Ccc

7,123 views

Published on

Published in: Health & Medicine, Education
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
7,123
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
53
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Ccc

  1. 1. Core Clinical Competencies inAnesthesiologyA case-based approachThe core clinical competencies in anesthesiology can be pretty blurry – just how do they apply toreal life? This book answers this question, incorporating the core clinical competencies into anengaging format that anesthesiologists like: case studies. So, far from being a dry and dustyvolume of forgotten lore, this book actually makes learning the competencies fun! Written in the same engaging style as a number of other anesthesia books (specifically, theBoard Stiff opus) by anesthesiologists from leading medical centers across the United States,this book brings the core clinical competencies to life for residents, attendings, and medicalstudents alike.Dr. Christopher J. Gallagher is an Associate Professor in the Department of Anesthesiology at StonyBrook University. He is the recipient of teaching awards from Duke University, University of Miami,and Stony Brook University. He was also awarded the Anesthesiology Teaching Recognition Award forAchievement in Education by the International Anesthesia Research Society. Dr. Gallagher is the author ofbooks on oral boards, anesthesia procedures, transesophageal echocardiography, and simulation. Outsideof medicine, he has written one book on tennis, one on World War I, and another on learning foreignlanguages. He is fluent in five languages, conversant in another five, and can ask for the bathroom in anadditional five. He has not yet achieved People magazine’s “50 Most Beautiful People” list, but hope springseternal in the human breast. He is the father of one and husband of one.Dr. Michael C. Lewis is a Professor at the Miller School of Medicine at the University of Miami (UM).He has served as chief of anesthesia service at the Miami Veterans Affairs Health Care Center and as itsdirector of medical student teaching. At UM, he has also held the position of chief of academic programsin transplant anesthesia in addition to his capacity as residency program director, chair of the MedicalSchool Faculty Council, and vice chair of the University Senate. Most recently, he was appointed assistantdean for international graduate medical education. Dr. Lewis has been awarded a Hartford Award fromthe American Society of Geriatrics and was a Fulbright Scholar in 2006. He is active in the Florida Societyof Anesthesiologists, presently serving as its president. He is also the current national president of theIsrael Medical Association, World Fellowship: USA, and is on two committees of the American Societyof Anesthesiologists, while being an active member of the House of Delegates of the American Board ofAnesthesiology. He is married to Judy and has three daughters.Dr. Deborah A. Schwengel is an Assistant Professor in the Department of Anesthesiology at JohnsHopkins School of Medicine and a pediatric anesthesiologist at the Johns Hopkins Children’s Center.She is the anesthesiology residency program director and designer of an innovative education program atJohns Hopkins. She is founder and director of the International Adoption Clinic of the Kennedy KriegerInstitute and the Johns Hopkins Children’s Center. In addition, she is a critical care consultant at St. AgnesHospital and Mt. Washington Pediatric Hospital, both in Baltimore. Dr. Schwengel’s research is focusedon clinical studies of the care of children with obstructive sleep apnea. She is also newly involved in edu-cational research, no longer content with the old apprenticeship and lecture hall residency educationprograms. She has three internationally adopted children who, together with 75 anesthesiology residents,make life a never-ending string of dramatic and humorous tales.
  2. 2. Core Clinical Competencies inAnesthesiologyA case-based approachEdited byChristopher J. GallagherStony Brook UniversityMichael C. LewisUniversity of MiamiDeborah A. SchwengelJohns Hopkins Medical Institutions
  3. 3. CAMBRID GE UNIVERSIT Y PRESSCambridge, New York, Melbourne, Madrid, Cape Town, Singapore,S˜o Paulo, Delhi, Dubai, Tokyo aCambridge University Press32 Avenue of the Americas, New York, NY 10013-2473, USAwww.cambridge.orgInformation on this title: www.cambridge.org/9780521144131c Cambridge University Press 2010This publication is in copyright. Subject to statutory exceptionand to the provisions of relevant collective licensing agreements,no reproduction of any part may take place without the writtenpermission of Cambridge University Press.First published 2010Printed in the United States of AmericaA catalog record for this publication is available from theBritish Library.Library of Congress Cataloging in Publication dataCore clinical competencies in anesthesiology : a case-basedapproach / edited by Christopher Gallagher, Michael Lewis,Deborah Schwengel. p. ; cm.Includes bibliographical references and index.ISBN 978-0-521-14413-1 (pbk.)1. Anesthesia – Case studies. I. Gallagher, Christopher J.II. Lewis, Michael (Michael C.) III. Schwengel, Deborah A.[DNLM: 1. Anesthesia – Case Reports. 2. ClinicalCompetence – Case Reports. WO 200 C7965 2010]RD82.45.C67 2010617.9 6–dc22 2009036865ISBN 978-0-521-14413-1 PaperbackCambridge University Press has no responsibility for thepersistence or accuracy of URLs for external or third-partyInternet Web sites referred to in this publication and doesnot guarantee that any content on such Web sites is, or willremain, accurate or appropriate.Every effort has been made in preparing this book toprovide accurate and up-to-date information that is in accord withaccepted standards and practice at the time of publication.Although case histories are drawn from actual cases, every efforthas been made to disguise the identities of the individuals involved.Nevertheless, the authors, editors, and publishers can make nowarranties that the information contained herein is totally freefrom error, not least because clinical standards are constantlychanging through research and regulation. The authors, editors,and publishers therefore disclaim all liability for direct orconsequential damages resulting from the use of materialcontained in this book. Readers are strongly advised to pay carefulattention to information provided by the manufacturer of anydrugs or equipment that they plan to use.
  4. 4. To that person who coined the phrase that guides residency directorseverywhere: “a residency director should beat the love of learning into hisor her residents with a stout stick.”
