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  • 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. Core Clinical Competencies inAnesthesiologyA case-based approachEdited byChristopher J. GallagherStony Brook UniversityMichael C. LewisUniversity of MiamiDeborah A. SchwengelJohns Hopkins Medical Institutions
  • 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. 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. 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. 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. 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. 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. 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. 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. Core Clinical Competencies inAnesthesiologyA case-based approach
  • 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. 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. 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. 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. 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. 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. 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. Part Contributions from Stony Brook 1 University under Christopher J. Gallagher
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
  • 31. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 2. Kashefi C, Messer K, Barden R, Sexton C, Parsons JK. Incidence and prevention of iatrogenic urethral 1. Chavez AH, Reilly TP, Bird ET. Vena cava air injuries. J Urol 2008;179:2254–2257; discussion embolism after traumatic Foley catheter placement. 2257–2258. Urology 2009;73(4):748–749.22
  • 32. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 3 Bad airway in the Andes Christopher J. Gallagher and Khoa NguyenThe case made to make sure the patient and her family under- stand everything that is being discussed. Make sure“They don’t have electricity up there, in the moun- to answer all questions asked by the patient and fam-tains,” the plastic surgeon told me. “It’s all oil lamps. ily after listening to all their concerns. Having a localKerosene. And then the kids, you know, they’re crawl- translate may also be helpful in that he or she coulding around, pulling on things, so they pull on the blan- give you an idea of what may be considered appro-ket that’s hanging down, and everything comes down priate and disrespectful behavior in this region of theon them. The lamp, too. That’s how they get burned.” world, as I am sure that there are differences between And did they get burned. Maria Luisa was the worst this region and the United States.of all. “But the scarring?” I asked. “We get burns in Amer- Gather essential and accurate information aboutica all the time, but you don’t see scarring like this.” their patients. “No,” the surgeon said, “you don’t.” Maria Luisa’s lip was fused to her chest, her 13- As accurately as possible, get a detailed historyyear-old head bent straight down, forcing her to be from the patient and her family regarding the injuryforever straining her eyes upward to see forward. and her general state of health. Make sure a full phys-Drool ran down her chest. She dabbed at it every few ical exam is done to best determine physical health,minutes. but obvious attention should be placed on the head Maria Luisa looked up/forward at us. With her lip and chest exam, considering that that is our area offused to her chest, she was in the exact wrong position expertise.for placing the endotracheal tube. And we were stand-ing in Loja, Ecuador, high in the Andes, at a small hos- Make informed decisions about diagnostic andpital. They didn’t have any fiber-optic equipment here. therapeutic interventions based on patientHow was I going to get that tube in? information and preferences, up-to-date scientific evidence, and clinical judgment.Patient care Considering the obvious limitations due to lack ofResidents must be able to provide patient care that resources in our current location and the severity ofis compassionate, appropriate, and effective for the her injuries, the patient and her family should be giventreatment of health problems and the promotion of a detailed explanation of all the risks, benefits, andhealth. alternatives to make the best informed decision they Communicate effectively and demonstrate caring can about the upcoming surgery. The glaring risk for and respectful behaviors when interacting with her surgery is loss of her airway, as she would be con- patients and their families. sidered a “difficult airway” in my book. Regional anes- thesia is definitely not an option here. Do we have any This is an extremely important issue, especially equipment to aid in obtaining the airway? Is the sur-when dealing with a difficult situation in a foreign geon prepared to perform an emergency surgical air-country. First, if one does not speak Spanish (or the way maneuver? In addition, if and when we secure thelocal language) fluently, then make sure that some- airway, what if we cannot extubate? Can the facilityone who does is in the room to translate. As a part handle such a patient postoperatively? Laryngeal mask 23of being respectful and caring, every effort should be airways seem to work well in these types of patients,
  • 33. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 per our colleagues in India and the Middle East, as your staff in the operating room (OR) should also be their case reports seem to show, though some imagina- observant of what is transpiring to be ready to jump tion is required for their placement. If none of the nec- into action at the drop of a hat. essary tools that may be required are at our disposal, then would postponing this case and transferring her Medical knowledge to a larger, more well-equipped facility that can handle Residents must demonstrate knowledge about estab- her delicate situation be a better choice? lished and evolving biomedical, clinical, and cog- Develop and carry out patient management plans. nate (e.g., epidemiological and social-behavioral) sci- ences and the application of this knowledge to patient The patient and the family are desperate and do care. not have the means to travel to another hospital, so we are moving forward here. Luckily, we have brought Demonstrate an investigatory and analytic variously sized laryngeal mask airways (LMAs), endo- thinking approach to clinical situations. tracheal tubes (ETs), and stylets. The patient is top- icalized with 1% lidocaine, which we happened to You knew things were bad as soon as you saw have, through a syringe attached to a 20-gauge angio- the patient, and immediately, you went into difficult catheter. She can barely open her mouth, but there airway mode. The first thing that came to mind was is enough wiggle room for us to work. We induce awake fiber optics, but that is just not an option, espe- with some inhaled halothane from the local anesthe- cially when you do not have a fiber-optic scope handy. sia machine and then hold our breaths as we try to You performed a thorough history, and after speaking secure the airway. She is spontaneously breathing well, to the surgeon, you made the patient and her family so minimal assistance is required for mask ventilation. aware of the situation. Using the resources available, you made the best plan you could to secure the airway. Counsel and educate patients and their families. Know and apply the basic and clinically The patient and her family are made aware of our supportive sciences that are appropriate to their concerns regarding her surgery, and all questions are discipline. answered as thoroughly as possible with the help of our trusty translator. The difficult airway algorithm runs through your head over and over, and you regret not buying that Use information technology to support patient handheld fiber-optic scope you saw on eBay. Nonethe- care decisions and patient education. less, you adhere as closely to the algorithm as possible with what you have, and fortunately, it works. Not many people in the Andes have Internet capa- bilities, including the hospital, so information technol- ogy is not so helpful here. Practice-based learning Perform competently all medical and invasive and improvement Residents must be able to investigate and evaluate their procedures considered essential for the area of patient care practices, appraise and assimilate scientific practice. evidence, and improve their patient care practices. Place all available monitors that we have (our portable pulse oximeter, electrocardiogram machine, Analyze practice experience and perform and blood pressure cuff) and obtain intravenous access practice-based improvement activities using a in the event that trouble finds us. systematic methodology. Work with health care professionals, including Not often are you put in a situation in which you those from other disciplines, to provide have such an unusually difficult airway with no real patient-focused care. equipment, as in this case, so this is the perfect time to analyze the experience. If you plan to travel to exotic24 Make sure that the plastic surgeon is in the room destinations and perform anesthesia on any patient at all times if a surgical airway is required. The rest of that may come, then consider investing in a small
  • 34. Case 3 – Bad airway in the Andesarsenal of equipment such as portable fiber-optic You obtained informed consent prior to the opera-scopes, intubating LMAs, and other such emergency tion and confirmed the site with your eyes. Confiden-devices. Do some research into the area of travel to tiality is not really possible as everyone in the villagelearn more about the health care system and the larger knows that Maria is going to surgery, but keeping thehospitals in the area, if needed, to better acquaint your- details of the operation private may provide some levelself with what you’re getting yourself into. of privacy. Locate, appraise, and assimilate evidence from Demonstrate sensitivity and responsiveness to pa- scientific studies related to their patients’ health tients’ culture, age, gender, and disabilities. problems. You made sure that you asked the translator several Not a great many studies exist on cases, but it times what not to do so that you would not offend theis always helpful to read case studies on how others people of region. You tried your best to make Maria feelobtained the airway and performed anesthesia on such comfortable, even though she was severely deformed,difficult cases. by looking her in the eyes when you spoke to her and even offering to dab the saliva from her chest. Use information technology to manage information, access online medical information, and support their own education. Interpersonal and communication After returning from the trip, make an effort towrite up the case with all the details and cross reference skillsthem with the current case reports. The more infor- Residents must be able to demonstrate interpersonalmation we have on a subject, the better, as these case and communication skills that result in effective infor-reports may give someone an idea in the future about mation exchange and teaming with patients, theirhow to handle a difficult airway in a remote area. patients’ families, and professional associates. Create and sustain a therapeutic and ethically sound relationship with patients.ProfessionalismResidents must demonstrate a commitment to carry- This was addressed earlier with a local transla-ing out professional responsibilities, adherence to eth- tor, as we made sure that the patient and her familyical principles, and sensitivity to a diverse patient pop- fully understood everything that was involved in theulation. case. Part of sustaining a sound relationship entails obtaining the patient’s trust, which we do by answering Demonstrate respect, compassion, and integrity; a all her questions as honestly and compassionately as responsiveness to the needs of patients and society possible. that supersedes self-interest; accountability to patients, society, and the profession; and a Use effective listening skills and elicit and provide commitment to excellence and ongoing information using effective nonverbal, professional development. explanatory, questioning, and writing skills. Demonstrate respect, compassion, and integrity by Having the local translator there is the most effec-being honest about the whole situation, providing a tive skill we have. We make sure to listen atten-translator to make sure the patient and her family fully tively as the patient, her family, and the translatorunderstand all that was discussed, and provide the best speak, although we can only catch bits and pieces ofcare that you can with the available instruments. their mile-a-minute Spanish. Then we listen attentively again as the translator explains the answers in English. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical Work effectively with others as a member or care, confidentiality of patient information, leader of a health care team or other professional informed consent, and business practice. group. 25
  • 35. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 As the anesthesiologist, you make the effort to be best represent our superb training and ourselves. Hav- a team leader in the OR. Coordinating duties between ing experiences like this under our belt helps us realize surgeons, nurses, and aids in the OR is no easy task, how fortunate we are to have the tools we do and gives but you do what is necessary for the patient, especially us more knowledge to handle difficult situations with one with special needs. the tools at hand. Practice cost-effective health care and resource Systems-based practice allocation that does not compromise quality of Residents must demonstrate an awareness of and care. responsiveness to the larger context and system of Not much choice here. We never compromise the health care and the ability to effectively call on system quality of care we provide, but cost is not an issue as resources to provide care that is of optimal value. we don’t have many options to choose from. Understand how their patient care and other Advocate for quality patient care and assist professional practices affect other health care patients in dealing with system complexities. professionals, the health care organization, and the larger society and how these elements of the If we can teach the local physicians how to use their system affect their own practice. present tools more effectively and introduce them to new tools in anesthesia, we can advocate for better Our actions in a foreign country represent those quality patient care and thus assist the most important of our home country, so we must act and perform to piece of the health care system: the patients.26
  • 36. Case 3 – Bad airway in the AndesAdditional reading pediatric-burned patient: a new solution to an old problem. Paediatr Anaesth 2006;16:360–361.1. Rutledge C. Difficult mask ventilation in 5-year-old due to submental hypertrophic scar: a case report. 3. Karam R, Ibrahim G, Tohme H, Moukarzel Z, Raphael AANA J 2008;76:1778. N. Severe neck burns and laryngeal mask airway for frequent general anesthetics. Middle East J Anesthesiol2. Khan RM, Verma V, Bhradwaj A, et al. Difficult 1996;13:527–535. laryngeal mask airway placement in a 27
