Funderburg Lecture - New Drugs and Pain Therapies, Jackie Rowles1000-1030 Refreshments & Exhibits Open1030-1130 12 Lead EKG: Quick and Easy Interpretation, Garry Brydges1130-1230 AANA Region 7 Update, Garry Brydges1230-1400 ALANA Update/Business Meeting with Congressman Gary Palmer- Invited, Working Lunch & Exhibits Open

1400-1500 Anesthesia Considerations in Neck Imaging, Dr. Ronald Thompson 1700-1830 ALANA Membership Reception on the Club House Patio

Sunday, October 18 – 5 CE Credits0630-0700 Registration & Continental Breakfast0700-0730 Anesthetic Management of Myasthenia Gravis, Lindsay Bonner RN, BSN0730-0800 Anesthetic Implications of Demyelinating Diseases, Rachel Pickett RN, BSN0800-0900 Anesthetic Management of Patients with Prader Willi Syndrome, Nora Bradshaw, CRNA, MSN0900-0915 Break0915-1015 Radiology Fundamentals: Understanding the Chest X-Ray, Dr. Ronald Thompson1015-1115 Liability Issues for CRNAs, John McCall, Starnes, Davis, Florie1115-1215 Cell Phones & Other Electronic Distractions in the OR, John McCall, Starnes, Davis, Florie1215 Adjournment

2 ALANA NewsBulletin • Fall 2015 • www.alabamacrna.org

President’s Message . . . David Gay, CRNA

As the hot and humid dog days of summer begin to fade into the cooler days and long shadows of fall, I find myself reflecting over the past year as I sit down to pen my last President’s Address. The opportunity to represent Alabama CRNAs this past year as president has been a challenging, exhausting, and highly rewarding experience for me. It has been an honor to serve the CRNAs of Alabama. I have had the pleasure of working alongside an extremely talented board of directors and staff of the association. I will be forever grateful for their work, dedication, and perseverance. With every move and decision they have made, they have sought to promote and protect the profession of nurse anesthesia in Alabama.

This presidency and my time on the board have afforded me many opportunities to meet many members of the ALANA, to assist our members with challenging issues, and to advocate and promote our profession. I have made several trips to Washington D.C. and countless trips to Montgomery to speak with our elected officials and leaders of our state agencies to ensure that our profession is protected and that our voice is heard. I’ve also had the pleasure of working with the AANA and I have gained firsthand experience learning what our national association does for us. The ladies and gentlemen at the AANA are striving to advance the future of our profession and are a tremendous resource for us all. Seeing the compassion, the professionalism and the dedication that CRNAs provide to the citizens of Alabama has made me even more proud to be a CRNA and more humbled to serve on this board.

While the GOP continues to sort through a colorful list of candidates in anticipation of the republican nomination for next year’s elections, I would highly encourage everyone to vote in the upcoming ALANA elections. The nominat-ing committee has put together a roster full of talented and capable CRNAs from around the state. This is your op-portunity to let your voice be heard and elect those who will lead our association into the future. Every vote counts.

Please be sure to vote. To the nominees, thank you for your willingness to serve our profession. It is a worthy and hon-orable endeavor.

Congratulations to Alayna Wells and Elizabeth Reynolds. They are the SRNA winners of the 2015 AANA Foundation Scholarship. Alayna and Elizabeth will be recognized at a reception at the 2015 Annual Congress in Salt Lake City.

The fall meeting in Birmingham is right around the corner. Once again, Larry Vinson and the program committee have an outstanding agenda put together. The 2015 ALANA fall meeting will be held at the Ross Bridge Golf Resort and Spa near Birmingham, October 16-18. Join us for the adult and pediatric cardiovascular symposium on Friday. The AANA update will be given by our AANA Region 7 Director, Garry Bridges, DNP, CRNA, ACNP-BC, MA, FAAN. This year’s Funderburg lecturer, sponsored by the Samford Uni-versity Nurse Anesthesia Program and alumni, will be Jack-ie Rowles, CRNA, ANP-BC, MBA, MA, FAAN. She will be addressing the fluoroscopy issue and pain management therapies. I will have the honor of presenting the ALANA Distinguished Service Award to a most deserving CRNA.

We will have our Annual Business Meeting on Saturday with the ALANA update. We will install our new directors to the board and the very accomplished Dr. Michael Hum-ber will assume the role of the ALANA President. This will be an information-packed meeting with lots of time to visit with students and old classmates, and make new friends in the anesthesia profession. Join us at the Renaissance Bir-mingham Ross Bridge Golf Resort and Spa. It is one of my favorite places in Alabama. This first class facility provides a quiet getaway from the busyness of the city to allow at-tendees to relax, golf, learn, and socialize all while being surrounded by the beautiful environment of the resort.

An important component of your professional practice is

ALANANewsBulletin

Calendar of Events

ALANA NewsBulletin Copyright 2015 • Alabama Association of Nurse Anesthetists, Inc. • All Rights Reserved.

The ALANA NewsBulletin (USPS 019-869) is published quarterly by the Alabama Association of Nurse Anesthetists, Inc, Post Office Box 240757, Montgomery, Alabama 36124.

Volume 33, Number 3 Fall 2015PublisherAlabama Association of Nurse Anesthetists Post Office Box 240757 • Montgomery, Alabama 36124 334.260.7970

protecting your scope of practice and practicing to the fullest extent of your education and training. Many threats to your scope of practice and your ability to perform at your highest level of training occur at the legislative level of government. We must have the resources to get our message out to our political leaders and decision makers. Please continue to financially support your state and federal PAC. If you or your coworkers have pic-tures of CRNAs promoting our profession, please post your pictures on Facebook and tag ALANA or on Twitter @alabamaCRNAs or email to [email protected].

This has been an exciting and challenging year for me that has been full of change and new experiences. I will be forever thankful for the support and patience bestowed upon me from my family. They have given sacrificially without hesitation to allow me to attend to the business of the association. To my board of directors and association staff, thank you for doing what you do. You have made this year possible. To Michael Humber and Joe Knight thank you for your listening ear, your counsel, and your encour-agement. To my mentor, thank you for your indulgence and always sound advice.

As always, be Proud of your profession. Promote your profession. Protect your profession. It’s a great day to be a CRNA.