  5. 5. Contents Rogues’ Gallery of Contributing Authors xi Introduction: “From the mountain” 1 Case 10. Flame on! 56 Christopher J. Gallagher and Matthew Neal1 An anesthetic view of the Core Clinical Competencies 3 Case 11. What date would you like carved in stone? 612 Anesthetic cases through the Core Clinical Competencies looking glass 7 Christopher J. Gallagher and Anna Kogan Case 12. Spasm, spasm, how do I treat thee? Bronchospasm in a stage IV Part 1 – Contributions from Stony breast cancer patient 65 Brook University Medical Center Bharathi Scott and Shiena Sharma under Christopher J. Gallagher Case 13. Why don’t you join the HIT Case 1. Pop goes the aneurysm 11 parade? HIT in a cardiac surgery patient 69 Christopher J. Gallagher and Tommy Corrado Bharathi Scott and Jason Daras Case 2. No Foley, no surgeon; what Case 14. Bad lungs in the ICU 73 now? 18 Shaji Poovathor and Rany Makaryus Christopher J. Gallagher and Khoa Nguyen Case 15. A simple breast biopsy 79 Case 3. Bad airway in the Andes 23 Neera Tewari and Ramtin Cohanim Christopher J. Gallagher and Khoa Nguyen Case 16. Fast-track perioperative Case 4. Wedge is 18; he must be full 28 management of patients having a laparoscopic colectomy for colon Christopher J. Gallagher and Dominick cancer 83 Coleman Brian Durkin and Sofie Hussain Case 5. Calling across specialties 34 Case 17. Treatment of complex Christopher J. Gallagher and Kathleen Dubrow regional pain syndrome when the Case 6. Extubation wrecking a payer doesn’t know anything about perfectly good Sunday 40 what you are treating 86 Christopher J. Gallagher and Eric Posner Marco Palmieri and Brian Durkin Case 7. The sin of pride after an awake Case 18. OB case with cancer and intubation 43 hypercoagulable state 90 Christopher J. Gallagher and Eric Posner Joy Schabel and Andrew Rozbruch Case 8. Brown-Sequard and the Case 19. Extubated and jaws wired shut 95 orthopedic knife extraction 46 Peggy Seidman and Ramon Abola Christopher J. Gallagher and Tommy Corrado Case 20. Code Noelle: A tale of Case 9. When were those stents placed? 52 postpartum hemorrhage 102 Christopher J. Gallagher and Matthew Neal Rishimani Adsumelli and Ramon Abola vii
  6. 6. Contents Case 21. Are you sure there’s a baby Case 36. Mr. Whipple and the case of there? A tale of the morbidly obese the guy who likes to mix a few vikes parturient 108 with his vodka 184 Ellen Steinberg and Ramon Abola Misako Sakamaki and Brian Durkin Case 22. Smoking, still smoking, and won’t quit 114 Part 2 – Contributions from the Deborah Richman and Rany Makaryus University of Medicine and Case 23. Pseudoseizures following office extubation 119 Dentistry of New Jersey under Ralph Epstein and Andrew Drollinger Steven H. Ginsberg Case 24. What happened to the ETT Case 37. Burn, baby, burn: Anesthesia tip? 123 inferno 191 Ralph Epstein and Tate Montgomery Jeremy Grayson and Stephen Lemke Case 25. Jerry and Terry want one Case 38. CABG 198 more baby 128 John Denny and Salvatore Zisa Jr. Rishimani Adsumelli and Vishal Sharma Case 39. The Da Vinci Code for Case 26. Overhextending yourself 134 anesthesiologists 203 Helene Benveniste and Jonida Zeqo Steven H. Ginsberg, Jonathan Kraidin, and Peter Chung Case 27. Broken catheter after Whipple 137 Xiaojun Guo and Khoa Nguyen Case 40. Transhiatal esophagectomy: Do you have the stomach for it? 211 Case 28. Pierre who? 142 Jonathan Kraidin, Steven H. Ginsberg, Ron Jasiewicz and Khoa Nguyen and Tejal Patel Case 29. Submandibular abscess 147 Syed Azim and Jane Yi Part 3 – Contribution from the Case 30. ERCP with sedation: A Big University of Texas M.D. Anderson MAC (monitored anesthesia care), supersized! 153 Cancer Center under Marc Rozner Tazeen Beg and Michelle DiGuglielmo Case 41. Never yell fire in a crowded OR 217 Case 31. On call in labor and delivery: Charles Cowles and Marc Rozner The morbidly obese nightmare 158 Ursula Landman and Kathleen Dubrow Part 4 – Contributions from the Case 32. Kidney transplant 164 University of Miami Miller School Syed Azim and Louis Chun of Medicine under Michael C. Lewis Case 33. Electrical glitch 169 Daryn Moller and Joseph Conrad Case 42. Nephrectomy 227 Michael C. Lewis and V. Samepathi David Case 34. What do you mean you stop breathing in your sleep? 175 Case 43. Another day at the Deborah Richman and Vishal Sharma office. . . based anesthesia 232 Steven Gil and Nancy Setzer-Saade Case 35. Please prevent postop puking 181 Case 44. OB to the core 236viii Neera Tewari and Vedan Djesevic Deborah Brauer and Murlikrishna Kannan
  7. 7. ContentsCase 45. Cut off at the knees 240 Case 58. DIC: DisseminatedAshish Udeshi intravascular coagulation or devastating injury to the cervix? 313Case 46. Neuro 246 Sayeh Hamzehzadeh and Tina TranEric A. Harris and Miguel Santos Case 59. All I had was a kneeCase 47. Cardiac catheterization bursectomy; now do I have RSD (CRPS)? 318laboratory to cardiac operating room 252 Adam J. Carinci and Paul J. ChristoLebron Cooper and Adam Sewell Case 60. Obstetricians cannot detectCase 48. Lap choly in someone great FH sounds, and Mom’s cyanotic: What’swith child 260 an anesthesiologist to do? 324Amy Klash Pulido and Shawn Banks Ramola Bhambhani and Lale OdekonCase 49. Renal transplant 263 Case 61. A case of mistaken identity 334Carlos M. Mijares and Sana Nini Nishant Gandhi and Bradford D. WintersCase 50. Surprise! It’s a liver and Case 62. “To block or not to block, thatkidney transplant 266 is the question”: Anticoagulation andMichael Rossi and Sujatha Pentakota epidural anesthesia 340Case 51. Left lower extremity pain 269 Brandon M. Togioka and Christopher WuOmair H. Toor and David A. Lindley Case 63. Anterior mediastinal massCase 52. Trauma 276 with total occlusion of the superiorEdgar Pierre and Patricia Wawroski vena cava and distal tracheal compression 347Case 53. Whack-an-eye 281 Andrew Goins and Daniel NyhanSteve Gayer and Shafeena Nurani Case 64. Puff the magic dragon 352 Steven J. SchwartzPart 5 – Contributions from Johns Case 65. “You mean the screw isn’tHopkins Medical Institutions supposed to be in the aorta?” Massive bleeding during spine surgery 360under Deborah A. Schwengel Melissa Pant and Lauren C. BerkowCase 54. Singin’ the OSA blues 289 Case 66. Oh no, someone get the NO! 365Jennifer K. Lee and Deborah A. Schwengel Rabi Panigrahi, Brijen L. Joshi, andCase 55. Oxygen 295 Nanhi MitterJustin Lockman and Deborah A. Schwengel Case 67. What to do when HITT hitsCase 56. “My patient’s an airhead!” the fan 369Management of air embolism during Ira Lehrer and Nanhi Mittersitting craniotomy 301 Case 68. “Just don’t stop my achy,Alexander Papangelou breaky heart. . . ” 375Case 57. Fifty-one-year-old female Sapna Kudchadkar and R. Blaine Easleywith abdominal pain, diarrhea, Case 69. Too bad, so sad. . . it’s Fridayflushing, and heart murmur for afternoon with a VAD 382exploratory laparotomy 307 Jeremy M. Huff and Theresa L. HartsellPeter Lin and Ralph J. Fuchs ix
  8. 8. Contents Case 70. The disappearing left Case 75. Mind, body, and spirit 425 ventricle: A double lung transplant in a Christina Miller and Adam Schiavi patient with severe pulmonary hypertension 391 Case 76. He’s not dead yet! 434 Kerry K. Blaha and Dan Berkowitz Veronica Busso and Mark Rossberg Case 71. Exit procedure – twins! 397 Gillian Newman and Eugenie Part 6 – Contribution from the Heitmiller Medical College of Wisconsin Case 72. OMG, that’s the RV! 403 under Elena J. Holak Christine L. Mai and Robert S. Greenberg Case 77. The Four Horsemen of Notre Case 73. Aborted takeoff 410 Dame or the Four Horsemen of the Emmett Whitaker and Deborah Apocalypse? The story of how horses A. Schwengel tried to ruin my first night on call 441 Elena J. Holak and Paul S. Pagel Case 74. Revenge of the blue crab cake 416 Summary 449 Samuel M. Galvagno Jr. and Theresa L. Hartsell Index 451x
  9. 9. Rogues’ Gallery of Contributing AuthorsThe following people allegedly contributed to this Misako Sakamaki, MD, Residentbook. An insignificant number (p Ͻ .05) were water- Joy Schabel, MD, Associate Professorboarded into this admission. Bharathi Scott, MD, Professor Peggy Seidman, MD, Associate ProfessorStony Brook University Medical Center Shiena Sharma, MD, ResidentRamon Abola, MD, Chief Resident Vishal Sharma, MD, ResidentRishimani Adsumelli, MD, Associate Professor Ellen Steinberg, MD, Associate ProfessorSyed Azim, MD, Assistant Professor Neera Tewari, DO, Assistant ProfessorTazeen Beg, MD, Assistant Professor Jane Yi, DDS, ResidentHelene Benveniste, MD, Professor Jonida Zeqo, MD, ResidentLouis Chun, MD, ResidentRamtin Cohanim, MD, Chief Resident University of Medicine and Dentistry ofDominick Coleman, MD, ResidentJoseph Conrad, MD, Resident New JerseyTommy Corrado, MD, Resident Peter Chung, MD, ResidentJason Daras, DO, Resident John Denny, MD, Associate ProfessorMichelle DiGuglielmo, MD, Chief Resident Steven H. Ginsberg, MD, Associate ProfessorVedan Djesevic, MD, Resident Jeremy Grayson, MD, Assistant ProfessorAndrew Drollinger, DDS, Resident Jonathan Kraidin, MD, Associate ProfessorKathleen Dubrow, MD, Resident Stephen Lemke, DO, ResidentBrian Durkin, DO, Assistant Professor Tejal Patel, MD, ResidentRalph Epstein, DDS, Assistant Professor Salvatore Zisa Jr., MD, FellowChristopher J. Gallagher, MD, Associate ProfessorXiaojun Guo, MD, Assistant ProfessorSofie Hussain, MD, Resident University of Texas M.D. AndersonRon Jasiewicz, DO, Assistant Professor Cancer CenterAnna Kogan, DO, Resident Charles Cowles, MD, InstructorUrsula Landman, DO, Associate Professor Marc Rozner, MD, PhD, ProfessorRany Makaryus, MD, ResidentDaryn Moller, MD, Assistant ProfessorTate Montgomery, DDS, Resident University of Miami Miller School ofMatthew Neal, MD, ResidentKhoa Nguyen, MD, Resident MedicineMarco Palmieri, DO, Resident Shawn Banks, MD, Assistant ProfessorShaji Poovathor, MD, Assistant Professor Deborah Brauer, MD, Assistant ProfessorEric Posner, MD, Resident Lebron Cooper, MD, Assistant ProfessorDeborah Richman, MB, ChB, FFA(SA), Assistant V. Samepathi David, MD, Fellow Professor Steve Gayer, MD, Associate ProfessorAndrew Rozbruch, DO, Resident Steven Gil, MD, Resident xi