  • 37. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 4 Wedge is 18; he must be full Christopher J. Gallagher and Dominick Coleman The case These include the vitals from the monitor, PA num- bers, intravenous (IV) fluid/nutritionals or drips the A 72-year-old vasculopath goes to the operating room patient may be on to maintain hemodynamic stability, (OR) for endovascular repair of a thoracoabdominal and also output such as urine and drains. In addition, it aortic aneurysm. At first, all seems well, the stent would be important to know the hematocrit and coag- deploys in the OR, and the patient seems all better. ulation status. Alas, things take a turn. The stent causes a leak in the aorta and the patient bleeds like nobody’s business, Make informed decisions about diagnostic and requiring a heroic trip back to and through the OR. therapeutic interventions based on patient Blood, factors, packing the abdomen, reexploration – information and preferences, up-to-date scientific the whole shooting match. evidence, and clinical judgment. Now the patient is back in the intensive care unit (ICU), urine output is down, and someone has floated The patient is s/p (status post) endovascular the almighty pulmonary artery (PA) catheter. Wedge aneurysm repair (EVAR) with hemorrhage from an is 18, and the renal service advises furosemide. “The aortic puncture, which was explored intraop and con- wedge is 18; he must be full,” they say. trolled. Although the patient was aggressively resusci- A furosemide drip is started. The next day, the tated with blood products and factors in the OR, inter- patient is started on continuous venovenous dialysis. compartmental fluid shifts would warrant ongoing resuscitation to ensure adequate perfusion. It would be necessary to monitor for ongoing bleeding and also be Patient care aware of the complications related to EVAR and also Residents must be able to provide patient care that is those related to the repair that was necessary to control compassionate, appropriate, and effective for the treat- the bleeding (e.g., were any vessels ligated that could ment of health problems and the promotion of health. lead to bowel ischemia?). Also, the patient is in renal failure, which is assumingly inadequately responsive Communicate effectively and demonstrate caring to a lasix drip, thus requiring continuous veno venous and respectful behaviors when interacting with hemodialysis (CVVHD). patients and their families. Develop and carry out patient management plans. Assuming that the patient is intubated and the sur- geon has communicated with the family the events in At minimal, a CVP would be necessary, along with the OR, at this point, the family would need to be appropriate colloid, crystalloid, and factor replace- updated as to the current state of the patient, including ment. Fluid replacement would be guided by lab val- concerns regarding the low urine output. It would be ues, blood pressure, and urine output. Use of a PA appropriate to explain why the patient is still intubated catheter (PAC) in the acutely ill patient, as in this case, and answer the family’s questions truthfully, without is useful for determining the CO, pulmonary filling omission. This would likely involve answering ques- pressures, and mixed venous O2 saturation. tions about pain, death, and length of stay in the ICU. Counsel and educate patients and their families. Gather essential and accurate information about28 their patients. As stated previously, honest and open discus- sions with the family regarding the patient’s status are
  • 38. Case 4 – Wedge is 18; he must be fullimportant to help minimize stress. They should be Medical knowledgeinformed of the efforts being taken to get the patient Residents must demonstrate knowledge about estab-better and also be made aware that there is a possibil- lished and evolving biomedical, clinical, and cognateity that the patient may expire. (e.g., epidemiological and social-behavioral) sciences Use information technology to support patient and the application of this knowledge to patient care. care decisions and patient education. Demonstrate an investigatory and analytic thinking approach to clinical situations. At some point, the patient may need a computedtomography (CT) angiogram to assess the repair. Also, Currently the patient is being treated for low urinedepending on kidney function, a renal ultrasound may output, which could be prerenal (low intravascular vol-be warranted in the future. ume or blockage of one or both of the renal arteries by the graft), renal (acute tubular necrosis or ATN), Perform competently all medical and invasive or postrenal (kinked Foley). Also, there is concern procedures considered essential for the area of regarding the elevated wedge of 18, which could be due practice. to pulmonary (evolving ALI/ARDS) or cardiac causes A PAC was placed in this patient, which may not (valvular disease). Knowing that the patient is a vascu-have been necessary; however, an arterial (CVP) line lopath almost always implies the presence of coronarywould be appropriate, as would an ALine. artery disease (CAD), and possibly even cerebrovascu- lar disease (CVD) and/or peripheral vascular disease Provide health care services aimed at preventing (PVD). Therefore sustaining a myocardial infarction health problems or maintaining health. (MI) or stroke in the immediate future is a real pos- sibility. Aseptic technique when placing all invasive lines isparamount. The patient should be on broad-spectrum Know and apply the basic and clinicallyIV antibiotics. It is important to perform frequent supportive sciences that are appropriate to theirsuctioning of the endotracheal tube (ETT) while on discipline.the ventilator and chest physical therapy (PT) as the The patient has sustained a hemorrhage requir-chance for ventilator-associated pneumonia is high. ing both crystalloid and colloid resuscitation. BeingAlso, turning the patient at least every 2 hours would aware of the fluid shifts and hemodynamic changeshelp with preventing decubitus ulcers, and placing and their consequences is important. The low urinesequential compression devices (SCDs) would ward off output implies decreased perfusion of the kidneys butacute deep venous thromboses (DVTs) with resultant could also be the result of damage caused by the kid-pulmonary embolus (PE). neys being hypoperfused previously. Giving diuretics Work with health care professionals, including intravenously on an as-needed basis or as an infusion those from other disciplines, to provide should stimulate the kidneys to make urine, provided patient-focused care. that perfusion is adequate. However, if there is signifi- cant damage, dialysis is necessary. Efficient and appropriate consults are important. Wedge pressure is an indirect measure of left-sideAs in this case, the renal service was consulted due to atrial pressure, normal being approximately 6–12. Ele-low urine output and the appropriate management was vation would be due to either a cardiac or pulmonaryimplemented. However, consults are not golden, and cause. When interpreting the data, understanding theso their recommendations should be factored into the Startling curve is helpful. A wedge of 18 may be presentequation. Their concern with the wedge of 18 is possi- in someone who has had an MI or long-standing car-bly inconsequential as the patient may be developing diac disease and needs a high wedge to maintain CO.acute lung injury/acute respiratory distress syndrome In the absence of significant cardiac disease, the ele-(ALI/ARDS) due to the amount of transfusions and vated wedge would be due to fluid overload or pul-fluid replacement. Furthermore, questions regarding if monary pathology. When giving massive transfusions,or when to start IV anticoagulation would need to be it is important to remember the sequelae that can 29answered by the surgeon. result, including fluid overload and/or ARDS.
  • 39. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Practice-based learning Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and and improvement other information on diagnostic and therapeutic Residents must be able to investigate and evaluate their effectiveness. patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. As stated, it is known that EVAR offers an aneurysm-related survival benefit over an open repair. Analyze practice experience and perform One multicenter randomized control study (RCT) practice-based improvement activities using a demonstrated this benefit to be approximately 3%. systematic methodology. However, the postoperative complications for up to 4 years postprocedure were significantly higher with With regard to improvements, the sentinel event in the EVAR group. Furthermore, there is no difference this case is a known complication related to the pro- between EVAR and open as it relates to all-cause mor- cedure. There should be a discussion at some point tality. to determine what might have gone wrong to cause such a big leak. Was it a flaw with the equipment being Use information technology to manage used, or was it a technical error on the part of the sur- information, access online medical information, geon? and support their own education. Familiarity with literature using such databases as Locate, appraise, and assimilate evidence from PubMed is most beneficial when addressing issues scientific studies related to their patients’ health such as those presented in this case. For a more problems. comprehensive review of specific topics, information Abdominal aortic aneurysms (AAAs) can be resources like UpToDate are helpful. repaired either open (i.e., laparotomy) or endovascu- larly. Patients are selected for EVAR based on vari- Professionalism ous factors, including body habitus, anatomy of the Residents must demonstrate a commitment to carry- AAA, and comorbidities. It is known that EVAR offers ing out professional responsibilities, adherence to ethi- a slight survival benefit as it relates to the aneurysm cal principles, and sensitivity to a diverse patient popu- itself; however, EVAR is associated with more com- lation. plications than an open repair. These complications include having to reoperate for bleeding secondary to Demonstrate respect, compassion, and integrity; a endoleaks around the stent. As with any major bleed, responsiveness to the needs of patients and society prompt resuscitation with crystalloid and blood prod- that supersedes self-interest; accountability to ucts is key to maintain hemodynamics and adequate patients, society, and the profession; and a end-organ perfusion. The use of a central venous pres- commitment to excellence and ongoing sure (CVP) catheter or PA catheter to help assess ade- professional development. quacy of resuscitation is determined on an individual basis. Respect and compassion, while caring for this and any other patient in the ICU, are important. When the Obtain and use information about their own patient is unable to communicate for himself or her- population of patients and the larger population self, at least one family member is usually available from which their patients are drawn. to inform the service of the patient’s wishes, includ- ing whether the patient would not want blood prod- This is an elderly patient with vascular disease ucts due to religious beliefs or personal preference. undergoing an AAA repair. One can assume that the This would have also been addressed with the patient patient has CAD and possibly some degree of renal preoperatively as part of the informed consent. Also, insufficiency. Prior to going to the OR, the patient depending on the patient’s prognosis, at some point, would have been medically optimized and assessed for there may need to be a discussion with the family about30 appropriateness to undergo an EVAR procedure. do not resuscitate/do not intubate (DNR/DNI) status.
  • 40. Case 4 – Wedge is 18; he must be full Integrity would be demonstrated by ensuring that Use effective listening skills and elicit and provideeverything is being done for the patient, and by doing information using effective nonverbal,so in a timely fashion. For example, if a CT scan is explanatory, questioning, and writing skills.scheduled but there are delays, going the extra step todiscuss the matter with the CT tech to have the scan Allowing the patient to talk and ask questions is thedone faster would demonstrate integrity and commit- best way to determine how much the patient under-ment to the patient. stands about his or her condition, his or her beliefs related to health care in general, and his or her level Demonstrate a commitment to ethical principles of anxiety. Communicating effectively, both nonver- pertaining to provision or withholding of clinical bally and verbally, would be done by responding to any care, confidentiality of patient information, issues that may arise during the conversation. Again, informed consent, and business practice. this is building trust between you and the patient. Again, discussion of care-related issues with the Work effectively with others as a member orfamily of an intubated patient is usually done with a leader of a health care team or other professionaldesignated next of kin or health care proxy. It is impor- group.tant to be up front with any information that is known.At the same time, care for every patient should be opti- Working in the ICU implies work with a team,mal and not determined by social class, race, or abil- which includes doctors, nurses, social workers, a phar-ity to pay for the service. In addition, prior to the ini- macist, and a respiratory therapist. Effectively com-tial surgery, all patients should have informed consent municating within this multidisciplinary system opti-regarding the procedure and its potential complica- mizes care for the patient and thus again demonstratestions, including bleeding, infection, pain, and the need integrity.for additional surgery. Demonstrate sensitivity and responsiveness to Systems-based practice patients’ culture, age, gender, and disabilities. Residents must demonstrate an awareness of and responsiveness to the larger context and system of An integral part of being professional is being able health care and the ability to effectively call on systemto deal with individuals from many different back- resources to provide care that is of optimal value.grounds with various beliefs and disabilities. Simplybeing dedicated to the patient and his or her well- Understand how their patient care and otherbeing, without bias, fulfills this requirement. professional practices affect other health care professionals, the health care organization, andInterpersonal and communication the larger society and how these elements of the system affect their own practice.skillsResidents must be able to demonstrate interpersonal The patient was taken to surgery for a minimallyand communication skills that result in effective infor- invasive procedure to repair an AAA and was takenmation exchange and teaming with patients, their back promptly for bleeding. In the recovery period,patients’ families, and professional associates. resuscitation with transfusions, while at the same time properly diagnosing and managing any other issues, Create and sustain a therapeutic and ethically such as low urine output or transfusion reactions, have sound relationship with patients. implications for length of stay in the hospital. The same is true with regard to appropriately ordering diagnos- Developing a trustworthy relationship with the tic studies.patient begins at the very first meeting; first impres-sions are lasting impressions. If the patient feels that Practice cost-effective health care and resourceyou care, are approachable, and are open in your dis- allocation that does not compromise quality ofcussions with him or her, you will have effectively care.developed a sound relationship. 31