October 16-18, 2015 ALANA Fall MeetingRoss Bridge Resort

November 21 & 22, 2015 ALANA Board Leadership RetreatBirmingham, AL

March TBA, 2016 Legislative DayMontgomery, AL

April 3-6, 2016 AANA Midyear AssemblyArlington, VA

April 22-24, 2016 ALANA Spring MeetingDestin, FL

September 9-13, 2016 Nurse Anesthesia Annual CongressWashington, D.C.

www.alabamacrna.org • Fall 2015 • ALANA NewsBulletin 3

David Gay, CRNA, MSN, MNAPresident-Elect6615 Lubarrett WayMobile, AL 36695251.895.2880 (cell)[email protected]

Michael W. Humber, CRNA, DNP, MNAPresident-Elect1816 Hardwood View DriveBirmingham, AL. 35242205.981.0557 (home)205.934.5977 (office) 205.999.7544 (cell) [email protected]

Heather Fields, CRNA, MBA, MSNVice-President/Secretary2330 Ridge RoadOpelika, Alabama 36804334.749.3031 (home)334.728.3030 (cell)[email protected]

Matt Hemrick, CRNA, MSNTreasurer709 Braddock AveBirmingham, AL 35213205.246.0183 (cell)[email protected]

Todd Hicks, CRNA, MNASenior Director8600 Lenox WayMontgomery, AL 36116334.559.9333 (cell)[email protected]

Jay Kendrick, CRNA, MSNSenior Director2529 Simpson Point RoadGrant, AL 35747256.728.7308 (home)770.547.5793(cell)[email protected]

Lisa Vallely, CRNA, MSNASenior Director 4314 Boulder Lake CircleVestavia Hills, AL 35242205.977.9931 (home)205.504.1090 (cell)[email protected]

Trey S. Burg, CRNA, MNADirector202 Pebble Creek LnEnterprise, Al. 36330334.308.1012 (home)334.494.2178 (cell)[email protected]

Lisa M. McKinley CRNA, MSDirector9900 Turtle Creek Lane SouthMobile, AL 36695251.259.2020 (cell)[email protected]

David Sloan, CRNA, MSNDirector125 Easy StreetAnniston, AL 36207256.741.1606 (home)256.310.5855 (mobile)[email protected]

Board of DirectorsBryan A. Wilbanks, CRNA, DNPDirector105 Shady Spring DriveHarvest, AL 35749256.721.8531 (home)256.503.4360 (mobile)[email protected]

Salima P. Mulji, CRNA, MNANominating Committee Chair1503 Scout Ridge Dr,Birmingham, AL 35244205.835.5234 (cell)[email protected]

Christina Smyth, SRNAUAB Student Representative633 12th Street NWAlabaster, AL 35007)334.558.2052 (cell)[email protected]

Aaron Smith, SRNASamford Student Representative480 Walker WayPelham, AL 35124256.694.1593 (cell)

Brad A. Hooks, CRNA, MSNAReimbursement Chair9411 DunleithMontgomery, AL 36117334.414.3435 (cell)334.356.9970 (office)334.269.8783 (fax)[email protected]

Amy P. Neimkin, CRNA, DNP, MBAFederal Political Director368 Woodward Ct.Birmingham, AL 35242205.991.9405 (home)205.243.8382 (cell)[email protected]

Susan HansenGovernment Relations Specialist4120 Wall StreetMontgomery, AL 36106334.244.2187 (office)334.320.7539 (cell)[email protected]

Joe Knight, CRNA, JDALANA General CounselKress Building, Suite 500301 19th Street NorthBirmingham, Alabama 35203205.655.4501 (home)205.458.1200 (office)205.531.5157 (cell)[email protected]

Larry Vinson, CAE, MPAALANA Executive DirectorPost Office Box 240757Montgomery, AL 36124334.395.4663 (home)334.260.7970 (office)334.462.8035 (cell)334.272.7128 (fax)[email protected]

ARE CAUDAL BLOCKS FOR PAIN CONTROL SAFE IN CHILDREN? AN ANALYSIS OF 18,650 CAUDAL BLOCKS FROM THE PEDIATRIC REGIONAL ANESTHESIA NETWORK (PRAN) DATABASEAnesth Analg 2015:120:151-156 Suresh S, Long J, Birmingham PK, De Oliveria GS Jr.

AbstractPurpose The purpose of this study was to evaluate the safety profile of caudal regional anesthetic blocks in children. Additionally, the authors investigated patterns of local anesthetic dosing for caudal blocks.

Background The caudal block is the most commonly performed regional anesthetic in pediatric surgical patients. Pediatric neuraxial blocks are typically performed while the patients are under general anesthesia as compared to the blocks typically being performed on adult patients who are awake or lightly sedated. This difference allows for the potential risk of neurologic complications in the pediatric population.

Caudal blocks have been performed since 1933. The latest systematic reviews have yet to address safety concerns raised by previous reports. Further, a large safety analysis has yet to be performed producing providers and parents with crucial risk information which is vital when deliberating the performance of caudal blocks in children.

Methodology This study was performed using the Pediatric Regional Anesthesia Network (PRAN) database. Data were collected from 2007 through 2012. Demographic data included patients’ age, ASA status, and gender. Block performance data included level of consciousness during the block (awake, sedated, or general anesthesia), as well as block performance techniques; landmark or ultrasound- guided. Local anesthetic type, dose, and volume were retrieved and recorded.

The following were defined as complications from a caudal block:a) block failure (unable to place, difficult to inject, subcutaneous injection)b) vascular puncture (blood with aspiration) c) positive intravascular test dose d) dural puncture (CSF with aspiration) e) seizuref) cardiac arrest g) sacral pain h) other neurologic symptoms

Complications were recorded as either temporary or permanent.

Blocks performed using ropivicaine were converted to equipotent doses of bupivicaine using the following equivalency: 1mg ropivicaine = 0.7 mg bupivicaine. Logistic regression analysis examined the association between the type of anes-thesia (general versus awake) on the development of complications.