  10. 10. Rogues’ Gallery of Contributing Authors Eric A. Harris, MD, Assistant Professor Jeremy M. Huff, DO, Resident Murlikrishna Kannan, MD, Resident Brijen L. Joshi, MD, Fellow Michael C. Lewis, MD, Professor Sapna Kudchadkar, MD, Fellow David A. Lindley, DO, Assistant Professor Jennifer K. Lee, MD, Fellow Carlos M. Mijares, MD, Assistant Professor Ira Lehrer, DO, Resident Sana Nini, MD, Research Associate Peter Lin, MD, Resident Shafeena Nurani, MD, Resident Physician Justin Lockman, MD, Fellow Sujatha Pentakota, MD, Resident Christine L. Mai, MD, Fellow Edgar Pierre, MD, Assistant Professor Christina Miller, MD, Resident Amy Klash Pulido, MD, Resident Nanhi Mitter, MD, Assistant Professor Michael Rossi, DO, Assistant Professor Gillian Newman, MD, Resident Miguel Santos, MD, Resident Daniel Nyhan, MD, Professor Nancy Setzer-Saade, MD, Associate Professor Lale Odekon, MD, PhD, Assistant Professor Adam Sewell, MD, Resident Rabi Panigrahi, MD, Resident Omair H. Toor, DO, Fellow Melissa Pant, MD, Resident Ashish Udeshi, MD, Resident Alexander Papangelou, MD, Instructor Patricia Wawroski, MD, Resident Mark Rossberg, MD, Assistant Professor Adam Schiavi, PhD, MD, Instructor Steven J. Schwartz, MD, Assistant Professor Johns Hopkins Medical Institutions Deborah A. Schwengel, MD, Assistant Professor Lauren C. Berkow, MD, Assistant Professor Brandon M. Togioka, MD, Resident Dan Berkowitz, MD, Professor Tina Tran, MD, Assistant Professor Ramola Bhambhani, MD, Resident Emmett Whitaker, MD, Resident Kerry K. Blaha, MD, Resident Bradford D. Winters, PhD, MD, Assistant Professor Veronica Busso, MD, Resident Christopher Wu, MD, Associate Professor Adam J. Carinci, MD, Resident Paul J. Christo, MD, MBA, Assistant Professor R. Blaine Easley, MD, Assistant Professor Medical College of Wisconsin Ralph J. Fuchs, MD, Assistant Professor Elena J. Holak, MD, PharmD, Associate Professor Samuel M. Galvagno Jr., DO, Fellow Paul S. Pagel, MD, PhD, Professor Nishant Gandhi, DO, Resident Andrew Goins, DO, Resident Note on the authors: In their defense, many of these Robert S. Greenberg, MD, Associate Professor authors were dropped on their heads several times dur- Sayeh Hamzehzadeh, MD, Resident ing their formative years. The rumor that others were Theresa L. Hartsell, MD, PhD, Assistant Professor abducted and raised by wolves has yet to be substanti- Eugenie Heitmiller, MD, Associate Professor ated.xii
  11. 11. Core Clinical Competencies inAnesthesiologyA case-based approach
  12. 12. Introduction: “From the mountain”A long time ago, in a medical galaxy far, far away, med- another, and the ground thereon to be sown with salt,ical education was a simple matter of apprenticeship: so nothing there shall ever grow again.” r You washed up on the shores of a residency. And the teachers of doctors trembled before the r For three years, you did anesthesia. men and women of education. And these same teach- r The residency released you into the wild, with the ers rent their garments and gnashed their teeth, crying admonition, “Go ye forth and minister anesthesia out, “Woe is us, that the daytime and the nighttime will unto the people.” be filled with documenting all we say and all we do. So great is the fury of the men and women of educationBut, alas, as time passed, the educational process grew that we will live all the years of our lives in fear andin complexity. loathing and documenting.” Enter the Core Clinical Competencies. Night fell. Wise men and women gathered themselves to- The sun rose the next day.gether and reconsidered the apprenticeship idea. And “Ah, what is this on Amazon.com?” a teacher ofthusly they spake, “The doctors know not of what they doctors cried out. “A book, a book which reviews anes-teach. They are misguided and errant in their ways. thesia cases via the Core Clinical Competencies! AsFor them to teach unto their young charges, they must manna from heaven fed those who wandered throughteach as we, the wise men and women of education, feel the desert, so also this book from three residencyyou must teach.” directors will feed those who wander through the And the wise men and women of education Core Clinical Competency land. Yea, verily, this isclimbed a great mountain, to seek commandments. a boon to medical students, residents, and teachersThey sought 10, but found they only 6. And these six alike.”commandments, they were writ in stone and given And great was the happiness.unto the wise men and women of education. From And now, as you read on, so also will your happi-the mountain came they down, bearing six command- ness be great.ments with them. And they showed these six com- For first we shall review the Core Clinical Compe-mandments to all who would teach doctors the art of tencies, and we shall show ye how these selfsame Corehealing the halt and lame. Clinical Competencies are viewed through the prism And the teachers of doctors became sore afraid. of anesthesia. Then we will leave off the jabber, for we And the teachers of doctors asked, “Whence came seek not to be as the cackling of hens or the screechingthese commandments, which we of needs must now of monkeys. We will go us forth into actual cases, casesemploy as we teach the young doctors?” we have done ourselves, and we will explain these cases So the wise men and women of education said, with great and terrible emphasis on the Core Clinical“Ye are not put on this earth to question the com- Competencies.mandments given from on high. Ye are to obey the And lo, your understanding will grow mightily.six commandments in all your teaching, and ye are to And you will use this knowledge to minister unto thosespend all the hours of the day and all the hours of the who are afflicted by the thousand and one ills that fleshnight documenting that ye are teaching via the com- is heir to.mandments. All those who disobey will be cast aside And when a dark cloud appears upon the hori-and their residencies shuttered, their hospitals razed zon, and a great crash of thunder is heard, and theunto the ground, so that one brick no longer lies upon Four Horsemen of the Residency Review Committee 1
  13. 13. Introduction: “From the mountain” (RRC) Apocalypse come pounding up to your door, Competencies, as we have been commanded by the you will hold up this selfsame book, and you will have men and women of education.” no need to avert your gaze or feel ashamed in your And the Four Horsemen of the RRC Apocalypse Accreditation Council for Graduate Medical Educa- will rein in their furious mounts, and away they will tion compliance nakedness. For you will say, “Look, ye ride, for no citations will they give, and no complaint terrible Horsemen of the RRC Apocalypse, and note will they raise. well. Much have we studied, and all through and with For the book is good. and under the benevolent wing of the Core Clinical And now you may rest under the shade of the tree.2
  14. 14. Chapter An anesthetic view of the Core 1 Clinical CompetenciesHere are the Core Clinical Competencies with an anes- but if the tube doesn’t find the trachea, or the spinalthetic twist. The first two, patient care and medical needle doesn’t splash down in cerebrospinal fluid, orknowledge, are the traditional things we’ve always the central line knifes through the pleura, then we’retaught. The last four are a bit softer and harder to nail doing it all wrong.down. But hey, you have to know all six, so let’s plow Patient care means taking care of the patient cor-through them. rectly, and to detail how you take care of a patient cor- rectly, read Miller cover to cover and do a residency. Because it all boils down to taking good care of thePatient care patient:Residents must be able to provide patient care that is r Secure that airway.compassionate, appropriate, and effective for the treat- r Get the line in.ment of health problems and the promotion of health. r Keep an eye on those vital signs.Residents are expected to do the following: r Provide good analgesia.r communicate effectively and demonstrate caring r React to changes and problems. and respectful behaviors when interacting with r Keep those lines open between you and the patients and their familiesr surgeon, the obstetrician, and the consultants so gather essential and accurate information about you don’t miss anything. their patientsr make informed decisions about diagnostic and That is the anesthetic take on patient care, and there’s therapeutic interventions based on patient not a lot of room for interpretation. information and preferences, up-to-date scientific evidence, and clinical judgmentr develop and carry out patient management plans Medical knowledger counsel and educate patients and their families Residents must demonstrate knowledge about estab-r lished and evolving biomedical, clinical, and cognate use information technology to support patient (e.g., epidemiological and social-behavioral) sciences care decisions and patient educationr and the application of this knowledge to patient care. perform competently all medical and invasive Residents are expected to do the following: procedures considered essential for the area of r demonstrate an investigatory and analytic practicer provide health care services aimed at preventing thinking approach to clinical situations r know and apply the basic and clinically supportive health problems or maintaining healthr work with health care professionals, including sciences that are appropriate to their discipline those from other disciplines, to provide patient-focused care The anesthetic take on medical knowledge The anesthetic take on medical knowledge is littleThe anesthetic take on patient care removed from the anesthetic take on patient care. YouThis is the most inherently obvious of the clinical com- need to know the medicine to care for the patient:petencies. We are patient care people, after all! You can r Chest pain, ST segment changes? You have to 3wax dreamy about all the other educational rigmarole, know the components of ischemia, know the latest