  • 41. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Again, an example of this would be appropri- social services workers would ensure that these things ately ordering diagnostic studies. Also, placing the PA are available. catheter could compromise quality of care due to mis- interpretation of the data gathered. Inappropriately Know how to partner with health care managers bolusing the patient or starting pressors or vasodilators and health care providers to assess, coordinate, could lead to compromised care and also incur costs and improve health care and know how these due to prolonged hospitalization and potential com- activities can affect system performance. pounding complications. Again, communicating with the team members Advocate for quality patient care and assist effectively, letting everyone know the plan for the day, patients in dealing with system complexities. and keeping abreast of any changes that may have occurred will help to optimize care. When every- The multidisciplinary team approach in the ICU one is informed and ideas are shared, the patient is setting is set up to specifically deal with quality of care better cared for and unforeseen problems are better and also with helping the patient and his or her fam- managed. ily deal with social issues in the hospital and at home. A final word – I felt that they should have placed If a social worker is not involved, contacting the social a transesophageal echocardiograph (TEE) to see if he work service and communicating with them through- really was overloaded at a wedge of 18. He may have out the patient’s stay in the hospital is important. This been empty, with the wedge falsely elevated by the would be useful especially if the patient has limited extensive abdominal packing. insurance but requires extensive and prolonged treat- I strongly advocated for the ICU to incorporate ment. In addition, when the patient leaves, if there is TEE into their evaluations rather than placing faith in a need for equipment in the home, working with the the (ever controversial) PA catheter.32
  • 42. Case 4 – Wedge is 18; he must be fullAdditional reading 3. Greenhalgh RM, Brown LC, Epstein D, et al. Endovascular aneurysm repair versus open repair in1. Barkhordarian S, Dardik A. Preoperative assessment patients with abdominal aortic aneurysm (EVAR trial and management to prevent complications during 1): randomised controlled trial. Lancet high-risk vascular surgery. Crit Care Med 2004; 32: 2005;365:2179–2186. S174–S185. 4. Vincent J-L, Pinsky MR, Sprung CL, et al. The2. Ferguson ND, Meade MO, Hallett DC, Stewart TE. pulmonary artery catheter: in medio virtus. Crit Care High values of pulmonary artery wedge pressure in Med 2008;36:3093–3096. patients with acute lung injury and acute respiratory distress syndrome. Intensive Care Med 2002;28: 1073–1077. 33
  • 43. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 5 Calling across specialties Christopher J. Gallagher and Kathleen Dubrow The case to quickly check all the monitors and recycle the manual blood pressure cuff. If an arterial line is in A 59-year-old woman is having a transhiatal esopha- place, then double-check the transducer location. This gectomy. She suffers from malnutrition (she has not patient will likely need blood; ask the nurse in the been able to eat well for many months), chronic ob- room to make sure that this patient has a current type structive pulmonary disease (COPD), and coronary and cross and to get cross-matched blood in the room artery disease (CAD). The general surgeon is having as soon as possible. a hard time during the reach-up part of the opera- tion, and the anesthesiologist must remind him sev- Make informed decisions about diagnostic and eral times that he is compressing the mediastinum and therapeutic interventions based on patient forcing the blood pressure down. information and preferences, up-to-date scientific A distinct “oops” is heard coming from his lips as evidence, and clinical judgment. he tries to wedge free the esophagus way up by the neck. Bright blood is seen filling up the neck, and the It is likely that the surgeon has avulsed or ruptured blood pressure drops to the 50s. an artery (descending aorta?) while manipulating the esophagus. This patient is becoming hypovolemic from the rapid blood loss, and the anesthesiologist Patient care needs to hang blood on the patient as soon as pos- Residents must be able to provide patient care that is sible. While waiting for the blood, the patient needs compassionate, appropriate, and effective for the treat- to be given crystalloid/colloid for fluid replacement. ment of health problems and the promotion of health. If necessary, further intravenous (IV) access needs to be established, and supportive vasoactive medications Communicate effectively and demonstrate caring need to be administered, if necessary. While the anes- and respectful behaviors when interacting with thesiologist is trying to save the patient, the surgeon, it patients and their families. is hoped, will be trying to stop the source of bleeding, When evaluating this patient preoperatively, we and the circulating nurse will be calling the cardiotho- can show caring and respect by explaining the anesthe- racic surgeon for a sideline consult. sia management in terms that the patient can under- Develop and carry out patient management stand and by answering any questions that the patient plans. or family member may have. As anesthesiologists, we should continue this behavior in the postoperative The anesthesia team needs to hang blood, open up period, as well. During this particular situation, we fluids, start an arterial line if one is not already in place, would not have any family members around, but an and obtain further peripheral and central IV access. All anesthetized patient who has become acutely critical these things need to be done immediately and basically needs our quick attention. all at the same time. The anesthesia team may need to expand. Gather essential and accurate information about their patients. Counsel and educate patients and their families.34 This patient needs quick action to attempt to reach At this point, it may be difficult to consider the the best possible outcome. The anesthesiologist needs patient’s family. If and when the patient becomes more
  • 44. Case 5 – Calling across specialtiesstable, a conversation could be held with the family teamwork between the anesthesia, surgical, and nurs-regarding the patient’s status. If the outcome is poor ing personnel. Morbidity and mortality will be reducedwith this patient, the wishes of the patient and the if patient care is a team effortfamily regarding end-of-life care, further resuscitation,and possible organ donation need consideration. Evenif the patient and family were educated regarding all Medical knowledgepossible risks of the surgery prior to the procedure, Residents must demonstrate knowledge about estab-a poor outcome will necessitate counsel and support lished and evolving biomedical, clinical, and cog-from the surgical and anesthesia team. nate (e.g., epidemiological and social-behavioral) sci- ences and the application of this knowledge to patient Use information technology to support patient care. care decisions and patient education. This patient may have computed tomography scans Demonstrate an investigatory and analyticof the chest preoperatively that will show his or her thinking approach to clinical situations.anatomy. The use of ultrasound-guided line placement In addition to acting quickly to improve the out-may be helpful. come for this patient, it is vital to determine the Perform competently all medical and invasive cause of this drastic change. The patient is having an procedures considered essential for the area of esophagectomy, possibly likely secondary to cancer. practice. While manipulating the esophagus, the surgeon likely ruptured or avulsed the aorta, which is obvious given Given this patient’s current critical condition, an the immediate rush of bright red blood and the dra-arterial line and central line are a necessity. This patient matic drop in blood pressure.needs multiple large bore IVs and possible Cordisplacement. Conversation between the anesthesiologist Know and apply the basic and clinicallyand surgeon will need to take place because this patient supportive sciences that are appropriate to theiris likely in the lateral position, which may make line discipline.placement extremely difficult. Cross-matched bloodand fluids need to be run wide open in this patient. The This patient is having this procedure likely becauseuse of a rapid fluid infuser would be very helpful. of esophageal cancer. Understanding a basic patho- physiology is helpful to an anesthesiologist in periop- Provide health care services aimed at preventing erative management. Esophagectomies performed for health problems or maintaining health. esophageal cancer are associated with increased mor- bidity and mortality. In between checking and hanging blood, placing Anesthetic considerations regarding a patient withlines, and praying, the anesthesiologist should ask the esophageal cancer include the following:circulating nurse to page the primary care doctor statto find out when this patient last had the flu shot and r chronic alcohol use (increase MAC)his most recent colonoscopy. (Just kidding!) r liver disease (drug metabolism) Prior to this catastrophic event, antibiotics should r significant smoking history (ventilatorybe given prior to incision within an hour. Assessment difficulties, COPD)of need and continuation of beta-blockers should also r emaciation, malnutrition (decreased reserve,be established. decreased preload and intravascular volume, hemodynamic instability) Work with health care professionals, including those from other disciplines, to provide patient-focused care. Knowledge of these factors will help the anesthesiolo- gist to better care for this specific patient. Perioperative This patient is in an extremely critical situation. problems may be prevented from an anesthesia per-To realize the best possible outcome for the patient, spective through anticipation and vigilance to patient 35it will be absolutely necessary to have rapid and fluid care.
  • 45. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Practice-based learning Use information technology to manage and improvement information, access online medical information, and support their own education. Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific The torture of the Dewey Decimal System is over. evidence, and improve their patient care practices. Feel free to Google away, but be aware of inaccurate sources. Look for respectable medical journals and Analyze practice experience and perform review articles for quick references. practice-based improvement activities using a systematic methodology. Professionalism An esophagectomy is an invasive surgery that must Residents must demonstrate a commitment to carry- be performed by a well-trained surgeon. Even in ing out professional responsibilities, adherence to eth- clinical situations where every manipulation is done ical principles, and sensitivity to a diverse patient pop- correctly by a world-class surgeon, complications or ulation. adverse outcomes may occur. Demonstrate respect, compassion, and integrity; a Regardless of the outcome for this unfortunate responsiveness to the needs of patients and society soul, a discussion should be held, possibly in the form that supersedes self-interest; accountability to of a mortality and morbidity conference. A conver- patients, society, and the profession; and a sation among a group of professionals in the surgical commitment to excellence and ongoing and anesthesia field may improve outcomes for future professional development. patients: r What went wrong? How was it handled? Did all Professionalism is the easy part. Respect and com- parties act accordingly? What could have been passion were obvious with the preoperative discussion done differently? What will be done next time? held with the patient and the patient’s family. As physi- r Was there enough surgical exposure? Should cians, we must act with integrity at all times by keeping cardiopulmonary bypass (CPB) have been more the patient’s safety and best interests in mind. Prepare readily available? accordingly for each case and show up ready to work and take care of each specific patient. Locate, appraise, and assimilate evidence from Demonstrate a commitment to ethical principles scientific studies related to their patients’ health pertaining to provision or withholding of clinical problems. care, confidentiality of patient information, informed consent, and business practice. What does the literature say about handling com- plications of esophagectomies? Esophagectomies are Prior to surgery, as an anesthesiologist providing usually performed in a minimally invasive laparo- care to an anesthetized patient, it is our responsibility scopic approach with possible conversion to a more to make sure that the patient has been fully consented invasive, open approach. Either approach may be effec- regarding risks, benefits, and alternatives to surgery. tive in achieving a successful anastomosis, but differ- The patient also needs to be aware of potential blood ences exist in postoperative outcomes. loss and the need for blood products intraoperatively. As part of the health care team, we need to respect Obtain and use information about their own confidentiality of patients. A simple act like placing the population of patients and the larger population chart in the appropriate area is important. When talk- from which their patients are drawn. ing to and examining patients, we should pull curtains The anesthesiologist will provide better care to and speak in appropriate tones to respect the privacy patients by being well read on esophagectomies, differ- of patients. ences in surgical approaches, potential complications, Demonstrate sensitivity and responsiveness to and considerations of anesthetic management (laparo- patients’ culture, age, gender, and disabilities.36 scopic vs. open, CPB, one-lung ventilation).