Result The analysis included 18,650 children who received a caudal block. Before 2010, 3% of caudal blocks were performed with ultrasound guidance compared to 2% in the following years. Caudal blocks performed while awake and/or sedated took place in the younger subjects, 2-18 months, compared to older patients,7-29 months, who had their blocks per-formed during general anesthesia. Overall, the estimated rate of complications from the placement of a caudal block was 1.9%. Complications were most prevalent in younger patients (median 11 months) while the older patients (median 14 months) were more likely to be complication free. No significant difference was noted in complication rates between

A n e s t h e s i a A b s t r a c t s


males and females. Further, the rate of complications did not differ when ultrasound- guidance was used compared to blocks placed without ultrasound-guidance. Complication rates in patients who were awake for the block were higher (4%) compared to patients who were under general anesthesia (2%). Complication rates were far less (1.2%) when a test dose was used compared to blocks that omitted a test dose (2.2%). The most common complications were:

• block failure 1% • blood aspiration 0.6% • intravascular injection (a positive test dose) 0.1%

Rates of other studied complications were as follows: • dural puncture 0.08% • cardiac arrest 0.005% • seizure 0.005%• sacral pain and muscle spasm 0.005%

No reported adverse events resulted in long-term complications. The rate of complications with any sequela was 0.005%. The median bupivicaine equivalent local anesthetic dose was 1.4 (0.78-2.51) mg/kg. Local anesthetic dose per kilogram weight was increased when epinephrine was used as an adjunct. Children who had a caudal block performed with ropivicaine received a larger total local anesthetic dose than those who had received a caudal with bupivacaine even after adjusting for the difference in drug potency, 1.66 mg/ kg ropivacaine (in bupivacaine equivalents) vs. 1.34 mg/kg bupivacaine.

A total of 4,406 patients (24%) received a large, potentially unsafe dose of more than 2mg/kg bupivicaine equivalent. And, 968 children (5%) received a potentially toxic dose of more than 2.5 mg/kg of bupivicaine. The children who received the potentially unsafe dose were younger than those who did not receive a potentially unsafe dose of caudal bupivicaine (11 months and 15 months respectively).

Conclusion A review of the PRAN database determined caudal blocks performed in over 20 different pediatric hospitals had an ex-tremely low rate of complications. The severe complications of cardiac arrest and seizure were found to be 0.005%, and the most common complication was block failure at 1%. No cases of long-term sequelae were recognized. However, a large variation in local anesthetic doses used for caudal anesthesia, including some potentially toxic and unsafe doses, were noted.

CommentRegional anesthesia is a pillar of anesthetic practice, offering remarkable efficacy. While the efficacy of caudal blocks has not been in question; some recent studies have presented safety concerns in pediatric surgical patients. This large and well-performed study debunks the majority of the previously proposed concerns, especially since 18,450 of the blocks were performed while the child was under general anesthesia. Additionally, the study highlights the importance of performing a test dose of local anesthetic prior to bolusing which was directly associated with lower complication rates.

There were some serendipitous findings during the study necessitating discussion. First, while adequately addressing the potential safety issues, the authors unmasked the large variability in dosing of both bupivicaine and ropivicaine. Secondly, the study highlighted the decreasing trend to implement ultrasound-guidance during caudal block placement.

Even with caudal bupivicaine administration reaching the potentially unsafe 2 mg/kg and potentially toxic 2.5 mg/kg doses, the study found no complications directly associated with the consistently high doses. Total local anesthetic dose


and patients’ weight had a linear relationship; however, patient weight was not the sole factor explaining such vari-ability. A quality improvement (QI) project should be focused on determining the reason for such high local anesthetic doses. The QI project’s conclusion will assist providers in avoiding unsafe local anesthetic doses for caudal anesthesia. Safe local anesthetic dosing is especially important in younger children who have been found to be the most “at-risk” for injury and toxicity.

Lastly, throughout the study, the use of ultrasound- guidance steadily declined, while the rate of caudal anesthetics consistently increased. A total inverse of the implementation of ultrasound-guidance for peripheral regional anesthesia in adults. The study suggested that ultrasound-guidance provides no increase to the safety profile of caudal anesthesia. Therefore, this finding should not be terribly surprising.

Caudal blocks in pediatric surgical patients are safe and effective. Providers should be vigilant with correct local anes-thetic dosing and confident in the evidence supporting the safety profile of regional anesthesia.

Kenneth J. Taylor, DNP, CRNAANESTHESIA ABSTRACTS IS A PUBLICATION OF LIFELONG LEARNING, LLC © COPYRIGHT 2015 ISSN Number: 1938-7172

Provided as a service to the ALANA by Anesthesia Abstracts (www.AnesthesiaAbstracts.com) Michael A. Fiedler, PhD, CRNA, Editor

ALA-CRNA PAC Needs YOUR Support!All CRNAs are asked to contribute to ALA-CRNA PAC. ALA-CRNA PAC is the voice for nurse anesthetists in Ala-bama. The PAC allows us to speak with one combined voice. Give something back to the profession that has been so good to you. Send contributions to ALA-CRNA PAC, 4120 Wall Street, Mtgy, AL 36106. Contribute to ALA-CRNA PAC today!


by Terri M. Cahoon, DNP, CRNAChair, Nurse Anesthesia Department, Ida V. Moffett School of Nursing

UpdateIn May, the twenty-three members of the Class of 2015 graduated and are starting their careers in eight different states. Fourteen graduates will be working in hospitals where they will become preceptors for our nurse anesthesia students. Fifteen of the 23 will be employed in rural or medically-underserved area hospitals. The success of nurse anesthesia students and graduates is a reflection of the incredible preceptors who mentor and teach them during their clinical education.

At a graduation luncheon in May, the Class of 2015 celebrated with the department faculty and staff. The Agatha Hodgins Award was given to Jason Asher as the most outstanding nurse anesthesia student. This award is to recognize Jason’s excellence in clinical practice, service and leadership skills as well as academic achievement. The Resa Culpepper Professionalism Award was given to Emily Bromley for her professionalism and service as an anesthesia student. Emily served with Med Mission to organize supplies for charitable use, participated in a medical missions trip to Ecuador in the spring, and shared with fellow students about her experience. The class also celebrated their achievements: 49,468 clinical hours, 18,588 anesthetic cases, 575 service-learning hours, and 23 jobs in waiting!

Several students were recognized at the annual awards day. Bethany Adkins received the Alumni Association Award for the nurse anesthesia student with the highest grade point average. Bethany graduated with a 4.0 and a class average of higher than 97.5%. Diana Horne received the Lonnie Funderburg Scholarship for commitment to the urban, underserved community. Looking back at her invaluable experience in critical care at Grady Memorial Hospital, Diana states, “I feel like I received far more than I gave at Grady. I received the immeasurable gift of awareness, and my eyes were opened to a world that I didn’t know existed.” Diana welcomes the possibility of returning to her passion of urban healthcare upon graduation.