  15. 15. Chapter 1 – An anesthetic view of the Core Clinical Competencies on beta-blockade (good and bad), and know how to raise a child. When it comes to interpreting med- best to intervene. ical information, it takes the global medical village to r New device for securing the airway safely? You guide our therapy. Here’s one example that affected our have to know how to use it to care for the patient. recent thinking: r New block (say, the transverses abdominalus r Beta-blockers are great! Studies drift out that seem planar (TAP) block for relieving abdominal pain)? to indicate that one beta-blocker pill given in the You need to know the landmarks, how you can tell perioperative period will stave off death for a the transverses abdominus on echo, and how to thousand years! lay the local anesthetic in there. r Hey, let’s give everyone beta-blockers, and all our This is just the knowing behind the doing, so there’s not patients will live forever. r This makes inherent sense because slowing down much interpretive wiggle room in this Core Clinical Competency. the heart prevents ischemia. Right! So far, so good. Now things get a little mushier. Now, the literature looks at this more rigorously. Out comes the POISE study, looking at 80,000 plus Practice-based learning patients and giving them all beta-blockers. And there’s and improvement a fly in the soup! Residents must be able to investigate and evaluate their r Ischemia is, indeed, down. patient care practices, appraise and assimilate scien- r But death and stroke rates are up. tific evidence, and improve their patient care practices. r Oh, no! The sacred cow of perioperative Residents are expected to do the following: beta-blockade is slain. r analyze practice experience and perform practice-based improvement activities using a Could any one of us, in our own experience, have systematic methodology come up with these conclusions? I don’t care how fast r locate, appraise, and assimilate evidence from you turn over a room; you’re not going to rack up scientific studies related to their patients’ health 80,000 anesthetics in a short time and study this issue problems – hence practice-based learning and improvement as a r obtain and use information about their own Core Clinical Competency. What’s the crucial skill you need in this area? You population of patients and the larger population need to answer the question, is the information in the from which their patients are drawn r apply knowledge of study designs and statistical literature valid? Is it meaningful? Should I change my practice based on what the authors say? methods to the appraisal of clinical studies and Every month, the journal articles are filled with other information on diagnostic and therapeutic studies – do you change your practice every time a new effectiveness r use information technology to manage paper comes out? Do you snap up every new procedure because it has an “Oh, that looks neat!” air about it? information, access online medical information, Obviously not. The connoisseur of the literature knows and support their own education the good stuff from the bad, the Dom P´rignon from e the Listerine. The anesthetic take on practice-based learning and improvement Interpersonal and This means looking at the literature. None of us have enough experience in our own individual practice to communication skills draw meaningful demographic conclusions. We tend Residents must be able to demonstrate interpersonal to stew in our empiric juices and say, “Well, I did this and communication skills that result in effective infor- once and somehow the patient survived, so gee whiz, mation exchange and teaming with patients, their this must be the way to do it!” patients’ families, and professional associates. Resi- This n of 1 that we’ve all leaned on doesn’t hold dents are expected to do the following:4 r create and sustain a therapeutic and ethically up to statistical scrutiny, so we have to go to the lit- erature. Hillary Clinton told us that “it takes a village” sound relationship with patients
  16. 16. Chapter 1 – An anesthetic view of the Core Clinical Competenciesr use effective listening skills and elicit and provide different cultures, being sensitive to gender concerns, information using effective nonverbal, being sensitive to different disabilities. explanatory, questioning, and writing skills This is the Core Clinical Competency that steamsr work effectively with others as a member or leader most anesthesiologists (and, I suspect, most other spe- of a health care team or other professional group cialties, too). Of course, we know to be professional! God all fishhooks, we went through premed and med school and are now in postgraduate training. Do I needThe anesthetic take on interpersonal the Core Clinical Competencies to tell me that I have toand communication skills be ethical? We all took the Hippocratic oath; our wholeThis competency and the next one (professionalism) life has been geared to taking good care of our felloware damned hard to tease apart. I wish they would have human beings. Now some educationo-wonk is tellingchecked with me before they split these into two. Here me I have to be sensitive and appropriate around agoes, but, as you will see, there’s a lot of overlap here. person of different background, or a person with a You can’t be an oaf, dolt, moron, or insensitive clod disability?with the patient, and you have to get ideas to them Gimme a break!and get ideas from them. Same goes for working withnurses, cardiopulmonary bypass techs, doctors, inten- Systems-based practicesive care unit staff, respiratory techs, you name it. Any- Residents must demonstrate an awareness of andone that crosses paths with you in the clinical orbit, you responsiveness to the larger context and system ofhave to work well with them and make sure you get the health care and the ability to effectively call on systeminformation right. resources to provide care that is of optimal value. Resi- dents are expected to do the following:Professionalism r understand how their patient care and otherResidents must demonstrate a commitment to carry- professional practices affect other health careing out professional responsibilities, adherence to eth- professionals, the health care organization, andical principles, and sensitivity to a diverse patient pop- the larger society and how these elements of theulation. Residents are expected to do the following: system affect their own practice r demonstrate respect, compassion, and integrity; a r know how types of medical practice and delivery responsiveness to the needs of patients and society systems differ from one another, including that supersedes self-interest; accountability to methods of controlling health care costs and patients, society, and the profession; and a allocating resources commitment to excellence and ongoing r practice cost-effective health care and resource professional development allocation that does not compromise quality ofr demonstrate a commitment to ethical principles care pertaining to provision or withholding of clinical r advocate for quality patient care and assist care, confidentiality of patient information, patients in dealing with system complexities informed consent, and business practice r know how to partner with health care managersr demonstrate sensitivity and responsiveness to and health care providers to assess, coordinate, patients’ culture, age, gender, and disabilities and improve health care and know how these activities can affect system performanceThe anesthetic take on professionalismAs noted previously, this goes hand in glove with The anesthetic take on systems-basedthe competency of interpersonal and communication practiceskills. A professional communicates well with patients, Money makes the world go round, and medicine isfellow doctors, and all other medical providers. (Core no exception. For anesthesiologists, the main idea weClinical Competencies force you to use administrato- glean from systems-based practice is related to money:speak, with stupid phrases like “health care providers” 5and crap like that.) Part of that communication is reg- r practice cost-effective medicineistering the different backgrounds your patients have – r know how you fit into the great big overall picture