  • 46. Case 5 – Calling across specialties Patients come from all different backgrounds, and When these critical events are happening with thisthis must be considered in a preoperative evaluation of patient, the operative team must act together quickly.patients. Addressing patients as “Mr.” or “Mrs.” shows The surgeon must control the bleeding; the anesthesi-a great deal of respect. Maybe a female’s religion pro- ologist must treat hemodynamic instability; and nurs-hibits men from seeing her exposed, and a different ing must be ready to run for supplies and make callsoperative team may need to be assembled. for help, make a crash cart available, and be ready to Showing respect to patients isn’t just for health give report to the intensive care unit (ICU). The car-care professionals. Being respectful to people in gen- diothoracic surgeon and CPB team need to be imme-eral makes someone a good human being! diately aware of this patient. The blood bank needs to be called to make available a full supply of blood prod-Interpersonal and communication ucts. If the patient is able to make it out of the operat-skills ing room, then respiratory therapy should be available for ventilatory management. Pharmacy needs to knowResidents must be able to demonstrate interpersonal about this patient to make sure plenty of vasopressorsand communication skills that result in effective infor- are made available for inotropic support.mation exchange and teaming with patients, theirpatients’ families, and professional associates. Systems-based practice Create and sustain a therapeutic and ethically Residents must demonstrate an awareness of and sound relationship with patients. responsiveness to the larger context and system of Build a relationship with the patient during the health care and the ability to effectively call on systempreoperative evaluation and postoperative follow-up. resources to provide care that is of optimal value.Explain the procedure in terms the patient will under- Understand how their patient care and otherstand. Let the patient know of possible complica- professional practices affect other health caretions and adverse outcomes, and discuss his or her professionals, the health care organization, andwishes with the patient should extremely poor out- the larger society and how these elements of thecomes occur. As physicians, we need to both act and system affect their own practice.look the part. Looking professional and exuding con-fidence will help to instill confidence in their physi- This patient needs quick action to realize the bestcians in the patient. Showing up with rumpled, day-old outcome. Despite best efforts by all parties involved,scrubs and bleary eyes will not help treat preoperative it is likely that this patient will go into hypovolemicanxiety. shock, suffer cardiac arrest, and die. Once efforts become futile, and any possibility for a good qual- Use effective listening skills and elicit and provide ity of life no longer exists, resources should no longer information using effective nonverbal, be used for this patient. Blood products are a limited explanatory, questioning, and writing skills. resource and will no longer benefit this patient. ICU Speak to patients and their families in a language care in hospitals is expensive and is sometimes used asthat they can understand, including about all risks, a wasted resource.benefits, alternatives to the surgery, and anestheticmanagement. This will need to be done with the coop- Practice cost-effective health care and resourceeration of the surgeon. Proper documentation of these allocation that does not compromise quality ofdiscussions should be made in the medical record. care.Invasive procedures with a high risk of morbidity and Every effort must be made to save this patient,mortality need proper explanations to patients, and using all the resources possible, until efforts becomedocumentation reflects completeness of patient care. futile, which is extremely likely with this patient. Blood Work effectively with others as a member or products, medical supplies, and ICU care should not leader of a health care team or other professional be used on a patient who has undergone hours of group. CPR and hemodynamic instability. It is also possible to care for this acutely critical patient by practicing 37
  • 47. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 cost-effective anesthesia. Expensive anesthetic agents well as the administrative duties they will have prior to like Precedex for sedation wouldn’t be indicated in releasing their family member. this patient. It is likely that minimal anesthetic agents would be needed in a patient who is so unstable. Know how to partner with health care managers and health care providers to assess, coordinate, Advocate for quality patient care and assist and improve health care and know how these patients in dealing with system complexities. activities can affect system performance. Prior to officially “calling” this patient, the family End-of-life issues will affect anesthesiologists should be informed of the critical nature of the patient. working with critically ill patients. We should be CPR could be continued until the patient arrives in the familiar with our hospitals’ policies and the methods ICU so that the family is able to see the patient prior for dealing with the death of a patient. This knowledge to passing. Once the patient has died, the family will will help to expedite the process for the family and need assistance from the operative team and the hos- allow the grieving period to continue outside the pital in handling the emotional aspect of the death as hospital.38
  • 48. Case 5 – Calling across specialtiesAdditional reading1. Nguyen NT, Hinojosa MW, Smith BR, Chang KJ, Gray J, Hoyt D. Minimally invasive esophagectomy: lessons learned from 104 operations. Ann Surg 2008;248:1081–1091. 39
  • 49. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 6 Extubation wrecking a perfectly good Sunday Christopher J. Gallagher and Eric Posner The case Develop and carry out patient management plans. A great hue and cry arises from the neuro intensive care unit (ICU). A patient has summoned sufficient The plan would be to call for help from my col- guff and moxie to extubate herself, in spite of a rich leagues and from surgery. array of clinical and laboratory signs that such a move Counsel and educate patients and their families. is detrimental to her health. Much to your dismay, on arrival at said neuro ICU, you see a note above her bed In this case, it would be best to speak to the family saying, “Extremely difficult intubation, took 1 hour at length after the intubation is complete; however, I with a fiber optic.” would briefly explain to them that their family member Respiratory therapy is mask ventilating the patient. needs to be intubated and possibly may need a surgical You see the world’s shortest chin and neck. You are airway. alone in this setting as it’s Sunday afternoon. Perform competently all medical and invasive Patient care procedures considered essential for the area of Residents must be able to provide patient care that is practice. compassionate, appropriate, and effective for the treat- Wise counsel would indicate that the trachea is the ment of health problems and the promotion of health. intubation target of choice because the esophagus has Communicate effectively and demonstrate caring done poorly in several attempts at being a respiratory and respectful behaviors when interacting with organ. patients and their families. Provide health care services aimed at preventing Because of the urgency involved, it would be best to health problems or maintaining health. tell the family, if they are present, that this is an emer- This is not immediately applicable; however, gency and that their loved one needs to be reintubated restraints may be needed after the patient is intubated. immediately, and I would ask them to step out and then I will speak to them after. Work with health care professionals, including Gather essential and accurate information about those from other disciplines, to provide their patients. patient-focused care. The information that I need seems to be there. The In this case, I would need help from my anesthesia writing is on the wall, literally. colleagues as well as surgeons and nursing and respi- ratory therapy. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific Medical knowledge evidence, and clinical judgment. Residents must demonstrate knowledge about estab- lished and evolving biomedical, clinical, and cog- The patient needs to be intubated. nate (e.g., epidemiological and social-behavioral)40
  • 50. Case 6 – Extubation wrecking a perfectly good Sundaysciences and the application of this knowledge to This patient is of the difficult intubation popula-patient care. tion; therefore I would apply my knowledge of this and be prepared for what could be a very difficult situation. Demonstrate an investigatory and analytic thinking approach to clinical situations. As this is an emergency, I would need to quickly Systems-based practiceformulate a plan with the help of others and carry out Residents must demonstrate an awareness of andthat plan as safely as possible. If the patient’s vital signs responsiveness to the larger context and system ofare stable, I would attempt to reintubate, with the sur- health care and the ability to effectively call on systemgeons standing by to perform a surgical airway. resources to provide care that is of optimal value. Practice cost-effective health care and resourcePractice-based learning allocation that does not compromise quality of care.and improvementResidents must be able to investigate and evaluate their It would be cost-effective to intubate this patient aspatient care practices, appraise and assimilate scientific quickly as possible to prevent any further damage toevidence, and improve their patient care practices. the patient. So you see, some cases require prolonged discus- Analyze practice experience and perform sions of all the core clinical competencies. But others, practice-based improvement activities using a such as this airway emergency, require only the briefest systematic methodology. treatment of the competencies. I would use the difficult airway algorithm. Obtain and use information about their own population of patients and the larger population from which their patients are drawn. 41
  • 51. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 2. Djabatey EA, Barclay PM. Difficult and failed intubation in 3430 obstetric general anaesthetics. 1. Williams WB, Jiang Y. Management of a difficult Anaesthesia 2009;64(11):1168–1171. airway with direct ventilation through nasal airway without facemask. J Oral Maxillofac Surg 3. Huang YT. Factors leading to self-extubation of 2009;67(11):2541–2543. endotracheal tubes in the intensive care unit. Nurs Crit Care 2009;14(2):68–74.42
  • 52. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 7 The sin of pride after an awake intubation Christopher J. Gallagher and Eric PosnerThe case The plan is to reintubate this patient.A 320-pound man with an ego to match attempts to Counsel and educate patients and their families.lift a 700-pound refrigerator. Rrrrip! His biceps tendonpeels off its attachment to the bone and goes fip-fip-fip After all is said and done, I would counsel theup his arm like an old window shade. patient about his difficult intubation and that he Clever you, you see that he will be a difficult intuba- should inform his anesthesiologists in the future abouttion (thick, muscular neck; Mallampati class IV view; this problem.big teeth), so you do an awake intubation. The case goes well, and now it’s time to extubate. Provide health care services aimed at preventingYou do all the cautious stuff – sitting him up, making health problems or maintaining health.sure he’s wide awake. You extubate, and within roughly To prevent future problems, I would counsel this6 nanoseconds, you see that this was not the bright- patient to lose weight and also to keep his doctorsest idea of your life. He starts to obstruct, arterial sat- informed about the fact that he is a difficult intubation.uration drops to the middle to low 80s, and his colorlooks less than reassuring. He has neither lost weight Work with health care professionals, includingnor improved his airway since last you intubated him, those from other disciplines, to providewhich was approximately 2 hours ago. patient-focused care. I would refer the patient to his primary care physi-Patient care cian to get help losing weight.Residents must be able to provide patient care that iscompassionate, appropriate, and effective for the treat-ment of health problems and the promotion of health. Medical knowledge Residents must demonstrate knowledge about estab- Communicate effectively and demonstrate caring lished and evolving biomedical, clinical, and cog- and respectful behaviors when interacting with nate (e.g., epidemiological and social-behavioral) sci- patients and their families. ences and the application of this knowledge to patient care. This is an emergency, and because there will be nofamily around, the best thing would be to reintubate Demonstrate an investigatory and analyticthis patient as quickly and safely as possible. When the thinking approach to clinical situations.patient is in the recovery room, I would then explainto the family members what is going on. This is a situation that would call for immediate action using the difficult airway algorithm. Gather essential and accurate information about their patients. Practice-based learning I already know that this patient is a difficult intu- and improvementbation. Residents must be able to investigate and evaluate their Develop and carry out patient management plans. patient care practices, appraise and assimilate scientific 43 evidence, and improve their patient care practices.
  • 53. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Locate, appraise, and assimilate evidence from This patient is obese and has a difficult airway, so scientific studies related to their patients’ health I would draw on my knowledge of this population to problems. treat this patient. There! We’ve made the point twice. Brief cases with I would not be able to look up any studies for the focused problems result in a brief brush on the core immediate care of this patient, but I would be expected clinical competencies, no more. to be aware of the current literature regarding airway management. Obtain and use information about their own population of patients and the larger population from which their patients are drawn.44
  • 54. Case 7 – The sin of pride after an awake intubationAdditional reading 2. de Almeida MC, Pederneiras SG, Chiaroni S, de Souza L, Locks GF. Evaluation of tracheal intubation1. Kheterpal S, Martin L, Shanks AM, Tremper KK. conditions in morbidly obese patients: a comparison of Prediction and outcomes of impossible mask succinylcholine and rocuronium (in Spanish). Rev Esp ventilation: a review of 50,000 anesthetics. Anestesiol Reanim 2009;56:3–8. Anesthesiology 2009;110:891–897. 45