Five students in the classes of 2016 and 2017 will be attending the AANA Annual Congress in Salt Lake City in August. Through the generosity of our alumni and friends, the students’ registration and hotel accommodations will

be covered by the Anesthesia Student Travel Fund. Precious Stallings will be representing Samford in the 2015 Anesthesia College Bowl on Monday night. Alayna Wells will receive an ALANA Scholarship at the AANA Annual Meeting Student Scholarship Luncheon. Bradley Messner was selected as a recipient of an Army Nurse Corps Scholarship.

Many students have volunteered with different com-munity ministries as part of the program’s service learning emphasis. In April, ten stu-dents participated in the inter-professional IVMSON Disaster Simulation with graduate and undergraduate stu-dents from other disciplines as well as commu-nity partners from Homewood and Jefferson County. Along with serving in a triage role during the simulation, they used their creativity to “make” victims to lend to the realism of the event. In late August, eight stu-

Continued on next page

Aimee Russell and Jessica Aubin preparing a victim for the disaster drill.


Bradley MessnerPrecious Stallings Alayna Wells

dents will serve as role models and instructors for undergraduate students in simulation related to airway management and hemodynamic monitoring. A team of students will participate in the Bell Center’s Tailgate event in the fall as well. Mrs. Amy Snow will continue to host the “Lunch and Learn” sessions to inform students of professional, community, and ministry service opportunities.

The department was recently awarded a Nurse Anesthetist Traineeship (NAT) Program grant from the U.S. Depart-ment of Health and Human Services’ Health Resources and Services Administration (HRSA). This grant will provide $25,527 to both first and second year students to help defray tuition, books, and living expenses. This is the 12th year for Samford to receive a NAT grant. To date, Samford has received more than $213,525 through the HRSA NAT Pro-gram.

During the summer, the nurse anesthesia program received the maximum 10 years of continuing accreditation from the Council on Accreditation of Nurse Anesthesia Educational Programs (COA). Notification of the accreditation deci-sion follows an extensive self-study and site visit conducted in fall 2014. We are grateful for supportive administration and staff, caring faculty, and incredible students and alumni. We are indebted to clinical coordinators, preceptors, and alumni who came to campus to meet the reviewers and allowed them to observe in the OR, especially Children’s of Alabama, Princeton Baptist Medical Center, Brookwood Medical Center and St. Vincent’s Health System.

The students, alumni, and faculty of the nurse anesthesia program are excited to welcome Jackie Rowles, MBA, CRNA, ANP-BC, FAAN as the Funderburg Lecturer at the ALANA Fall Meeting. Ms. Rowles serves as the President of the International Federation of Nurse Anesthetists and specializes in pain management. The Funderburg Lectureship Series was established by alumni of the Birmingham Baptist Nurse Anesthesia Program and the Samford program to honor Dr. Lonnie W. Funderburg, a dedicated and selfless leader in healthcare education.


Maggie Kelley “creating” a victim for the IVMSON Disaster Simulation.

Maggie Kelley, Aaron Smith, Jessica Aubin, Brooklyn Williams, Austin Bowen, Zach Adams, Aimee Russell, Lacey Denton,

Christine Wood, and Alicia Gladden served in triage during the IVMSON Disaster Drill.

Todd L. Hicks, MNA, CRNA, Assistant Professor

Update

As summer comes to a close, the students and faculty at UAB have been extremely busy. We currently have three classes matriculated, the Class of 2015 is wrapping up clinical rotations and Graduate Projects as they approach graduation in December. The Class of 2016 has com-pleted the first two months of their 18 month clinical rotations. The Class of 2017 has just begun their didactic work on campus. Our program is fortunate to have the extensive resources associated with the University, as well as the medical center and high-fidelity simulation centers.

We look forward to the AANA Annual Congress in Salt Lake City. Both faculty and students will attend the meeting, and one of our senior students, Cari Evans, was selected to represent UAB Nurse Anesthesia in the College Bowl tournament where the students face off against the CRNA team!

In other news, Senior Elizabeth Reynolds received both the ALANA and GANA Student Scholarships this year. Senior Joshua Thomas received the UAB William Groce Campbell Endowed Nursing Scholarship, and junior Shelby Woltjen received the Violet Terrell Clark Nursing Scholarship. Finally, the UAB students were thrilled to win the Sandcastle Trophy at the ALANA Spring Meeting.

Go Blazers!



Brent H. Ledford, MS, CRNAHuntsville, AlabamaStaff Anesthetist Huntsville Hospital, Huntsville, Alabama

Education/Service:Birmingham-Southern College, BS Biology/Chemistry 1981University of Alabama in Huntsville BSN 1985Middle Tennessee School of Anesthesia MS Anesthesia 1994ALANA BOD 2000-2005

I am a mid-fifties recent empty nester, with two kids at Au-burn, and a wonderful wife named Cindy that is an Auburn pharmacy graduate. If you can’t find me on any given Saturday in the fall, I am probably trying to find the latest, greatest shortcut between Huntsville and Auburn. So, right up front, I guess you know where my allegiance lies. Look, all I can tell you is that if you are not OK with that then I guess you will have to vote for someone else for this position. Seriously though, I look forward to the day that you will not only have a choice of whom you vote for, but that we may have to turn down qualified people that want to run for the board because we have too many that are interested.

Some of you may remember that a few years ago I served on the ALANA BOD for six years, including two terms as president. I believe that an organization is best represented by a BOD that is composed both of experienced members that are seasoned (read older), and new younger members that often bring an exuberance and fresh perspective to the table. I will strive to always listen to the seasoned and the fresh, as well as to any member that wants to contact me regarding any issue that is pertinent to the practice of nurse anesthesia in Alabama.

I currently practice in both an ACT environment in a level one trauma center as well as solo for a plastic surgery group in their office. Each arrangement has its unique challenges and rewards, and I am thankful to be able to do both. The level one trauma center keeps my skills sharp, and the office practice reminds me of the importance of the AANA,

President-Elect

the ALANA, and our lob-byists and directors that do their work not in a hospital, but in the offices of our na-tional and state capitals.