  17. 17. Chapter 1 – An anesthetic view of the Core Clinical Competencies r do QA things (they don’t call it that anymore – about the Core Clinical Competencies, you’ll probably they say continuous quality improvement – but we get some variant of my barbed comments. all know that’s just more administrato–double But they’re here to stay, and we have to know how talk) to teach them, so that’s why this book exists. Rather than sit here and dwell on them and debate their rela- There you have it, the Core Clinical Competencies tive merits, let’s do what we’re best at: clinical anesthe- laid out, complete with the anesthetic take on them. sia. We’ll lay out a case, then wrap that case around the Sound jaded? Core Clinical Competencies. That way, we’ll breathe Yeah, it’s a little jaded. If you pull aside the aver- some life and relevance into these bastards. So grab age resident or attending and ask what he or she thinks your hat and mask, and let’s have at it.6
  18. 18. Chapter Anesthetic cases through the Core Clinical 2 Competencies looking glassWithout further ado, we launch into the meat of Every case will not be so exhaustive. Slavish adher-the book – clinical cases with interesting twists (we ence to each and every sentence in the Core Clinicalactually did these cases!). And we’ll look at each Competencies is not the purpose of these cases, nor iscase through the prism of the Core Clinical Compe- it the purpose of this book. Different anesthetic chal-tencies. lenges provide different areas of emphasis. As you will The first case, “Pop Goes the Aneurysm,” is over see, there will be cases in which all we talk about is twothe top/overdone/overkill/too much. I have linked or three of the competencies.aspects of the case to every single sentence of every sin- So bear with us on this first one. This will show yougle competency. As you will see, this leads to interest- how you can take a case, or one horrific moment ining verbal gymnastics as I struggle to find a connec- midoperation, and wrap it around the Core Clinicaltion. Competencies. 7
  19. 19. Part Contributions from Stony Brook 1 University under Christopher J. Gallagher
  20. 20. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 1 Pop goes the aneurysm Christopher J. Gallagher and Tommy CorradoThe case Make informed decisions about diagnostic andA previously healthy 45-year-old man developed therapeutic interventions based on patientheadaches and blurry vision. Workup revealed a large information and preferences, up-to-date scientificcerebral aneurysm requiring a heroic procedure. In evidence, and clinical judgment.effect, his face would be taken apart to get at theaneurysm. The lesion itself was extremely large, and It doesn’t take a genius to peg this as Cushing’s triadthe neurosurgeon was quite concerned about whether stemming from a catastrophic intracerebral bleed.he’d be able to “get the clamp around the base.” Clinical judgment says that you have to do everything After an initial tracheostomy and 5 hours of dis- you can to decrease swelling in the brain, and you havesection, a faint and barely audible pop! was heard, fol- about an eighth of a second to do it.lowed by a nonfaint and easily audible “oh, shit!” fromthe surgeon. The patient’s blood pressure rose to 260, Develop and carry out patient management plans.and his heart rate fell from 90, to 80, to 70, and didn’tstop until reaching 40. Slam in some Pentathol and go with hyperventila- A glance over the ether screen revealed a brain bal- tion (to hell with concerns about cerebral ischemia –looning out of the skull. The brain was stretched so taut you are in disaster mode).that there were no sulci present, just “lines on a globe”where the sulci used to be. Counsel and educate patients and their families. At this point, you’d need to jump into a timePatient care machine and go back to the preoperative area to dis-Residents must be able to provide patient care that is cuss what will be done if things go wrong intraop. Herecompassionate, appropriate, and effective for the treat- is a patient who was healthy up to this point, but therement of health problems and the promotion of health. is a genuine worry that things may end up very badly (keep in mind that the surgeon himself was extremely Communicate effectively and demonstrate caring concerned, and even getting at the aneurysm required and respectful behavior when interacting with quite an effort). patients and their families. Does the patient have a living will? Is organ dona- tion (see the later discussion) something the patient No family is in the room, and the patient is under and family are willing to discuss and consider?general anesthesia, so we don’t have to sweat about car-ing and respectful behavior in our interaction. We can Use information technology to support patientshow the most respect by reacting like lightning to the care decisions and patient education.developing catastrophe. Again, this is the sort of thing that is best handled Gather essential and accurate information about in the preoperative phase of the operation. You look their patients. up any studies the patient has had (a chest X-ray or the computed tomograph or magnetic resonance image of Check those monitors; make sure the transducer the aneurysm) so that you will have knowledge of whatdidn’t fall on the floor. the surgeon will be doing. 11
  21. 21. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Perform competently all medical and invasive rate went down for a linked reason (vagal response procedures considered essential for the area of to the massive increase in blood pressure). Of course, practice. you do a quick check to make sure nothing else could have caused this insta–pole vault of the blood pressure At induction, a competent anesthesiologist would (syringe swap, patient instantly getting “very light”). skillfully place adequate venous access and a preinduc- You jump to Cushing’s triad by putting it all together tion arterial line (to monitor blood pressure on a beat- – complexity of the case; physiology of increased pres- to-beat basis during induction and intubation) and sure in the brain; your look into the field, confirming a would secure the airway appropriately. Later, when the disaster. surgeon has placed the tracheostomy (done because the face would be so disrupted by the approach), the Know and apply the basic and clinically anesthesiologist would make sure the switch from oral supportive sciences that are appropriate to their endotracheal tube to tracheostomy was done well. discipline. Provide health care services aimed at preventing Before you cross the threshold into the neuro- health problems or maintaining health. surgery room, you make sure you understand all the physiology that applies to these complex cases: The number-one preventive measure we take dur- cerebrospinal fluid formation; cerebral autoregulation; ing such a case is timing the delivery of prophylactic function of the blood-brain barrier; intracranial pres- antibiotics. Current standards dictate that antibiotics sure; and cerebral blood flow responses to hypoxemia, be delivered within 1 hour of incision. hypo/hypercarbia, and potent inhaled agents. The Obviously, this aspect of the Core Clinical Compe- supportive science for neuroanesthesia fills hernia- tencies seems a bit Pollyannaish at this point – worry- inducing textbooks. ing about maintaining health when the patient has just The quick and dirty physiology that you draw on had a massive and potentially life-threatening bleed right now follows: into the very center of his brain. This is included for r the aneurysm popped the sake of completeness (each case considers all the r blood is pouring into the “meat” of the brain Core Clinical Competencies, but different competen- r as the brain expands, it attempts to maintain cies receive different emphasis). perfusion by increasing the blood pressure r the heart (which has no way of knowing what’s up Work with health care professionals, including those from other disciplines, to provide in the head) “sees” high blood pressure and reacts patient-focused care. by slowing down Right now, you are married to that neurosurgeon – you are joined at the hip, one and the same, because death stalks the land right now. Are you going to work Practice-based learning closely with the neurosurgeon and all the other mem- and improvement bers of the operating room (OR) team to get out of this Residents must be able to investigate and evaluate their jam? As Sarah Palin would say, “You betcha!” patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Medical knowledge Analyze practice experience and perform Residents must demonstrate knowledge about estab- practice-based improvement activities using a lished and evolving biomedical, clinical, and cognate systematic methodology. (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Something about the surgeon being spooked about this case and saying “oh, shit!” tells you that you are in Demonstrate an investigatory and analytic deep trouble right now. Call it the world’s fastest “anal- thinking approach to clinical situations. ysis of practice experience”:12 r This surgeon has been working for years. On goes your thinking cap – that blood pressure went through the roof for a reason. And that heart r He knew this was bad going in.