  • 55. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 8 Brown-Sequard and the orthopedic knife extraction Christopher J. Gallagher and Tommy Corrado The case Gather essential and accurate information about Love is many things, earning the sobriquet “a many- their patients. splendored thing” among others. But Cupid’s arrows may sometimes be too barbed, as one 32-year-old man A protracted and extensive medical and social his- learned too late. tory may seem contraindicated in the case of a patient Lover boy’s lover took a steak knife in her right who is having his intravascular volume maintained by hand and registered her displeasure with events by a knife now acting as a wine cork. First and foremost, burying this knife to the hilt, right in the middle of the think the ABCs. Is he acutely stable (relatively) or man’s back. Perfect precision was the order of the day, unstable? Does he have an airway? Is he actively hem- as she created a perfect Brown-Sequard syndrome. orrhaging buckets, or is his bleeding relatively con- The knife is still sticking out of his back, and he’s trolled? Do we have good access, or are we working off going to the operating room (OR) for removal. He can’t a 22 Ga in the scalp? As mentioned before, if the patient lie on his back, and angiography shows the knife inside is able to communicate, we can speak directly to him the aorta, with the perfect position of the knife acting (while being mindful not to move or agitate him – sta- as a tamponade. bility is not this guy’s strong suit). If not, we would like to hear from the trauma team that is caring for him and the emergency medical service (EMS) responders, and Patient care the results of the studies taken. Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treat- Make informed decisions about diagnostic and ment of health problems and the promotion of health. therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment. Communicate effectively and demonstrate caring and respectful behaviors when interacting with Now that we know what we can about this patient, patients and their families. we have to get him to the OR (this isn’t a wait-and- see type of injury). The big hurdles we are looking at Effective communication may not be this gentle- here are going to be smoothly securing the airway of a man’s strong suit (the overwhelming majority of lovers’ patient who cannot be moved and maintaining hemo- quarrels fortunately don’t end up in a stabbing), but dynamic stability in a patient with a major vascular it’s our duty to tactfully and efficiently gather as much injury and an acute spinal cord injury. information about this situation as possible. If the patient is awake and responsive, we can first reassure Develop and carry out patient management plans. him that we will do everything we can to help him (he’s probably having a pretty rough day as it is) and Like any good Boy Scout could tell you, being pre- then get a quick history (allergies, last meal, medical pared is going to be key for this patient’s survival. This conditions and medications, assess airway, etc.). If he means appropriate equipment, primary and ancillary came in accompanied by someone, it may be worth- services, and sufficient personnel. Blood bank should while talking to that person, as well (the same person be made aware, with matched blood obtained, if avail-46 who stuck him in the back may be the one who pushes able, and O negative, if necessary, as well as sufficient his insulin every morning). other products (fresh frozen plasma [FFP], platelets,
  • 56. Case 8 – Brown-Sequard and the orthopedic knife extractionfactor VII, etc.). Ideally, we would like to be able to removed, we have to be ready for the inevitable changeisolate the lungs to aid the surgeons, but all our plans in hemodynamics (huge fluid shifts; the potential needneed contingencies – a surgical airway if we fail; per- for cross-clamping, requiring the use of sodium nitro-fusionists ready for partial cardiopulmonary bypass prusside (SNP), nitroglycerin, or esmolol, as seen in(CPB), if necessary. Appropriate intensive care unit aortic aneurysm repair, etc.).(ICU) care should be arranged for the patient to ensure Not only do we have to worry about the knife inthe smooth transfer of care. the aorta, but we also have the spinal cord injury to worry about. While the loss of sensation contralateral Counsel and educate patients and their families. and loss of motor function ipsilateral to and below the Acutely, the family should be made aware of the lesion in Brown-Sequard syndrome may not affect usseverity of the situation and should be provided with much now, the possible decrease in spinal cord reflexeswhatever support is available (e.g., a chaplain should and the potential drop in SBP may complicate issuesbe made available should they request one). intraoperatively. Also, we have to be mindful of the likelihood of a growing hematoma in a patient at severe Use information technology to support patient risk for coagulopathy. care decisions and patient education. Provide health care services aimed at preventing While the time for an in-depth literature review health problems or maintaining health.is not at hand, information technology may still playa role. Many hospitals now have integrated computer Not only should we be aware of the immediatesystems, which allow the practitioner to view radiolog- issues, but also, we should be thinking about optimiz-ical studies, access old records, and so on. A quick look ing long-term outcomes. Things like dosing and redos-at the patient’s angiogram and any other studies he may ing of antibiotics, steroid administration for spinalhave had will certainly help direct anesthetic care. cord injury, and maintaining euthermia all play a role in positive patient outcome. Perform competently all medical and invasive procedures considered essential for the area of Work with health care professionals, including practice. those from other disciplines, to provide patient-focused care. Now we have to use our clinical knowledge andskill. For all intents and purposes, we are living an oral Eventually, this patient is going to have significantboards stem. Airway issues will be paramount here. needs that may require the assistance of many differ-Not only can we not lay this guy on his back, but ent services (appropriate surgical follow-up, neurol-with any movement, we run the risk of him bucking ogy and physical and occupational therapy for his neu-and dislodging the knife that is, at present, holding rological deficits, pain management issues, and psychthe blood in him. While we are going to ensure that and social work, to name a few).the patient is adequately anesthetized and will havea fiber optic ready, with support to help us use it, as Medical knowledgewell as rescue equipment (maybe intubating laryngeal Residents must demonstrate knowledge about estab-mask airway (LMA), direct laryngoscope (DL) in a lished and evolving biomedical, clinical, and cognateweird position in a pinch), we are also going to want (e.g., epidemiological and social-behavioral) sciencessurgery to have open and ready everything necessary and the application of this knowledge to patient care.to do an emergent tracheostomy or cricothyrotomyshould the need arise. Apart from appropriate Amer- Demonstrate an investigatory and analyticican Society of Anesthesiologists (ASA) monitors, we thinking approach to clinical situations.would need invasive monitoring such as ALine (bothright arm and femoral monitoring would be nice to In this very complicated case, it was extremelymonitor perfusion pressures both above and below the important to break things down into recognizable andaortic lesion) as well as central access for both fluids manageable pieces that the resident had likely seenand medications. Perfusionists may want to prepare before. Understanding that airway management would 47for partial CPB, if necessary. When the knife is finally be difficult and being prepared with knowledge of
  • 57. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 the difficult airway algorithm were key. Recognizing r If any adverse events took place, at what point did the similarity between this case and aortic dissection/ they occur? Where was there a deviation from the rupture helped give direction to managing this patient standard of care, if any, and what policies can be from a hemodynamic perspective. Being aware that enacted to prevent a repeat of this deviation in the the spinal cord injury not only played an acute role in future? this patient’s management, but also had the potential to worsen throughout the case helped the resident main- Locate, appraise, and assimilate evidence from tain focus on the entire patient, not just on the obvious scientific studies related to their patients’ health and acute vascular wound. problems. As we mentioned before, this is no time for a liter- Practice-based learning ature search; rather, this looks like a case study wait- and improvement ing to be written up (not an M&M, it is hoped, should Residents must be able to investigate and evaluate their things go badly). It is possible, however, to extrapolate patient care practices, appraise and assimilate scientific information from related cases and apply that knowl- evidence, and improve their patient care practices. edge where appropriate. Keeping up to date with the current recommendations for managing a ruptured Analyze practice experience and perform aortic aneurysm, for example, would likely be applica- practice-based improvement activities using a ble to the patient who has recently had his or her aorta systematic methodology. redesigned at knifepoint. A quick literature search after the case, when the Like many traumas, there is less time for evaluation details are still fresh, would be a great idea. Doing this than action. After the case is done, however, a tremen- would allow the resident to reevaluate what was done dous amount can be learned from it. An interdisci- and possibly see how management of a similar case plinary debriefing would be hugely valuable. All too could be improved in the future. often, when a case is done, the team members line up to shake hands like a Little League baseball team and then retire to their respective dugouts. Taking the time Obtain and use information about their own to go over the critical events and reviewing, in a non- population of patients and the larger population judgmental way, what was done can help improve effi- from which their patients are drawn. ciency and safety. For example, points to address could It’s hard to think of a case for which this com- include the following: petency is more relevant. While it’s unlikely that r What was done right: take note of things that were many people will see this exact case on a regular done properly, which facilitated the case. Was the basis, the basic components are much more common. OR notified ahead so they had sufficient Major vascular injury (as a result either of trauma or equipment ready? Were appropriate team aneurysm rupture), penetrating trauma, spinal cord members present? Were adequate resources injury (either total or partial), and difficult airway are available? all entities most practitioners have seen at some point r What could be improved: was the transfer of the in their careers. What is required here is the ability to patient efficient and thorough? Did anesthesia extract relevant information about the care of each of notify surgery of changes in patient status these patients and combine it into a reasonable care (trending changes in pressure, urine output [UO], plan for this case in particular. etc.)? Did surgery notify anesthesia before any major interventions (cross-clamping, placing or Apply knowledge of study designs and statistical removing shunts, etc.)? Was paper work properly methods to the appraisal of clinical studies and filled out and returned? Was the patient other information on diagnostic and therapeutic adequately followed up by services other than effectiveness. primary services? For example, if the patient48 began to decompensate, were OR and anesthesia Obviously, this sort of case doesn’t lend itself to the notified in advance about the possibility of a randomized, prospective, double-blind study design. bring-back? Individual case studies or retrospective analyses may
  • 58. Case 8 – Brown-Sequard and the orthopedic knife extractionbe the only reasonable way to effectively evaluate this type of case, and a whirlwind of people are goingtype of patient. to be surrounding the patient, we can still do our best to maintain some semblance of modesty. This Use information technology to manage can include simple measures like closing curtains and information, access online medical information, moving bystanders along. (The same people who stop and support their own education. to look at a car crash will want to watch something like In the age of Medline, most people can string this. If they aren’t involved in the care of the patient,together enough Booleanisms to do a decent literature they have no place in the immediate area.)search, and this should certainly be the backbone ofany significant clinical investigation. Other resources, Interpersonal and communicationhowever, can add some depth and perspective to a res-ident’s education. Plugging a term into a search engine skillslike Google is bound to return a host of places to Residents must be able to demonstrate interpersonalbegin to get information, as is doing a wiki search. and communication skills that result in effective infor-While many of these sources aren’t peer reviewed and mation exchange and teaming with patients, theirtheir information may be flawed, they frequently have patients’ families, and professional associates.good references and can help focus your efforts. Many Create and sustain a therapeutic and ethicallysites have message boards or forums, in which people sound relationship with patients.post information about cases they have done and novelways they approached various problems. “I am going to put you to sleep so they can take the knife out of your spine and the giant vessel coming outProfessionalism of your heart” establishes a relationship pretty damnResidents must demonstrate a commitment to carry- fast. In reality, though, it’s the role of the anesthesiol-ing out professional responsibilities, adherence to eth- ogist to be a reassuring and calming presence in whatical principles, and sensitivity to a diverse patient pop- has the potential to be pandemonium.ulation. Use effective listening skills and elicit and provide Demonstrate a commitment to ethical principles information using effective nonverbal, pertaining to provision or withholding of clinical explanatory, questioning, and writing skills. care, confidentiality of patient information, A case like this invariably has a great deal of informed consent, and business practice. information flying around, and therefore the potential This is likely the case everyone is going to want exists for any number of mistakes. Properly checkingto talk about. When everyone has finally scrubbed blood products and medications helps prevent poten-out, you’ll want to tell a coresident and the nurses tially devastating errors. While in the heat of a traumaand maintenance and that nice lady in the cafeteria paper work seems tertiary at best, the OR record is aand . . . Long story short: while there is definitely valid- valuable tool for patient care. Trending vitals and not-ity to discussing a case for the sake of education, sen- ing times and types of blood products, medicationssitivity for the patient and his family and loved ones is and fluids given, and lab results like arterial bloodas much our responsibility as placing a tube. Patient gases (ABGs) can help guide patient care intraopera-information should never be discussed in a public tively. Also, should the case be reviewed at a later date,place (the elevator opens more mouths than Mac and anything written (or not written) in the chart can haveMiller combined), and identifiers like names or dates huge medical and legal implications.of birth shouldn’t be included when referring to the Work effectively with others as a member orcase for educational purposes. leader of a health care team or other professional Demonstrate sensitivity and responsiveness to group. patients’ culture, age, gender, and disabilities. Communication with all members of the health Sensitivity can be an issue in such an acute case, care team cannot be overemphasized. Roles may 49but there are still a few things we can do to soften change during the course of care, and the smooth tran-the situation a little. While chaos tends to follow this sition of power and communication are paramount.