I appreciate the opportunity to serve the CRNA’s of Alabama in this capacity. I will tell you that I don’t have a Facebook, Twitter, Instagram, or Snapchat account, as it is just not my style. I have an email address and a cell phone, both of which are published, and as I said before, I invite you to share your ideas for making nurse anesthesia in Alabama an even better profession. Heck feel free to share your ideas about SEC football, just remember that where my money goes, so goes my heart. Thanks for your consideration of my candidacy, hopefully for your vote, and for encouraging a seasoned (graybeard) CRNA to return to service for his colleagues.

Contact Information:Brent H. Ledford, MS, CRNA306 Broad Armstrong Dr.Brownsboro, AL 35741256-533-0642 home256-426-0503 cell 334-260-7970 ALANA State [email protected]

Brent H. Ledford, MS, CRNA

Vice President/SecretaryEdward W. Murphree, CRNA

Edward W. Murphree, CRNAPell City, AlabamaUniversity of Alabama Medical Center Staff CRNA

Education/Service:Jefferson State Community College, Associate Degree of Nursing 1986UAB School of Nursing, Bachelor of Science in Nursing 1992UAB School of Health Related Professions, Bachelor of Science 1994UAB School of Health Related Professions, Nurse Anesthesia 1994ALANA Board of Directors, 2000-2002

I come to you once again and offer myself as a tool to help hone the edge we need in order to stay on top of our practice. It’s not that “ah ha” moment we have with the spawn of ideas, but the work necessary to bring the thought to life that counts most. I am asking for your support to put me in place to lead us past our problems and build a stron-ger association.

Together we can continue to support one of the best pro-fessions offered to anyone willing to accept the challenge. Among us are weak and tired individuals that allow apathy to guide them, but we need to bind together and rise up for the many challenges we will face each day.

Thank you for your interest and support.

Contact Information: Edward W. Murphree, CRNA, BSN2025 Cleveland Farm ParkwayPell City, Alabama 35125205.338.1324 (home)205.616.0063 (cell)[email protected]

President-Elect


Vice President/SecretaryKyle Vanderford, CRNA, MSN

Kyle M. Vanderford, CRNA, MSNHelena, AlabamaUAB Highlands Hospital, Birmingham, ALStaff Anesthetist

Education/Service:University of Southern Mississippi, BSN, 2002Samford University, MSN, 2006Board of Directors 2010-2012Nominating Chair 2007-2008Welcoming Committee 2007-2010, 2012-2014PAC Committee 2015

Position Statement:I’m excited about the opportunity to serve the ALANA in another leadership position! Having served in the past as Nominating Chair, a Director, and on multiple committees, I know first hand how important it is to be involved in the Promotion and Protection of our Awesome Profession. After spending some time away to take care of my young family, I’m ready to be involved in ALANA Leadership once again. That is why I would appreciate your vote for Vice President/ Secretary. As a CRNA in Alabama, we have to be constantly vigilant in Montgomery to protect our FULL Scope of Practice while continuing to educate the public on our role and track record as Qualified, Educated, Safe, and Compassionate providers of the art and science of Anesthesia. This can not be done alone, but instead takes a large group of people who are dedicated to offer the time and effort it takes to serve All CRNAs in Alabama. Your ALANA Board of Directors is that group, and I want to be a part of it once again. I want to serve You as Vice President/ Secretary so that we can continue to keep our ability to practice independently in all healthcare settings in Alabama while being fully reimbursed for our services.

I would appreciate your vote and look forward to serving all of you in the future.

Contact Information: Kyle M. Vanderford, CRNA, MSN1603 Paddock LaneHelena, AL [email protected]


Vice President/SecretaryKyle Vanderford, CRNA, MSN

Director NorthRay Dunn, MNA, CRNA


Ray Dunn, MNA, CRNA is the Chief CRNA at Northport Hospital DCH as well as a practicing clinician. He earned his Bachelor of Science in Nursing degree from Auburn University Montgomery, his Masters of Nurse Anesthesia degree from The University of Alabama Birmingham, and is completing his Doctorate of Nursing Practice degree from the University of Alabama.

Ray is retiring from the United States Navy after 24 years of honorable service. He has served as enlisted and as an officer both active and reserve. He is a veteran of Operation Iraqi Freedom and Operation Enduring Freedom receiving numerous citations and awards to include the Department of Health and Human Services Commendation Medal, Army, Navy and Marine Corps Commendation Medals, Combat Action Ribbon and Navy and Marine Corps Achievement Medal to name a few.

He was named an Alabama Health Care Hero by the Alabama Hospital Association as well as an Employee of Excellence by the DCH Health System.

Contact Information: Ray Dunn, MNA, CRNA14810 Highway 171Northport, AL 35475

Director CentralRob Holt, MNA, CRNA

Robin Holt, MNA, CRNABirmingham,AlabamaUAB Hospital, Birmingham, Al.Staff Anesthetist

Education:University of North Alabama, BSN, 1995UAB Nurse Anesthesia Program, MNA, 2010

Position Statement:Today we are faced with many challenges in our ever changing profession as Anesthetists. We must embrace and move forward together as a community as these changes come. We have to protect our scope of practice and continue to provide quality service to our patient population in these times of change. As a profession, we must continue to grow strong as a community and one voice in legislation to ensure our practice is protected for now and in the future. Our voice must continue to be heard in legislation to educate those who may fail to understand the importance of our profession. Not only legislation, but we must also continue to educate our community around us to ensure they are aware of the service that we provide.

If elected, I will dedicate my time and abilities to maintain the service that has been provided by fellow Anesthetists that have served on the Board of Directors in the past. I will give my best effort to improve and protect our practice by joining with educators, legislators and others that work closely with the ALANA. I would appreciate your vote and hope to serve my community of Nurse Anesthetists.

Contact Information:Robin Holt, MNA, CRNABoard of Directors4036 Cambridge DriveMoody, Al. 35004205.613.0360 (cell)205.934.6948 (work)[email protected]


Director Central Patricia Smith, DNP, CRNA

Patricia Smith, MHS, DNP, CRNABirmingham, AlabamaUAB, Birmingham, AL Staff Anesthetist, Nurse Anesthesia Clinical Preceptor

Education/Service:University of West Alabama, RN, 1979University of West Alabama, Bachelor of Biology, 1993Texas Wesleyan University Nurse Anesthesia Program, MHS, 1998UAB, DNP, 2009UAB, Candidate for EMHA (current)

Position Statement:In today’s fast-paced working world, it’s easy to be part of the dispirited majority that sits on the sidelines when asked to participate in anything that requires something we have little of, time. I feel we owe much to the hard work of others who have gone before us and to that end must be prepared to do the things that will allow for the continued growth and awareness of our vocation.