  22. 22. Case 1 – Pop goes the aneurysmr He’s swearing and the brain is blowing up like a shortest of short terms and need all the help you can Macy’s Thanksgiving Day Parade cartoon get, so you abandon considerations of what’s best long character. term and just do what you can do to try to get a handle on things and save the patient. There is, unfortunately, no time right now to per-form a practice-based improvement activity, but all is Obtain and use information about their ownnot lost as far as this Core Clinical Competency is population of patients and the larger populationconcerned! The hospital, neurosurgery, and anesthe- from which their patients are drawn.siology should all have Continuous Quality Improve-ment committees. Obviously, right this minute, you This is another way of saying what was said pre-cannot whip up a committee, but later on, you should viously – you draw on your own experience, and youdo just that. Difficult cases, complications, deaths – all draw on the larger world of experience, that is, thethese things demand a systematic analysis afterward. experience described in the literature. In other words,You, as the anesthesiologist, should participate in these you review and keep abreast of experience with clip-“after-action reports.” Never assume, “we did every- ping cerebral aneurysms.thing right, so let’s not talk about it.” Maybe the case could have been done with coils? Apply knowledge of study designs and statisticalWas this case so horrifically complicated that it should methods to the appraisal of clinical studies andhave been referred to a better-equipped tertiary cen- other information on diagnostic and therapeuticter? Should the surgeon have done cardiopulmonary effectiveness.bypass with circulatory arrest to more safely clamp theaneurysm? Oh, just kill me now that they’ve mentioned statis- tics! Well, there’s no getting around it – if you’re going Locate, appraise, and assimilate evidence from to be more than a last-sentence-of-the-conclusion scientific studies related to their patients’ health reader, you have to dig in to the guts of the studies and problems. determine whether that last sentence is actually mer- ited. Who are we kidding? This is the gist of practice- Back to the cerebral aneurysm literature: let’s lookbased learning and improvement – keeping up with at just one aspect of the literature that is worth con-and analyzing the literature. This includes the hefty sidering. In the middle of this intracranial Armaged-command, “You need to know what constitutes good don, you might think, “Maybe we should cool this guyliterature and what constitutes dreck.” down a little! That will decrease his cerebral metabolic Ooph! In other words, you can’t just look at the rate and might protect him!”last sentence of the conclusion and say, “OK, sounds To the literature!good!” What does the literature say about this patient? No soap! Using mild hypothermia to improve neu-In a perfect world, each time you did a case, you’d rologic outcome has been examined in the litera-read a timely, scientific article on the very case you’re ture and has been found wanting. Although it makesdoing. What does the literature say about clipping physiologic sense that hypothermia would protect theaneurysms? Keep control of the pressure; be ready to brain, a study looking at that very issue showed thatdrop the pressure drastically if the surgeon’s having hypothermia does not protect the brain. Not only that,trouble getting the clip on; and administer adenosine but hypothermia causes its own problems (includingif you need a heart-stopping (literally, for you and the rhythm disturbances).patient both) few moments, good oxygenation (duh, as So, even in the hurry-up, oh-my-God! atmosphereif we need to hear that), and eucarbia to avoid cerebral of an OR emergency, you still have to be able to drawischemia. on the literature to guide individual steps. What does the literature say about a disaster likethis? It is difficult to do a double-blind, placebo- Use information technology to managecontrolled, multicenter, sufficiently powered study on information, access online medical information,how best to handle a disastrous and ultimately fatal and support their own education.bleed into the brain. So you’re left with your best phys- 13iologic guess right now. In the long term, hyperventi- What did we do before PubMed and all the otherlation is not a good idea, but right now, you are in the online wizardry that brings the world’s literature to our
  23. 23. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 fingertips? In this case, you wouldn’t be looking things teaching rounds, go to meetings, and get the latest on up in the OR, but rather, you’d look up neuroanesthe- medical practice. sia updates the night before and make sure you show up prepared. In the OR, you might use an automated Demonstrate a commitment to ethical principles record system to keep your hands free while the patient pertaining to provision or withholding of clinical is crashing. care, confidentiality of patient information, Support your own education with information informed consent, and business practice. technology? Of course. Get the latest American Society of Anesthesiologists refresher courses on neuroanes- Before the case, make sure that informed consent, thesia online, or troll the Internet for learning material site of surgery, and all the paperwork are in order. (different anesthesia programs have the PowerPoint Observe all HIPAA regulations (don’t talk about the presentations of their lectures online). Surf the Inter- case where others can overhear, and don’t reveal any net and get smart – what a concept! confidential patient information). When filling out your billing slips, be ethical. Bill for what you did and Professionalism nothing more. As noted previously, this is background behavior that applies to all cases. Residents must demonstrate a commitment to carry- ing out professional responsibilities, adherence to eth- Demonstrate sensitivity and responsiveness to ical principles, and sensitivity to a diverse patient pop- patients’ culture, age, gender, and disabilities. ulation. Say this patient were not a 45-year-old man with Demonstrate respect, compassion, and integrity; a a generic suburban lifestyle. You would make a note responsiveness to the needs of patients and society of each aspect of the patient’s background and hold it that supersedes self-interest; accountability to up for mock and ridicule to crack everyone up in the patients, society, and the profession; and a holding area, right? commitment to excellence and ongoing Uh, no. professional development. You could call this aspect of professionalism the OK, we’re in the middle of big trouble with this “Eagle Scout mandate.” Behave like an Eagle Scout intracranial fire hose pouring blood into the middle of around your patients, with appropriate deference and the brain. Is there a way to shoehorn this lofty profes- respect for everything that they are: sionalism stuff into the picture? In a practical sense, no, r Sexist comments to make someone feel not right this instant. But in terms of your background preparation for the case, yes, there is. (If this sounds uncomfortable about his or her gender? No, an like a stretch, I agree, it is.) Eagle Scout wouldn’t do that. r Disparaging comments about a patient’s national Respect and compassion are demonstrated to the patient and family in the preop visit and the holding identity? No, an Eagle Scout wouldn’t do that. r Poke fun at the elderly? Point and stare at the area. Integrity involves getting enough sleep the night before so you show up alert and ready to work. Check mentally or physically challenged? Of course not – your machine, and do all the things a good, sound if our imaginary Eagle Scout wouldn’t do it, then anesthesiologist does to provide the best possible neither should we. care. Responsiveness to the needs of patient and society, (Truth to tell, mandates like these set my teeth superseding self-interest? If you’re on call and this case on edge. Just what is the reason for laying this obvi- rolls in, this is no time to check the insurance status ous commandment out there? Is the implication that, and refuse if you’re not going to get paid. Account- before the Core Clinical Competencies came along, ability? Are your continuing medical education cred- doctors were taught to make fun of their patients and its, your licensing requirements, and your hospital treat them impolitely? The wise men and women of privileges all up to date? That is part of account- education may find this hard to believe, but before14 ability and, hence, professionalism. Commitment to the Core Clinical Competencies became the law of the excellence and your development? Attend hospital and land, we were taught to be respectful.)