  • 59. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Initially, EMS will come in with the patient and hand Practice cost-effective health care and resource off responsibility to the trauma team. A team leader allocation that does not compromise quality of should be recognized, and each member’s role should care. be well defined. As the case progresses, the anesthe- sia team will likely assume leadership as the patient If asked what they find most rewarding about their is anesthetized in the OR. When the patient is sta- job, most physicians would rank taking care of patients ble, the trauma surgeon assumes control of the patient. far above efficiently utilizing resources in an economi- While this is an oversimplification, constant and clear cally sound manner. That being said, it’s a grim reality communication is important. In a trauma such as this, that even medicine is subject to the limits of the bot- things should be structured but fluid enough to accom- tom line. There are a number of things the anesthesiol- modate any changes that occur. Coordination with ogist can do to operate in a more cost-effective manner. resources out of the OR (blood bank, chemistry lab, Using less expensive agents, not opening up equipment ICU) is also the role of the team leaders. or drawing up drugs unless they are going to be used, and disposing of only sharps in sharps containers save significant amounts of money over time. Judicious use Systems-based practice of blood products saves not only money, but also a very Residents must demonstrate an awareness of and limited resource. The smooth transfer of patient care responsiveness to the larger context and system of not only improves safety, but also more efficiently uti- health care and the ability to effectively call on system lizes manpower and time. resources to provide care that is of optimal value. Advocate for quality patient care and assist patients in dealing with system complexities. Understand how their patient care and other professional practices affect other health care After his surgery is complete, this poor guy still has professionals, the health care organization, and a world of obstacles ahead of him. Assuming no major the larger society and how these elements of the complications from the surgery itself, this person with system affect their own practice. Brown-Sequard syndrome will have to learn to cope with his new neurological impairment. For a 32-year- This patient definitely had a significant, life- old, this means not only loss of function, but possibly changing event. Goals for this patient should not focus also loss of employment and social and psychological only on his physical well-being. Not only do we want issues (let’s not forget that a good piece of his support to see him reach a state of optimal function, but we structure just planted a knife in him like she was rais- also want to see him return to a productive role in soci- ing a flag on Everest). Getting him in touch with social ety. Support is going to be necessary after his hospital work as early as possible will help him gain access to stay, and access to those resources should be provided the resources necessary to help him regain and rede- as soon as possible. fine a meaningful existence.50
  • 60. Case 8 – Brown-Sequard and the orthopedic knife extractionAdditional reading neurological syndrome. Spinal Cord 2005;43: 678–679.1. Jonker Frederik HW, Schl¨ sser Felix JV, Moll Frans L, o Muhs Bart E. Dissection of the abdominal aorta: 3. Simsek O, Kilincer C, Sunar H, et al. Surgical current evidence and implications for treatment management of combined stab injury of the spinal strategies: a review and meta-analysis of 92 patients. cord and the aorta – case report. Neurol Med Chir J Endovasc Ther 2009;16:71–80. (Tokyo) 2004;44:263–265.2. Harris P. Stab wound of the back causing an acute subdural haematoma and a Brown-Sequard 51
  • 61. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 9 When were those stents placed? Christopher J. Gallagher and Matthew Neal The case on your heart, and we need to discuss the implications of this on your surgery today.” A 65-year-old man has leukoplakia on his vocal cords. One of your hospital’s top referral bases (this ear-nose- Gather essential and accurate information about throat [ENT] doctor brings bazillions into the hospital, their patients. and people come from far and wide for her expertise) schedules him for a vocal cord biopsy tomorrow. When a case is taking longer than you planned and You get the nod because you’re a heart guy, and this the surgeon looks up and says, “I should be done in guy has “a little heart problem.” about 30 minutes,” it is usually safe to assume that “Yes?” you ask, ever curious. you aren’t going anywhere for at least an hour, prob- “He had two eluting stents placed two days ago, but ably more like an hour and a half. No anesthesiologist the cardiologist says his vessels are fine now. They’re I know takes a surgeon at his word on something as stented open, after all!” The ENT surgeon, who doesn’t benign as op time, so why would we take them at their like to hear no for an answer, says, “I gave the cardiolo- words on something as important as the patency (or gist your cell phone number to talk to you, in case you lack thereof) of a coronary or two? Patient care dictates get the heeby-jeebies. Have a nice day.” that you gather a little more information. You should get the patient’s records from cardiology, for instance, Patient care a cath report. Sure, the coronaries are stented open Residents must be able to provide patient care that is now, but oops . . . the ejection fraction is only 15%. It is compassionate, appropriate, and effective for the treat- amazing how many fun surprises you can uncover by ment of health problems and the promotion of health. digging into the patient’s chart, instead of just reading “medically cleared for surgery” off a prescription pad Communicate effectively and demonstrate caring and calling it a day. and respectful behaviors when interacting with The other important piece of information that is patients and their families. missing is why the patient went for cath 2 days ago. Was it a routine follow-up, was it a failed stress test, or In this case, the patient needs to be brought into is the patient now 2 days out from an acute myocardial the loop. Even if the patient doesn’t connect the dots infarction (MI)? These are all things you may want to between anticoagulation (i.e., aspirin and Plavix) and find out about. If the patient had an MI in the last few electively cutting on the airway, you, as a responsi- days, he is at risk for having another MI in the periop- ble health care provider, are obligated to connect the erative period. dots for him. Effective communication with the patient includes explaining the benefits as well as the risks of Make informed decisions about diagnostic and the proposed procedure. That being said, the situation therapeutic interventions based on patient needs to be handled tactfully; don’t open with some- information and preferences, up-to-date scientific thing like “Sir, I’ve met a lot of jackasses in my day, but evidence, and clinical judgment. that surgeon of yours sure takes the cake.” You need to find a way to explain the situation to the patient with- Elective surgery should be postponed for a min- out alarming him and without throwing the surgeon imum of 12 months after placement of drug-eluting52 underneath the bus. A better opening line might be stents, though exact guidelines for eluting stents are “Sir, I understand that you recently had a procedure tough to nail down. Even if the patient had a bare
  • 62. Case 9 – When were those stents placed?metal stent, the procedure should be postponed for Know and apply the basic and clinicallya least 6 weeks – not 2 days [2]. Even if the surgeon supportive sciences that are appropriate to theiris willing to operate on a patient who remains on discipline.antiplatelet therapy, the perioperative period inducesa hypercoagulable state, which makes the risk of stent The key issue here is the drug-eluting stents. Youthrombosis unacceptable. You should be prepared to need to know that a minimum of 1 year of antiplateletintegrate these facts into your decision-making pro- therapy is recommended after placement of a drug-cess when determining whether to go forward with the eluting stent [2]. You also need to know the riskscase. of bleeding if this procedure is performed with the patient 2 days out from his Plavix load. Counsel and educate patients and their families. This goes back to knowing the risks and benefits. Practice-based learningTo properly counsel the patient, you need to know and improvementthis stuff like the back of your hand. Maybe the rea- Residents must be able to investigate and evaluate theirson the surgeon is so gung ho to go ahead is because patient care practices, appraise and assimilate scientificshe doesn’t really understand the risks either. This evidence, and improve their patient care practices.could present a golden opportunity not only to educateyour patient, but also to educate one of your surgical Locate, appraise, and assimilate evidence fromcolleagues. scientific studies related to their patients’ health problems. Work with health care professionals, including those from other disciplines, to provide If you want the surgeon to change her plans, it will patient-focused care. probably help if you back up your request with some- thing more substantial than your own opinion. A 5- A phone call and/or face-to-face chat with the sur- minute PubMed search for the terms “eluting stent”geon is in order here. It is better to discuss the risks and “elective surgery” will probably yield the evidenceof going ahead with the surgery beforehand than it is you need. You could also consult a textbook or a moreto discuss what the hell just happened after you had to highly regarded colleague – every department has ashock the patient back to life and send him back to the couple of those.cath lab for the second time in 3 days. It should also benoted that timing is pretty important here. You shouldhave this conversation in the holding area, not in the Professionalismoperating room (OR), after the patient is strapped to Residents must demonstrate a commitment to carry-the table or, God forbid, already asleep. ing out professional responsibilities, adherence to eth- ical principles, and sensitivity to a diverse patient pop- ulation.Medical knowledgeResidents must demonstrate knowledge about estab- Demonstrate respect, compassion, and integrity; alished and evolving biomedical, clinical, and cognate responsiveness to the needs of patients and society(e.g., epidemiological and social-behavioral) sciences that supersedes self-interest; accountability toand the application of this knowledge to patient care. patients, society, and the profession; and a commitment to excellence and ongoing Demonstrate an investigatory and analytic professional development. thinking approach to clinical situations. Throw out your own ego and remember that your Investigate further. Look at the cath report; call the responsibility is to the patient, not to yourself. Ifcardiologist. After you have gathered some informa- you are having a disagreement with a surgeon, don’ttion, analyze it. What are the benefits of this procedure, take it personally; you should simply think about theand what are the potential risks? With this informa- implications for the patient. This will help you keep 53tion, you can decide on the best approach going for- a cool head while dealing with your colleague on theward. other side of the ether screen.
  • 63. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Demonstrate a commitment to ethical principles health care and the ability to effectively call on system pertaining to provision or withholding of clinical resources to provide care that is of optimal value. care, confidentiality of patient information, Understand how their patient care and other informed consent, and business practice. professional practices affect other health care This is the time to bring the patient into the loop. professionals, the health care organization, and With the cooperation of surgery, you should explain the larger society and how these elements of the all the risks and benefits of the procedure in terms the system affect their own practice. patient can easily understand. If the patient has family This is where you must consider the implications of members at the bedside, you should always ask permis- a disagreement with the surgeon. Ticking off a major sion before discussing sensitive medical issues in front source of revenue for your hospital could have negative of them. consequences for you and your department. It really By involving the patient and his family in the comes back to professionalism. You have to gather decision-making process, you can ensure that every- your evidence and figure out a way to approach the one has the patient’s best interests at heart. Even if you conflict in a professional manner so that nobody’s feel- risk angering a surgeon who brings in a lot of business, ings get hurt and the OR can remain a happy and pro- the professional thing to do is to involve the patient in ductive workplace. Remember that without the sur- the process. geons, you don’t have a job; nobody comes into the hospital to get anesthesia just to catch up on his or her Interpersonal and communication sleep. skills Practice cost-effective health care and resource Residents must be able to demonstrate interpersonal allocation that does not compromise quality of and communication skills that result in effective infor- care. mation exchange and teaming with patients, their patients’ families, and professional associates. Cost-effective health care includes avoidance of unnecessary tests and procedures. In this case, you Use effective listening skills and elicit and provide already have all the information you need to determine information using effective nonverbal, the patient’s cardiac status, and there is no need for explanatory, questioning, and writing skills. further testing. In other words, if you have a 2-day- After you speak your peace to the patient, take old cath report, don’t send the patient for an echo. It is time to listen to the patient’s questions and concerns. amazing how often we order a test without really stop- Communication does not begin and end with you. If ping to think about whether we really need it. A prime the patient wants references, give him references. If he example of this is the daily complete blood count and thinks he will have trouble remembering, then write it electrolyte panel. If it has been normal 6 days in a row, down for him. By taking just a few minutes to focus why order it every day? on the patient and his concerns, you can drastically An easy way out of the situation for you would be to improve your relationship with him. postpone the case for further testing – maybe you can even postpone it until you are postcall and it becomes someone else’s problem. This will probably add costs, Systems-based practice and nothing else, to the patient’s care. If you have the Residents must demonstrate an awareness of and information you need to make a decision, then make a responsiveness to the larger context and system of decision. Don’t just pass the buck.54
  • 64. Case 9 – When were those stents placed?Additional reading 2. Nuttall GA, Brown M, Stombaugh J, et al. Time and cardiac risk of surgery after bare-metal stent1. Rabbitts JA, Nuttall G, Brown M, et al. Cardiac risk of percutaneous coronary intervention. Anesthesiology noncardiac surgery after percutaneous coronary 2008;109:588–595. intervention with drug-eluting stents. Anesthesiology 2008;109:596–604. 55
  • 65. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 10 Flame on! Christopher J. Gallagher and Matthew Neal The case ate ends and interpersonal and communication skills begin, send me an e-mail. They sound awfully close to A smell like barbeque fills the entire emergency room. me! “Funny,” you think, “no one told me there was a pic- Bottom line – the patient care that is most com- nic.” You note that the smell is coming from the trauma passionate for a truly hopeless case (this patient had bay, and you go there as a code T (trauma) is called third-degree burns over every square inch of his body; overhead. the fact that he was even alive at this point was some Inside, a man is stripped completely bare of his skin kind of celestial miracle) is comfort care. He got as and hair. An industrial accident has left him burned much morphine as I could inject through the one IV over 100% of his body, yet he is talking, coherent, com- we were able to get through the burned skin. I warmed plains only of feeling cool, and has no pain. the room up, too (he felt cool, which patients some- “Give him morphine,” the resident tells you. “We times do if all the nerve endings are singed off). got an IV in him so just keep giving him morphine.” You ask if you’re going to intubate or what exactly Gather essential and accurate information about the plan is. their patients. “Morphine,” the resident tells you again. “That’s the plan, you follow me? He’s a goner.” I did a physical exam to confirm that, indeed, everything was burned off on this man. There were no Patient care eyebrows, no eyelashes, and his surface appeared white and meaty, for lack of a better term. Residents must be able to provide patient care that is Usually, in such a case, when you are in resuscita- compassionate, appropriate, and effective for the treat- tion mode, you would be scrambling for a host of lab- ment of health problems and the promotion of health. oratory data, as well: Communicate effectively and demonstrate caring r arterial blood gas, including carbon monoxide and respectful behaviors when interacting with level patients and their families. r hematocrit r electrocardiogram This is based on a real case, believe it or not. No one r chest X-ray could find any family members for this patient, and he was eerily and creepily awake and alert for about the But in this curious world of “provide comfort only,” first half hour I was with him. Given the extent of his the approach was different. Why get a bunch of labs injuries, it was downright Twilight Zone–esque that he that you’re not going to act on anyway? was so with it, so I had to give it to him straight. This event is among my most memorable experi- Make informed decisions about diagnostic and ences of a lifetime, and I will take this one with me therapeutic interventions based on patient until it’s time for me to get some morphine. (Now to go information and preferences, up-to-date scientific from the sublime to the ridiculous.) And this is where evidence, and clinical judgment. you can see the various Core Clinical Competencies tripping over each other because the main thing here I confirmed with the resident, and asked that we56 is communicating with the patient. If you can figure confirm with the attending, that this was truly a hope- out where providing patient care that is compassion- less case and that we weren’t writing someone off who
  • 66. Case 10 – Flame on!stood a chance. That was the consensus, and the burn Demonstrate an investigatory and analyticpeople came down and gave us their blessing on this, thinking approach to clinical situations.too. Shift into high gear and become the world’s leading Develop and carry out patient management plans. expert on burns in a hurry in this case. Although the focus in this case is comfort care, that doesn’t mean This is where I really hate the Core Clinical Compe- that the next burn patient is going to be as badly off.tencies. “Carry out patient management plans.” God, Following are the main points:what a bloodless and administrato-gobbledygook way r Watch for signs of an upper airway burn (singedof saying “be a doctor and treat the patient.” nose hairs, carbonaceous sputum) and secure the Counsel and educate patients and their families. airway right away in case of any doubt whatsoever. Once the airway swells up, the patient will become Back to Core Clinical Competency overlap land. an impossible intubation in no time.This is interpersonal and communications skills as well r Volume replacement can be tremendous as theas professionalism all wrapped into one. I’ll get into “insulation” is lost and the patient loses vastwhat I told the guy in the latter section. amounts of fluid. r Carbon monoxide inhalation is as stealthy as it is Use information technology to support patient deadly. A patient can appear perfectly lucid and care decisions and patient education. still have high levels of carbon monoxide, then, To hell with information technology at this point; later on, suffer severe neurologic damage.it’s all hands on and physical exam. Investigatory and analytic with a burn patient? Snoop around for the hidden problems of a burned airway, Perform competently all medical and invasive lost volume, and “stealth” carbon monoxide. procedures considered essential for the area of practice. Know and apply the basic and clinically supportive sciences that are appropriate to their As long as I didn’t stick the morphine syringe into discipline.the mattress by mistake, I was performing compe-tently. The main thing here was to keep misguided res- For anesthesia, this means the ABCs writ largecuers from running in the room and coding or intu- because this is our stock in trade.bating this guy. Provide health care services aimed at preventing Practice-based learning health problems or maintaining health. and improvement Residents must be able to investigate and evaluate their Day late and a dime short here. patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Work with health care professionals, including those from other disciplines, to provide Analyze practice experience and perform patient-focused care. practice-based improvement activities using a The most important element here is hooking up systematic methodology.with the burn people and making sure that I’m doing The most practical approach to this Core Clinicalthe right thing for this poor patient. Competency is simply this: review the literature perti- nent to burn patients and make sure that you are up onMedical knowledge the latest.Residents must demonstrate knowledge about estab- Locate, appraise, and assimilate evidence fromlished and evolving biomedical, clinical, and cognate scientific studies related to their patients’ health(e.g., epidemiological and social-behavioral) sciences problems. 57and the application of this knowledge to patient care.