Together we can work to embrace change and challenge the thinking of educators, legislators, and others who have interests in learning more about the roles we fulfill in the medical workplace today. I am committed to the position I seek and to doing my part as we continue to work to broaden public awareness while seeking to discover new and better ways to care for the lives we touch.

In an effort to give back to the Nurse Anesthetist community, I am interested in contributing my time and talents to being an active participant, by serving on the ALANA Board of Directors. I would appreciate your vote and will strive to be my best to represent the position.

Contact Information: Patricia Smith, DNP, CRNA1007 Watersedge CircleBirmingham, AL 35242205.995.0109 (home)205.807.7151 (cell)[email protected]


Director CentralRob Holt, MNA, CRNA

Director SouthWillie Furr, CRNA, MSN, DNPc

Willie Furr, CRNA, MSN, DNPcAndalusia, AlabamaStaff Anesthetist

Education/Service:Troy University, BSN 1999University of Tennessee at Chattanooga, MSN 2004Post Anesthesia EducationTroy University, DNP (current). Expected completion May 2016.Previously served on the ALANA PR committee

Position Statement:Health care continues to evolve, presenting challenges for many providers. So too then, must CRNAs be able to adapt and meet the healthcare needs of those we serve. It is an exciting time to be a CRNA where we have the opportu-nity to practice our profession in increasing roles. With the right to practice, comes responsibility. Responsibility to our patients, our peers, and to our profession. I believe that Advance Practice Nurses (APNs) like CRNAs will con-tinue to fill the primary care provider roles in an environ-ment where we can practice to the full extent of our scope of practice, and our education and training.

CRNAs will play a vital role in care that is moving away from physician centered care towards patient centered care. An environment where multiple disciplines, including CRNAs, will have equal, valuable, shared contributions in a collaborative environment. Where outcomes will be measured as a means of success. I believe through continued education, research, and participation in our state’s professional association, any obstacles can be overcome. I am honored to be nominated to serve on the ALANA Board of Directors, for the southern region, where I look forward to supporting and contributing to the success of Alabama’s talented CRNAs.

Contact Information:Willie Furr18157 Cross Creek RoadAndalusia, Alabama 36420(334)222-4775 (home)(334)488-6109 (cell)Email: [email protected]


Director SouthDarien H. Arrington, CRNA, MSN

Darien H. Arrington, CRNA, MSNSelma, AlabamaVaughn Regional Medical Center, Selma, AlabamaStaff Anesthetist

Education:Samford University, BSN, 1999Samford University, MSN, 2005

Position Statement:Working as a nurse anesthetist in a rural hospital for the past nine years I have strived to maintain a strong commitment to the patients and community I serve. Each CRNA in Alabama is a valuable asset to their respective community in so many ways. As nurse anesthetists we do not just provide anesthesia, but play a vital role in the healthcare, education, and community continuum.

The success of our profession is due in part to the strong, dedicated, and conscientious leadership of ALANA. AL-ANA has continuously advocated for the recognition and advancement of our profession. It would be an honor and privilege to serve as a member of the board of directors for such a highly esteemed association of professionals and continue to work towards advancing our practice and high standard of care.

Contact Information: Darien H. Arrington113 Deer Ridge DriveSelma, Alabama 36701334.872.7748 (Home)334.410.0735 (Mobile)[email protected]


Nominating Committee Emily Trammel, CRNA

Emily Trammell, CRNA, MSNStaff CRNA Anesthesia Resources ManagementSt. Vincent’s, Birmingham

Education/Service: UAB, BSN, 2005 Samford University, MSN, 2011

I have been working as a CRNA for two years. And everyday I know that I have chosen a wonderful profession. It is a challenging yet rewarding career and I feel blessed to be a part of this profession. As a relatively new CRNA I look forward to the opportunity to become more involved with my peers and my state organization.

I am so happy I was asked to serve on the Board of Directors and I am prepared to give my time and hard work to see continued growth in this vocation. In this ever changing healthcare climate it is important we work together to promote this profession. I would appreciate your vote and will give my best to this association.

Thank you.

Contact Info: Emily Trammell, CRNA, MSN 6927 Meadow Ridge Drive McCalla, AL 35111 205.994.4107 (cell) [email protected]


Nominating Committee Krista Niedermeier, CRNA, MNA, DNP

Krista Niedermeier, CRNA, MNA, DNPChildren’s of Alabama, Birmingham, ALStaff Anesthetist, Senior CRNA: Capital Equipment and Supplies

Education/Service:University of Alabama at Birmingham, BSN, 1989University of Alabama at Birmingham, MNA, 2006University of Alabama at Birmingham, DNP, 2013Program Committee 2009Program Committee Chair 2010Welcoming Committee 2014

I am proud to be an Alabama CRNA and it would be a privilege to be your next ALANA Nominating Committee Chairman. We have a strong, cohesive organization with an incredible leadership history and I want to continue that legacy by searching for those who have the vision, dedication and sheer determination to preserve and protect our practice on the state and national levels. In today’s competitive provider market, we must educate our patients, their families, and our elected officials about who we are, what we do, and how well we do it. Our ALANA officers are on the front line of the political arena and putting the best out there starts with the ballot.

As a former Program Committee Chair, Program Commit-tee member and Welcoming Committee member, I have worked with several ALANA boards. As a Children’s of Alabama CRNA for almost nine years, I have worked with hundreds of SRNAs who are now CRNAs throughout the state. With those networks, I will search statewide to fill the ballot with candidates who want to listen, advocate and commit to hard work. I am eager and prepared to serve the ALANA and would be honored to receive your vote.