  24. 24. Case 1 – Pop goes the aneurysmInterpersonal and communication Back to the case, what happened, and what we did. It became evident, after just a few minutes, that theskills bleed into the brain was unstoppable and the brainResidents must be able to demonstrate interpersonal damage was irreversible. There was no way to sal-and communication skills that result in effective infor- vage this man. Frantic medical attempts to drive downmation exchange and teaming with patients, their the pressure (whole sticks of Pentathol, Nipride widepatients’ families, and professional associates. open) as well as attempts to decrease intracranial pres- sure (hyperventilation, more head up, mannitol bolus) Create and sustain a therapeutic and ethically were all futile. The bleed into the brain from the burst sound relationship with patients. aneurysm was too much. The swollen and expanding Back in our time machine, fly back to yesterday brain looked like a scene from a science fiction movie.during the preop visit as well as this morning’s prein- We all suspected (and we later demonstrated) that theduction. Part of building up a sound and therapeu- man was effectively brain-dead.tic relationship starts with hand washing! Wash those What now? Turn off the ventilator and call it a day?hands before you go in to shake the patient’s hand. No. Here’s how the discussion among the teamIntroduce yourself, look professional, and give the went:patient your undivided attention. r We had to notify the family. r We now had an “otherwise healthy” man with Use effective listening skills and elicit and provide intact kidneys, liver, heart, and lungs. information using effective nonverbal, r Efforts should now focus on keeping all organs explanatory, questioning, and writing skills. viable for possible donation. As an anesthesiologist, your job is to get the infor- Clergy was brought into the discussion, along withmation you need – a directed history and physical. In organ procurement and surgical teams – a host of dif-the case of this 45-year-old man, you would pick up ferent members of the health care team joined in theclues as to the man’s level of understanding and gear process.your interaction appropriately. University professor inthe neurosciences? Your explanation can be technical.Blue-collar worker who never finished high school? Systems-based practiceDifferent tack on the explanation, of course. Residents must demonstrate an awareness of and Your preop note will demonstrate your writing responsiveness to the larger context and system ofskills. The rule here is simple: if, for some reason, you health care and the ability to effectively call on systemcan’t do the case (say, e.g., you get shot by a jealous hus- resources to provide care that is of optimal value.band between the preop visit and doing the case), thenmake sure all the information is there. In this particu- Understand how their patient care and otherlar case, you would want to make sure that your notes professional practices affect other health careinclude the surgeon’s concerns (big aneurysm, possi- professionals, the health care organization, andbility of rupture is real), the plans for the airway (intu- the larger society and how these elements of thebation followed by trach because of extensive dissec- system affect their own practice.tion in the facial area), and the patient’s understanding This first aspect of systems-based practice seguesof the risks. with the last aspect of professionalism just stated. Work effectively with others as a member or (These damned competencies overlap all over the leader of a health care team or other professional place – it’s hard to draw a line where one ends and group. another begins.) This neurosurgical patient has suffered a life- Aha! Now there’s some actual relevance, and we ending hemorrhage, but his organs may save the livescan get away from Eagle Scout discussions! (You will of others in society. Thus your responsibility has, insee this same pattern in subsequent cases discussed in a sense, shifted to the concerns of the larger society.this book – different areas of the Core Clinical Com- You are to take the best possible care of this patient to 15petencies merit emphasis in different cases.) ensure that his organs are best preserved. That means
  25. 25. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 maintaining hemodynamic stability, keeping fluids to The primary people who need assistance in system a minimum (to avoid pulmonary edema, thus ruin- complexities at this point are the family members, who ing the lungs for transplant), avoiding vasoconstrictors are wrestling with the heartrending consequences of (harmful to kidneys and liver), and keeping the patient the operation and the decision to donate organs. Your heart healthy (monitoring, preventing, and treating advocacy for quality patient care is manifested as you any ischemia) – all the considerations that go into pro- continue to take good care of all the physiologic vari- viding anesthesia care for an organ donor. ables (which can be tough, as the brain-dead patient can develop all kinds of instability). Know how types of medical practice and delivery Your assistance with the family may be required. systems differ from one another, including A few points (which we all know, and this is insulting methods of controlling health care costs and your intelligence) follow: allocating resources. r Get everyone in a private room – this is no hallway conference. The primary resource of interest here is the healthy r Turn your beeper and cell phone off – this is no organs of the soon-to-be donor. As an anesthesiologist, time for interruptions. you should be aware of the hospital’s policy on notify- r Allow time for family members to vent their ing the organ procurement team and how much lead time they need (including, of course, the all-important emotions. r Repeat information as necessary – this is difficult discussion with family). Allocation will be up to the organ team, but you should at least know how the sys- material to process. tem works (organ recipients are kept on call and are notified when an organ becomes available; extensive Know how to partner with health care managers blood work is required from the donor to make sure and health care providers to assess, coordinate, complex cross-match studies are performed). Different and improve health care, and know how these areas of the country have different teams. Sometimes a activities can affect system performance. harvest team is flown in, whereas sometimes surgeons This is another aspect of the case that is handled at the hospital do the harvesting for them. afterward. Keep in touch with hospital administration about where the organs went. A lot of times, the organ Practice cost-effective health care and resource procurement people will send letters to the OR team allocation that does not compromise quality of letting them know, for example, that the “kidney went care. to a 34-year-old woman, who was so happy to get off High flow of oxygen? Most expensive potent dialysis” and the “liver saved a man with idiopathic inhaled agent? No and no. Responsible care of the cirrhosis.” The whole team in the OR should main- patient at this point mandates standard cost-effective tain that link with the team outside the OR that was maneuvers: low flows of oxygen; no need for expen- involved in this patient’s care and, ultimately, his dona- sive desflurane, can use isoflurane; muscle relaxant – tion to other people’s lives. pancuronium. Because a quick wake-up is not exactly The first case (gloomy, admittedly) wrestles with in the cards here, you shift gears to the least expensive just what is brain death. An article on brain death is regimen, while always maintaining the optimal physi- included in Additional Reading. ologic environment for organ preservation. You will notice that in this, the first case, we wrote Advocate for quality patient care and assist something for each sentence of each competency. We patients in dealing with system complexities. won’t be doing that for all the rest of the cases because different cases will emphasize different competencies.16
  26. 26. Case 1 – Pop goes the aneurysmAdditional reading 2. Qureshi AI, Suri MF, Khan J, et al. Endovascular treatment of intracranial aneurysms by using1. Wijdicks EFM. The diagnosis of brain death. Guglielmi detachable coils in awake patients: safety Neurosurgery 2001;344:1215–1221. and feasibility. J Neurosurg 2001;94:880–885. 17
  27. 27. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 2 No Foley, no surgeon; what now? Christopher J. Gallagher and Khoa Nguyen The case made the snippy comments about looking for love in all the wrong places. (Oops, that was me. Forget that.) A 70-year-old man is scheduled for coronary artery bypass surgery in the usual way on the usual day Gather essential and accurate information about with the usual people. Ho hum, what could go wrong? their patients. Induction is carried out in the (what else?) usual fash- ion, and the airway is secured. Invasive lines are placed, Review the chart – have they had trouble placing a while the nurse attempts to place a Foley catheter. Foley before? Does the patient have a history of pro- No luck! statism or urethral stricture? The catheter won’t pass for love or money. Specu- Make informed decisions about diagnostic and lation arises as to prostatism or, perhaps, just perhaps, therapeutic interventions based on patient some kind of a urethral stricture (the hang-up is early information and preferences, up-to-date scientific on and not later on, pointing to the urethra as the cul- evidence, and clinical judgment. prit). Of course, a urethral stricture could arise from any number of things, but one subject of intense spec- At this point, the question is whether to get a gen- ulation is this patient’s early dalliances in the roman- itourinary (GU) consult or not to place the Foley. tic realm. Could this Foley-not-passing be evidence of They’ll likely need their fancier kinds of probes, per- looking for love in all the wrong places? haps going all the way to checking things out with a The cardiac surgeon is summoned because this