  • 67. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 A modern twist on all this? Google “burns,” or him, providing pain medication, waving off the code do a Medline search to see what the latest thinking is team, and staying until the end. This opens the whole regarding treatment of the burn patient. end-of-life discussion. Obtain and use information about their own Demonstrate a commitment to ethical principles population of patients and the larger population pertaining to provision or withholding of clinical from which their patients are drawn. care, confidentiality of patient information, I paged the burn team right away. They deal with informed consent, and business practice. this stuff all the time and know the ins and outs of the The main thing here is to withhold heroic care that burn unit, so they were the people to contact regarding would prolong the patient’s misery. this unfortunate patient. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and Interpersonal and communication other information on diagnostic and therapeutic skills effectiveness. Residents must be able to demonstrate interpersonal and communication skills that result in effective infor- Much as we hate statistics (most doctors glaze over mation exchange and teaming with patients, their when biostatistics are mentioned), we still have to patients’ families, and professional associates. know this deadly dull field. If we don’t know statistics, we cannot really weigh the validity of a study. Sugges- Use effective listening skills and elicit and provide tions for the reading public? Here’s what I did; you can information using effective nonverbal, run with it however you want. Aviva Petrie and Caro- explanatory, questioning, and writing skills. line Sabin [1] broke up the forbidding areas of statistics into digestible parts. Give this book a try if you’re lost This is the most important aspect of this case, so in statistics. I’ll linger here a while. Following is the conversation I had with this patient, as nearly as I can reconstruct it. Use information technology to manage (This was such an emotionally wrenching event that it information, access online medical information, made a hell of an impression on my memory banks.) and support their own education. You can agree or disagree with my approach and choice At the time of this case, the year was all of 1984, so of words, but here’s what I did. I’ll call the patient, for the Internet was not yet even a glimmer in Bill Gates’s the sake of this reconstruction, “Jim Smith.” eye. But today, of course, you’d Google anything you “Jim, I’m going to be giving you some morphine to didn’t know. make you a little more comfortable.” “It’s bad, huh?” (As mentioned earlier, he was sur- prisingly lucid.) Professionalism “Jim, you’re burned over all your body, and it’s all Residents must demonstrate a commitment to carry- third degree, that’s the worst kind.” ing out professional responsibilities, adherence to ethi- “It’s cold in here.” cal principles, and sensitivity to a diverse patient popu- I put a blanket over him; his nerve endings were lation. charred, so that didn’t hurt him. I turned up the ther- Demonstrate respect, compassion, and integrity; a mostat in the room. responsiveness to the needs of patients and society “Jim, this burn is pretty bad. I mean really bad. But that supersedes self-interest; accountability to I’m going to make sure you’re nice and comfortable.” patients, society, and the profession; and a “Will they be doing any operations or anything?” commitment to excellence and ongoing “No, Jim, we’re mainly going to make sure you professional development. don’t hurt. Do you follow what I’m saying? This is not the kind of burn you can recover from, Jim.”58 Translation for this case? Stick it out with this guy. The morphine started kicking in (I was being pretty He deserves that. I made sure I stayed in the room with generous), and he started getting sedated.
  • 68. Case 10 – Flame on! “Yeah, yeah, I know what you’re saying, Doc.” Understand how their patient care and other “Want me to call anyone, Jim? Jim?” professional practices affect other health care It was probably volume loss and hypotension that professionals, the health care organization, andfinished him. I was hoping that it would go that way the larger society and how these elements of theand not end up with an obstructed airway. system affect their own practice. Work effectively with others as a member or To subject a person with fatal burns to an epic jour- leader of a health care team or other professional ney of ventilator dependence, a million skin grafts, group. and a zillion dollars’ worth of treatment is a waste of We divided up the emergency room that night, and society’s resources when the issue has already beenI stayed with Jim. decided. But as treatments improve, the day may come when we “go for it” with such a patient. No easy answers here.Systems-based practice Practice cost-effective health care and resourceResidents must demonstrate an awareness of and allocation that does not compromise quality ofresponsiveness to the larger context and system of care.health care and the ability to effectively call on systemresources to provide care that is of optimal value. See the preceding comment. 59
  • 69. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 3. Cochran A. Inhalation injury and endotracheal intubation. J Burn Care Res 2009;30:190–191. 1. Petrie A, Sabin C. Medical statistics at a glance. 2nd ed. Malden, MA: Blackwell; 2005. 4. Belgian Outcome in Burn Injury Study Group. Development and validation of a model for prediction 2. Chai JK, Sheng ZY, Yang HM, et al. Treatment of mortality in patients with acute burn injury. Br J strategies for mass burn casualties. Chin Med J (Engl) Surg 2009;96:111–117. 2009;122:525–529.60
  • 70. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 11 What date would you like carved in stone? Christopher J. Gallagher and Anna KoganThe case emaciation could only confirm the obvious – no mat- ter what they found on this patient, he was not going toA 73-year-old man is scheduled for a mediastinoscopy. be able to endure chemo, radiation, or surgical therapy.He is emaciated, has positive findings of metastatic dis-ease on his chest X-ray, and is unable to lie down in the Make informed decisions about diagnostic andleast, getting short of breath if he’s anything other than therapeutic interventions based on patientbolt upright. information and preferences, up-to-date scientific He is to have this mediastinoscopy for a tissue diag- evidence, and clinical judgment.nosis of an obviously horrible cancer. He is now on theoperating table with the back all the way up, and you’re The main point about this case and this write-up ispreoxygenating him. It’s all you can do to get the satu- that you have to be a perioperative physician, not justration up to 92%. an anesthetic accessory to a surgical procedure. Suddenly, you throw up your hands, call for the sur-geon, and say, “This is ridiculous, I’m not doing this Develop and carry out patient management plans.case. What the hell are we doing this for?” The surgeon gets mad as a wet hen and takes you Cancel the stupid case!outside. You look him in the eyes and say, “What datedo you want carved in this guy’s stone? You might as Counsel and educate patients and their families.well carve today’s if I go ahead.” Believe it or not, it often falls to us, the anesthesi- ologists, to go out, sit down with the family, and spellPatient care out the entire picture. When I went out and talkedResidents must be able to provide patient care that is with the patient’s family, I asked what they pictured uscompassionate, appropriate, and effective for the treat- doing, and they all agreed that he was far too sick toment of health problems and the promotion of health. be subjected to some monstrous cure. Better to let him be. (After the burn case discussed in Case 10, you’re Communicate effectively and demonstrate caring going to think I’m some sort of angel of death, stalk- and respectful behaviors when interacting with ing the hallways of the hospitals with my scythe and patients and their families. robe!) OK, so maybe saying “what the hell are we doing Use information technology to support patientthis for” was not, precisely, caring and respectful, but it care decisions and patient education.sure was effective! The main thing here was to take astep back and look at the whole picture, not just this A complete review of the computed tomographyone procedure. scans confirmed that this guy’s entire mediastinum was involved and that nothing was going to save the day Gather essential and accurate information about here. their patients. Perform competently all medical and invasive A review of the chart and a physical exam con- procedures considered essential for the area offirmed everything I needed to know about this man. practice. 61The severe degree of disability and advanced state of
  • 71. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 I could have done the anesthetic, taking into ac- Locate, appraise, and assimilate evidence from count the considerations of mediastinal mass. But that scientific studies related to their patients’ health was not the point; rather, the point was to decide what’s problems. best, not just dish up an anesthetic. By all means, know about the implications of a Provide health care services aimed at preventing mediastinal mass on the airways and vascular struc- health problems or maintaining health. tures. The biggest concern is sedating, anesthetizing, and giving muscle relaxants and ending up with the It’s a little late to tell the patient to stop smoking. patient getting cardiorespiratory collapse from the mass. Work with health care professionals, including those from other disciplines, to provide Apply knowledge of study designs and statistical patient-focused care. methods to the appraisal of clinical studies and I didn’t have to slap the surgeon around to see my other information on diagnostic and therapeutic point of view. I just had to threaten to slap him around effectiveness. to get him to see my point. Oy! Statistics again. There’s no avoiding it – sort of like death and taxes. Medical knowledge Residents must demonstrate knowledge about estab- Professionalism lished and evolving biomedical, clinical, and cognate Residents must demonstrate a commitment to carry- (e.g., epidemiological and social-behavioral) sciences ing out professional responsibilities, adherence to ethi- and the application of this knowledge to patient care. cal principles, and sensitivity to a diverse patient popu- lation. Demonstrate an investigatory and analytic thinking approach to clinical situations. Demonstrate respect, compassion, and integrity; a The biggest analysis that needed doing here was responsiveness to the needs of patients and society seeing the forest for the trees. Don’t think “do anesthe- that supersedes self-interest; accountability to sia for this one procedure”; rather, think “do what’s best patients, society, and the profession; and a for the patient given his overall situation.” commitment to excellence and ongoing professional development. Practice-based learning To beat the same drum here, the best way to express respect for this man is to spare him a useless procedure and improvement that won’t help him or alter his treatment anyway. Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific Demonstrate a commitment to ethical principles evidence, and improve their patient care practices. pertaining to provision or withholding of clinical care, confidentiality of patient information, Analyze practice experience and perform informed consent, and business practice. practice-based improvement activities using a systematic methodology. When I went out in the hall to talk with his fam- ily, I made sure I followed HIPAA and commonsense This is where being clinically and scientifically pre- guidelines. We went to a private room and discussed cise can be very tough. Where, oh, where, in the world all this far from prying ears. is there a well-controlled, large study that looked at this exact situation – an emaciated patient with advanced everything, and you wonder whether you should pro- Interpersonal and communication ceed with a mediastinoscopy. This is where medicine skills62 is more art than science, all due apologies to practice- Residents must be able to demonstrate interperson- based learning and improvement. al and communication skills that result in effective
  • 72. Case 11 – What date would you like carved in stone?information exchange and teaming with patients, their Systems-based practicepatients’ families, and professional associates. Residents must demonstrate an awareness of and Use effective listening skills and elicit and provide responsiveness to the larger context and system of information using effective nonverbal, health care and the ability to effectively call on system explanatory, questioning, and writing skills. resources to provide care that is of optimal value. Most of the listening came in that private room, as Understand how their patient care and otherI dealt with the family’s concerns. A major point is to professional practices affect other health carelet them have their say and not try to steer the conver- professionals, the health care organization, andsation so much. the larger society and how these elements of the system affect their own practice. Work effectively with others as a member or leader of a health care team or other professional The main thing in this case was “think what we’ll group. do with this information.” That’s what made me throw up my hands and say, “Enough!” So we find out it’s Of course, the surgeon got fussy, but what can this or that cancer. Are we going to treat it anyway?you do? They’re always mad. Maybe we should sneak If the answer is no, then don’t do the case in the firstProzac into their cornflakes? place. 63
  • 73. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading the ICU facilitate end-of-life decision making. Am J Hosp Palliat Care 2009. 1. Slinger P, Kursli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr 3. Pantilat S. Communicating with seriously ill Opin Anaesthesiol 2007;20:1–3. patients: better words to say. JAMA 2009;301: 1279–1281. 2. Marik PE, Callahan A, Paganelli G, Reville B, Parks SM, Delgado EM. Multidisciplinary family meetings in64