Contact Information:Krista Niedermeier, DNP, MNA, CRNANominating Committee Chairman6074 William O LaneGardendale, AL 35071205.563.0602 (cell)[email protected]


May [email protected]

Keywords: anorectoplasty, prone, revision, pediatric, imperforate anus

Anorectal malformations occur in 1 of every 2500-5000 births and are classified as low, intermediate, and high.1 The most common surgical approaches to treat these conditions are laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP).2

Case ReportA 12 year old, 35 kg female presented with complaints of frequent constipation for an open revision of a posterior sagit-tal anorectoplasty. The patient had a past history of imperforate anus surgically corrected by modified Pena posterior-sagittal anorectoplasty at age one year, with subsequent history of frequent constipation and impaction removal at age nine years. Other pertinent history included sickle cell trait and fluid deficit of 1200 mL. Upon arrival to the operating room and application of monitors, the patient underwent an inhalation induction with oxygen 8 L/min and sevoflurane 8% inspired concentration. Once through excitement stage, a 20 gauge peripheral intravenous catheter was inserted in the patient’s left hand and lactated Ringer’s was started. While the patient was hyperventilated with sevoflurane 8% inspired concentration and 8 L/min oxygen, lidocaine 40 mg, propofol 100 mg, fentanyl 25 mcg, and ondansetron 4 mg were administered. The trachea was intubated and a 5.5 cuffed endotracheal tube was secured 18 cm at the lip with respirations controlled by a mechanical ventilator in pressure-control mode. The volatile agent was changed to desflu-rane and maintained at 8-9% inspired concentration with a gas mixture of oxygen 0.25 L/min and air 0.25 L/min. The eyes were taped and an esophageal temperature probe was placed. The patient was transferred from the stretcher to the bed and placed in a prone jack-knife position with all pressure points padded and upper body forced-air-warming device applied. Zosyn (piperacillin/tazobactam) 3.375 gm was administered per surgeon request. Once the patient was prepped and draped, a time out was performed and the procedure began. Upon incision, fentanyl 25 mcg was administered. The patient received an additional fentanyl 25 mcg during cauterization of bleeding vessels approximately one hour into the case, and a final fentanyl 25 mcg during wound closure at the end of the 2.5 hour case. Upon closure, the patient was placed supine on the stretcher, the desflurane and air were discontinued, and oxygen flows were increased to 8 L/min. Tape was removed from the patient’s eyes, the esophageal temperature probe was removed, and the oropharynx was suctioned. Out of excitement stage and upon return of regular respirations with noted grimace, the endotracheal tube was removed and spontaneous respirations were confirmed. Total blood loss was 25 mL while total fluid infused was 1500 mL. The patient was then transported to the recovery room without complaints of pain or nausea.

DiscussionThe most common methods of surgical repair for anorectal malformations are laparoscopic-assisted anorectoplasty and posterior sagittal anorectoplasty.2 This case was a repair of a previous sagittal approach, so the surgeon used the same open posterior approach.

An important consideration for this type of procedure is the patient’s respiratory status. If the patient has adequate respiratory reserve, the prone jackknife position is appropriate. Otherwise, the patient may require a lithotomy position to maximize respiratory efficiency.4 The prone position can limit diaphragmatic excursion if the abdomen is compressed by the body’s weight or positioning devices.5 This abdominal compression can be ameliorated by allowing the abdomen to hang free, which improves diaphragmatic excursion.5 The patient had no pre-existing respiratory pathophysiology, allowing her to be placed in the prone jackknife position to maximize surgical exposure. She tolerated this position with-out respiratory compromise while steps were taken to insure her abdomen was not compressed, maximizing diaphrag-matic excursion.

Open Revision of Anorectoplasty in Pediatric Patient

Aaron Smith, Samford University



A second consideration for this type of procedure is the potential for pressure injuries, nerve injuries, and ophthalmic in-juries.3 Pressure injuries occur due to a reduction in vascular supply and drainage from an area that is being compressed.3

These were prevented in this patient as the surgeon and anesthesia providers examined all potential pressure points and padded them with foam, pillows, or gel rolls. Nerve injuries are thought to occur due to compression or undue stretch of peripheral nerves, leading to neuropathy.3 These were prevented in this patient by placing the patient’s arms with flexion less than 90 degrees at the shoulder and elbow to protect the brachial plexus and ulnar nerves, respectively. Ophthalmic injuries can occur due to direct pressure on the eyes, leading to retinal artery occlusion or global ischemia.3 These were prevented in this patient with a foam prone head positioner padding the patient’s face. Holes were torn out of the foam pad eyehole to insure no pressure on the eyes. Additionally, frequent checks for eye pressure occurred throughout the case. Normotension was maintained throughout the procedure to prevent damage via global ischemia.

A third consideration for this type of procedure is a potentially decreased cardiac output. It is thought that a decrease in preload from abdominal compression could contribute to this.3 The mechanism for this decreased preload is thought to stem from multiple sources: blood trapping in dependent body parts, vena cava compression, and positive pressure ventilation.3 This patient was positioned with the abdomen hanging free, preventing a decreased preload from vena cava compression. Blood trapping in dependent body parts and positive pressure ventilation were not noted to be significant to the patient’s blood pressure, as the patient remained normotensive throughout the entire procedure.

One final consideration for this type of procedure is airway management. The airway of choice for patients in the prone position is a securely fastened cuffed endotracheal tube.3 This helps to prevent accidental extubation and the occurrence of gastric regurgitation and aspiration. Thus, this patient’s trachea was intubated with a 5.5 cuffed endotracheal tube. The cuff was sealed to a 20 mm Hg leak, and was then securely taped to the patient’s face with two pieces of pink tape after equal bilateral breath sounds were confirmed. While re-positioning the patient to a prone jack-knife position, the anes-thesia circuit was disconnected and a constant secure grip was maintained by the anesthesia practitioner on the endotra-cheal tube to prevent accidental extubation. Once the patient was prone, tube position was again checked and bilateral breath sounds were auscultated to confirm the tube had not migrated from its original placement. The patient’s endotra-cheal tube and respiratory status were frequently monitored throughout the entire procedure.

Summarily, this type of procedure demands attentiveness to detail. Small differences in patient position can have drastic implications: respiratory compromise, pressure injury, hemodynamic compromise, or accidental extubation. The an-esthesia practitioner must maintain vigilance throughout this procedure, and all procedures, to achieve optimal patient outcomes.