scope. In the last word on this, with no way at all to looks like a tough Foley placement. Consideration is place a Foley, the next step is a suprapubic catheter. also given to summoning clergy so that the patient can receive a stern admonition as to wayward conduct/the Develop and carry out patient management plans. sins of the flesh/eternal damnation and related top- God, how I hate phrases like patient management ics of the ecclesiastic bent. (This latter idea is quashed, plan. It has an air of the administrator who calls more’s the pity.) patients “clients” and junk like that. The surgeon doesn’t answer the call. Still, the Foley The current best (gag) patient management plan in won’t pass, and now there’s blood in the tip of the organ the cardiac realm is to use the common sense that all of interest. Now what? anesthesiologists have when watching any patient: r keep the myocardial oxygen supply–demand ratio Patient care favorable Residents must be able to provide patient care that is r fast-tracking makes sense – get the patient off the compassionate, appropriate, and effective for the treat- ventilator and breathing on his own as soon as ment of health problems and the promotion of health. safe and practical r to minimize the time on the table, call the GU Communicate effectively and demonstrate caring and respectful behaviors when interacting with consult right away and get that Foley in r give gram-negative antibiotic coverage; all this patients and their families. digging around in the urethral area may well be The patient is under anesthesia, so we can’t be talk- seeding the bloodstream with gram-negative18 ing to the patient or family. To instill a little more bacteria, and the last thing you need is a respect in the room, consider smacking the people who perioperative infection in a cardiac patient
  28. 28. Case 2 – No Foley, no surgeon; what now? Perform competently all medical and invasive Practice-based learning procedures considered essential for the area of and improvement practice. Residents must be able to investigate and evaluate their No real thinking here – get your art line and central patient care practices, appraise and assimilate scientificline in competently. evidence, and improve their patient care practices. Provide health care services aimed at preventing Analyze practice experience and perform health problems or maintaining health. practice-based improvement activities using a systematic methodology. Be sure to follow the current guidelines to mini-mize the possibility of central line infection: In the middle of a difficult situation with a bleed- ing urethra and no surgeon, this is not the optimalr wash hands ahead of time time to get a committee together to discuss how we canr gown and glove improve on the situation and possible future situationsr full body drape like it. That would best be discussed after the Foley was placed and the case went off without a hitch. Possible Work with health care professionals, including discussion topics could include a more detailed med- those from other disciplines, to provide ical and social history, an array of different catheters patient-focused care. to fit the various different anatomical specimens seen in the operating room (OR), and an alternative If that cardiac surgeon doesn’t show up, then you method to drain urine with the help of our urologyhave to assume the role of consultant getting a consul- colleagues.tant and do what’s right for the patient. Tell the GU docwhat’s going on and get him or her whatever equip- Locate, appraise, and assimilate evidence fromment is necessary for the funky Foley placement. scientific studies related to their patients’ health problems.Medical knowledge Since you were prepared for anything that mightResidents must demonstrate knowledge about estab- occur with your patient, you did your research intolished and evolving biomedical, clinical, and cognate difficult Foley placement. You read several case stud-(e.g., epidemiological and social-behavioral) sciences ies of the effects of traumatic Foley placements, includ-and the application of this knowledge to patient care. ing urethral strictures postoperatively to even (gasp!) a venous air embolism in the vena cava. There are Demonstrate an investigatory and analytic not a great deal of scientific data regarding the place- thinking approach to clinical situations. ment of Foleys. The gist of the available data shows that educating the people who place Foleys (i.e., nurses It doesn’t take Sherlock Holmes or Albert Einstein and physicians) about the anatomy and proper tech-to analyze this situation. The case is at a standstill and nique reduces the incidence of iatrogenic injury. Thethe surgeon is AWOL. Nothing can happen until the moral of story is that you hope the nurse who tried tourine drainage situation is addressed, so have at it. place the Foley has been properly trained and educated about the anatomy; otherwise, he or she should defer Know and apply the basic and clinically to someone who has more experience placing a diffi- supportive sciences that are appropriate to their cult Foley such as our urology colleagues. discipline. Apply knowledge of study designs and statistical Basic science tells us that a cardiac case involves a methods to the appraisal of clinical studies andlot of fluid administration, including lots of fluids con- other information on diagnostic and therapeutictaining mannitol (from the cardiopulmonary bypass effectiveness.machine). This will fill the bladder with lots of urine, soproceeding without a Foley invites problematic blad- Again, not many studies have looked at difficult 19der overdistension, or even rupture. Foley placement as they are usually unanticipated
  29. 29. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 cases; otherwise, we could prepare for them and make consult, while another person should be continuing to them not so difficult. contact the surgeon. If possible, a nurse or technician may start to look for alternative Foley catheters and Use information technology to manage prepare for suprapubic placement of a catheter, if nec- information, access online medical information, essary. and support their own education. With the Internet at our fingertips these days, there is a wealth of knowledge waiting to be obtained. Systems-based practice PubMed is always available for finding articles related Residents must demonstrate an awareness of and to your desired topics. Having our urology colleagues responsiveness to the larger context and system of give the OR department a refresher on tips and tricks health care and the ability to effectively call on system to placing a Foley may not be a bad idea, as well. resources to provide care that is of optimal value. Understand how their patient care and other Interpersonal and communication professional practices affect other health care skills professionals, the health care organization, and the larger society and how these elements of the Residents must be able to demonstrate interpersonal system affect their own practice. and communication skills that result in effective infor- mation exchange and teaming with patients, their Our current dilemma with the Foley may involve patients’ families, and professional associates. other services, such as urology, but should not affect the larger society per se. How we handle this situation Create and sustain a therapeutic and ethically may affect patients who face similar problems in the sound relationship with patients. future and, it is hoped, affect them in a positive way This should have been done during the preoper- as we determine the best course of action, having been ative visit, and again that morning, prior to entering through this once already. the OR. Make sure that all questions are answered and Practice cost-effective health care and resource everyone is on the same page. Also, make sure you look allocation that does not compromise quality of and act professional, and that includes being on time. care. Use effective listening skills and elicit and provide Cost-effective health care, at this point, may information using effective nonverbal, include not opening every Foley catheter that the OR explanatory, questioning, and writing skills. has stocked and waiting for our urology associates to determine what they need and have those tools avail- This was mentioned previously as part of devel- able. oping a sound relationship with the patient. Listen to what the patient has to say and provide all explana- Advocate for quality patient care and assist tions effectively using whatever methods work best for patients in dealing with system complexities. the patient. Hone your writing skills as you write your updated history and physical in the patient’s chart as During the case, you can advocate for the least well as your possible plan for the case. invasive but safest method for placement of the Foley catheter, but if you called a urology consult for expert Work effectively with others as a member or advice, it would probably be smart to follow that leader of a health care team or other professional advice. There are not a great deal of complexities in the group. system about Foleys. With no surgeon to be found, you as the anesthe- Know how to partner with health care managers siologist must take the lead in the OR. Communicate and health care providers to assess, coordinate, with those in the room and start to delegate respon- and improve health care and know how these20 sibility to the other team members about a plan of activities can affect system performance. action. One person should be calling for a urology
  30. 30. Case 2 – No Foley, no surgeon; what now? This can be done once the case is completed. A Our urology colleagues can also, at that time, give usmultidisciplinary team of nurses and physicians can sit a refresher on the anatomy and proper technique ofdown to determine the best way to prevent trauma dur- placing a Foley catheter to help improve the outcomesing difficult Foley placements and what do to in the of future placements and reduce cost from lost ORevent of such an event in the middle of an OR case. time as well as complications. 21

×