References1. Danielson J, Karlbom U, Graf W, Olsen L, Wester T. Posterior sagittal anorectoplasty results in better bowel function and quality of life in adulthood than pull-through procedures. J Pediatr Surg. 2015. doi:10.1016/j.jped-surg.2015.02.004. 2. De Vos C, Arnold M, Sidler D, Moore SW. A comparison of laparoscopic-assisted (LAARP) and posterior sagittal (PSARP) anorectoplasty in the outcome of intermediate and high anorectal malformations. S Afr J Surg. 2011;49(1):39-43.3. Feix B, Sturgess J. Anaesthesia in the prone position. Contin Educ Anaesth Crit Care Pain. 2014;14(6):291-297.4. Shelton AA, Pineda CE, Welton ML, Guta C, Hsieh V. Colorectal surgery. In Jaffe RA, Samuels SI, Schmiesing CA, Golianu B, eds. Anesthesiologist’s Manual of Surgical Procedures. 4th ed. Philidelphia, PA:Lippincott Williams & Wilkins; 2009:525-547.5. Thompson JL. Positioning for anesthesia and surgery. In Nagelhout JJ, Plaus KL, eds. Nurse Anesthesia. 5th ed. St. Louis:Elsevier; 2014:403-422.

Fall Meeting 2015October 16-18, 2015

Ross Bridge, Birmingham, AL

We will open on Friday at noon with Adult and Pediatric Cardiovascular Symposiums. At the conclusion of the Symposium, ACLS and PALS testing will be made available for those interested in getting their card. On Saturday we open early with an exciting lecture by AANA Region 7 Director, Garry Brydges, DNP, CRNA, ACNP-BC, who will also provide the AANA Update later in the morning. We will also offer a special breakfast meet-ing for our students. The Funderburg Lectureship Series follows, which is sponsored by the Samford University Nurse Anesthesia Program and its alumni. This year’s Funderburg lecturer will be Jackie Rowles, CRNA, ANP-BC, MBA, MA, FAAN. She will be addressing the fluoroscopy issue and pain management therapies. She is a past president of the American Association of Nurse Anesthetists and currently practices in an inter-disciplinary pain management clinic in Carmel, Indiana.

We have scheduled our ALANA Update and Business Meeting Saturday and have invited Congressman Gary Palmer to address our group. Dr. Ronald Thompson wraps up the afternoon with an interesting presentation on Neck Imaging.

Later that afternoon, we invite ALL ALANA members to join us for a Membership Reception on the Club House Patio. It will feature your favorite beverages and some delicious food. We will have a number of fun items in our Ala_CRNA Pac raffle, so don’t miss this opportunity for fun.

On Sunday, we start early again with more outstanding professional development sessions featuring anesthesia issues in dealing with Myasthenia, Demyelinating Diseases and Prader Willi Syndrome. After a short break, we conclude with sessions on radiology and liability issues for CRNAs.

We promise an information-packed meeting with lots of time to visit old classmates and make new friends in the anesthesia profession. ALANA offers the absolute finest in nurse anesthesia continuing education. We’ve earned this reputation by offering excellent speakers, classroom seating, complimentary continental breakfast and beverage service, complimentary Saturday Luncheon, and the best exhibitors ~ all of which make for a first-class meeting at a very affordable price.


Special ALANA Membership Reception - Please Join Us on the Club House Patio

We are inviting all ALANA members to join us for drinks and hors d’oeuvres on Saturday afternoon, October 17th, at the beautiful Ross Bridge Resort. We promise a wonderful afternoon of socializing with your peers in the anesthesia profession. We will have the games on, have a number of exciting items in our ALA-CRNA PAC raffle and more.

Please email the ALANA Office at [email protected] or call us at 334.260.7970 and let us know you are coming so we can make the appropriate plans.

Hope to see ALL ALANA members there.

Michael Humber, DNP, CRNABirmingham, AL

Scott Karr, M.Ed., NREMT-PMedical Education Associates

John McCallStarnes, Davis FlorieMobile, AL

Rachel Pickett, RN, BSNBirmingham, AL

Dr. Ronald ThompsonRadiology Enterprises

Fall Meeting 2015October 16-18, 2015

Reservations should be made directly with Ross Bridge at 1.205.916.7677. Rooms blocked for ALANA are at a discounted group rate of $163 per night single/double. The cut-off date for hotel reservations is September 10th. Select the registration options you wish to attend, then mail your registration form to the ALANA Office. Or, register and pay online at the ALANA web site www.AlabamaCRNA.org. If you have questions, just contact the ALANA Office at (334) 260-7970.

Name

Address

City State Zip

E-mail address

AANA Number

Method of Payment:

£Checks payable to: ALANA

£Credit Card: £MasterCard £Visa £AE

Card Number: Expiration:

Signature:

Refund Policy: Refunds on tuition will be honored upon receipt of a written request prior to October 1, 2015, subject to a $50.00 cancellation fee.

Send completed registration form and payment to:ALANA

Post Office Box 240757Montgomery, AL 36124

Or, register and pay online at AlabamaCRNA.org


Funderburg LecturerJackie Rowles, CRNA, ANP-BC, MBA, MA, FAANNRI Clinic for Complementary Medicine Indianapolis, Indiana

Lindsay Bonner, RN, BSNBirmingham, AL

Garry Brydges, DNP, CRNAMD Anderson Cancer Center Houston, TX

Nora Bradshaw, CRNA, MSNBirmingham, AL

David Gay, CRNA, MSN, MNAPresident, Alabama Association of Nurse Anesthetists

Faculty

Pre-registration rates listed here. Walk up registration rates will be 10% higher. CEUs Member

Non-Mem-ber

All Sessions, ACLS & PALS 20 $450 $550ala-cart

Adult Cardiovascular & ACLS (Friday Afternoon) 4 $100 $125

Pediatric Cardiovascular & PALS (Friday Evening) 4 $100 $125

All Regular Sessions (Sat & Sun) 12 $275 $350Saturday Only 7 $150 $200Students if pre-registered $25 $25ALANA Golf Outing $150 $200Sunday Only 5 $125 $150ALA-CRNA PAC Contribution

Sponsor-A-Student $25 $25

Total (enter total CEUs and fees)

ALANA NewsBulletin • Fall 2015 • www.alabamacrna.org

Dues Non deductibility Notice In addition to the amount of your member dues determined by the American Association of Nurse Anesthetists, Inc. as not tax deductible due to lobbying activities on the Federal level, the Alabama Association of Nurse Anesthetists, Inc. reasonably estimates that $57.00 of your dues is attributable to lobbying activities on the State Level and is, therefore, not tax deductible.

MBMMedical Business Management

“CRNA Billing Specialist”Contact: Joe Gribbin

1025 Montgomery Highway, Suite 100Birmingham, AL 35216

[email protected]

www.MBMPS.com

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