  • 74. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 12 Spasm, spasm, how do I treat thee? Bronchospasm in a stage IV breast cancer patient Bharathi Scott and Shiena SharmaThe case Gather essential and accurate information aboutA 54-year-old black female presented with a lung nod- their patients.ule of unknown origin for thoracosopy and partial It is essential to recognize, acknowledge, andresection of the right lower lobe. The patient had a his- address anxiety preoperatively. This is the compassiontory of breast cancer, reactive airway disease, and high component of being a physician, as applied to anes-anxiety. The patient was sedated in the holding room, thesia, in particular. A reassuring smile or squeeze ofbrought back to the operating room, and induced and the hand can do wonders in alleviating preop jittersintubated with a right-sided double lumen tube. The and utilizes the one competency seldom taught in text-patient subsequently went into bronchospasm, which books: the power of human touch.was ultimately broken by our superb efforts. The patient was extubated on termination of the Make informed decisions about diagnostic andcase and was completely unaware of our quick and therapeutic interventions based on patientstoic measures to battle the beast of anesthesia, the information and preferences, up-to-date scientificspasm, a wild and unruly creature whose insidious evidence, and clinical judgment.and sudden onset can throw off even the most expe-rienced of the people under the drapes (OK, so we We spoke to the patient after careful review ofare behind the drapes, but this phrase reminded me of the chart and confirmed her history, allergies, and allPeople under the Stairs . . . anyone see that movie?). the good stuff that goes into a thorough preoperative evaluation. We identified that her history of reactive airway disease had no relation to smoking and wasPatient care related to anxiety and weather. We decided that hav-Residents must be able to provide patient care that ing an inhaler intraop would be a good idea, hence theis compassionate, appropriate, and effective for the Proventil.treatment of health problems and the promotion ofhealth. Develop and carry out patient management plans. Communicate effectively and demonstrate caring The master plan was induction, intubation and respectful behaviors when interacting with (smooth as butter, of course), ALine, surgical proce- patients and their families. dure, extubation . . . lunch! On arrival, Mrs. Z had high anxiety, but not the Use information technology to support patient“Oh, my God, am I gonna die?” type. She was quiet care decisions and patient education.and reserved – a true picture of composure. However,a careful, real look into those big, round eyes, and I General anesthesia was explained, followed by anwas reminded of Bambi facing a semi on Interstate 495. explanation of standard monitors and invasive moni-We reassured her and her daughter and told them that tors.we would take care of her to the best of our ability Perform competently all medical and invasiveand make her as comfortable as possible. I maintained procedures considered essential for the area ofgood eye contact, answered the patient’s questions, and practice.smiled . . . then versed incoming! 65
  • 75. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Because this case involved isolating a lung for sur- During this time, it was quickly noted how diffi- gical procedure, it was important to have read about cult it was to hand ventilate the patient. Peak airway the surgical requirements of the procedure in the pressures were in the 50s, and auscultation of squeaky, preop period. Effective placement of the double lumen high-pitched, distant breath sounds were appreciated. tube, including confirmation of placement with a fiber- optic scope, should be reviewed. Know and apply the basic and clinically supportive sciences that are appropriate to their Provide health care services aimed at preventing discipline. health problems or maintaining health. Rather than collapse in a heap of panic and frenzy The patient took albuterol on the morning of the and radio every airway specialist overhead, a system- procedure. atic and structured approach was utilized to identify the problem. The fiber-optic scope was quickly placed Work with health care professionals, including to determine if the tube was in an appropriate position, those from other disciplines, to provide which it was. The patient was maintained on 100% patient-focused care. oxygen, and sevoflurane was turned on to highest Surgical considerations and requirements for this minimum alveolar concentration. Muscle relaxant type of case are of utmost importance. One must be in was administered, corticosteroids were given intra- sync with the ventilating and dropping of the surgically venously, and Proventil was administered via an endo- marked lung per the surgeons’ request. tracheal tube. Medical knowledge Professionalism Residents must demonstrate knowledge about estab- Residents must demonstrate a commitment to carry- lished and evolving biomedical, clinical, and cognate ing out professional responsibilities, adherence to eth- (e.g., epidemiological and social-behavioral) sciences ical principles, and sensitivity to a diverse patient pop- and the application of this knowledge to patient care. ulation. Demonstrate an investigatory and analytic Demonstrate respect, compassion, and integrity; a thinking approach to clinical situations. responsiveness to the needs of patients and society that supersedes self-interest; accountability to When performing a one-lung ventilation case, patients, society, and the profession; and a one must anticipate complications and roadblocks to commitment to excellence and ongoing maintaining adequate ventilation. A physician’s job is professional development. to consistently adapt and apply his or her fund of knowledge to challenging situations and unforeseen Sometimes under the legality of medicine, we com- complications in a timely manner. Hence all critical sit- promise our most basic instincts of nurturing. We fear uations require touching our patients because it can be interpreted the r investigation wrong way. In this case, I felt compassion that super- r formulation of a hypothesis seded any legal guidelines involving physical contact r correction of supposed underlying problems with patients that I had received in those mega (bor- (aided by hours of training, journal clubs, QA, ing) all-resident conferences. lectures, experience, and mistakes) Here was a lady who had been through a lot. She r prevention of future occurrences was scared. I felt her fear. So I went with my instinct and stroked her head and verbally consoled her to the In our case, shortly after induction with the “reg- best of my ability, as her tired eyelids closed slowly ulars,” a 35-mm left-sided double lumen tube was and the milky white snaked its way up her veins. My placed on the first attempt. Anesthesia’s friends were all attending stood by me, one hand in the patient’s hand, in attendance to confirm proper placement, including the other gently on her neck. It was an act of compas-66 Mr. EtCO2 , Mrs. Equal B/L B.S, and, of course, Se˜ or n sion, and it was more than any textbook could ever fiber optic. teach me.
  • 76. Case 12 – Spasm, spasm, how do I treat thee? We all know that at times, anesthesia gets the Demonstrate sensitivity and responsiveness to stigma of being “impersonal and isolated” in terms of patients’ culture, age, gender, and disabilities. establishing good patient relationships due to the mere With the patient being a victim of breast cancer and fact that, hey, we put people to sleep for a living. Howradiation, my attending and I were very aware of the can we talk to them – they’re asleep!guarded nature of patients who have been in the health In this case, however, it was demonstrated thatcare system. They are often weary of medical profes- effective communication has no time constraint andsionals and, in general, approach procedures with a no indication for verbalization. Simply listening atten-sense of impending doom. It is our job not only to treat tively and patiently to your patient can give you cluesmedical ailments, but also to be sensitive of patients’ to deliver an above average standard of care.fragility and fears. Work effectively with others as a member or leader of a health care team or other professionalInterpersonal and communication group.skills The cardiothoracic (CT) surgeon approached meResidents must be able to demonstrate interpersonal and said, “You know, I just wanted to thank you forand communication skills that result in effective infor- your care with that patient the other day. I saw hermation exchange and teaming with patients, their today, and she mentioned that the anesthesiologist waspatients’ families, and professional associates. so kind and caring and appreciated the gentle stroking Create and sustain a therapeutic and ethically of her head as she fell asleep. Thank you for making it sound relationship with patients. a pleasurable experience. Nice touch.” Wow . . . yeah, I was grinning ear to ear, no lie! But after all, we are a My attending consistently reminded me that if I team!treated all patients as my own family, I could never go Surgeons, anesthesiologists, nurses, techs – we arewrong – good advice! the well-oiled machine that delivers optimal care. Although a patient is considered to be CT-surgery or Use effective listening skills and elicit and provide an ortho patient, they are all our patients. This is all the information using effective nonverbal, more reason to work with our peers as one big unit, explanatory, questioning, and writing skills. rather than as a subdivision of specialties. 67
  • 77. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 2. Mayne IP, Bagaoisan C. Social support during anesthesia induction in an adult surgical population. 1. Nadaud J, Landy C, Steiner T, Pernod G, Favier JC. AORN J 2009;89:307–310, 313–315, 318–320. Helium-sevoflurane association: a rescue treatment in case of acute severe asthma (in French). Ann Fr Anesth Reanim 2009;28:82–85.68
  • 78. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 13 Why don’t you join the HIT parade? HIT in a cardiac surgery patient Bharathi Scott and Jason DarasThe case on a clinical basis and is supported with the previously mentioned tests and therapy.A 70-year-old male is scheduled for coronary arterybypass graft (CABG) on pump. He has the usual his- Develop and carry out patient management plans.tory of unstable angina, diabetes, and hypertension.The cardiac catheterization report shows triple vessel Communicate the issues with all members of thedisease with normal left ventricular ejection fraction. surgical team. Choices of alternate method of antico-You are thrilled that finally, you have a routine CABG agulation therapy are argatroban, bivalirudin, and lep-this week. No big deal, been there and done that. Just irudin. Bivalirudin (Angiomax) is the most commonlyas you are walking down the floor to see the patient, used antithrombin agent in cardiac surgical patients.the friendly cardiologist says, “The patient has recently Dosing involves an initial loading dose (1 mg/kg) fol-dropped his platelet count and we are waiting for the lowed by a maintenance infusion of 2.5 mg/kg/hour.antibody test. I think the patient has HIT [heparin- Activated clotting times are monitored and the dosageinduced thrombocytopenia]. We stopped heparin yes- is adjusted accordingly. Dosage is reduced in patientsterday and started him on argatroban.” What the . . . ? with renal insufficiency and failure. Argatroban is more commonly used in patients undergoing percu- taneous coronary intervention.Patient careResidents must be able to provide patient care that is Perform competently all medical and invasivecompassionate, appropriate, and effective for the treat- procedures considered essential for the area ofment of health problems and the promotion of health. practice. Communicate effectively and demonstrate caring Stick to the basics of bypass surgery! Secure and respectful behaviors when interacting with your airway, invasive monitors, and, if needed, trans- patients and their families. esophageal echocardiography (TEE). Be sure to min- imize traumatic tube and line placement – the less of The anesthesia team must be able to communicate the red stuff, the better. Appropriate blood and bloodthe special issues involved in the anticoagulation man- products should be readily available.agement with the patient, surgeon, and other membersof the operating room (OR) team, especially the perfu- Work with health care professionals, includingsionists. those from other disciplines, to provide patient-focused care. Gather essential and accurate information about their patients. Whether it is in or out of the OR, health care professionals must understand that they are working The anesthesia team should make sure the appro- toward the same goal. All health care providers mustpriate steps are taken to provide alternative anticoag- be included.ulation for surgery. This includes special attention toplatelet count and response to cessation of heparin. Check the platelet factor 4 antibodies in vitro to Medical knowledgeconfirm the diagnosis of HIT (type II). In addition, it is Residents must demonstrate knowledge about estab- 69important to recognize that diagnosis of HIT is made lished and evolving biomedical, clinical, and cognate
  • 79. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 (e.g., epidemiological and social-behavioral) sciences Demonstrate respect, compassion, and integrity; a and the application of this knowledge to patient care. responsiveness to the needs of patients and society that supersedes self-interest; accountability to Demonstrate an investigatory and analytic patients, society, and the profession; and a thinking approach to clinical situations. commitment to excellence and ongoing When you find yourself staring down the belly of professional development. HIT, you must think of a differential for the drop in So this patient with this possibly devastating con- platelets before confirming the HIT diagnosis. Could dition is thrown your way. No sweat . . . or at least, never this patient have leukemia? Could he or she have been let them see you sweat. True to life, if you break down exposed to a virus or some other drug that may have and start screaming at others in the OR, they will caused this? start screaming back; the patient, if awake, will start to What does this mean for your intraop manage- panic, and then you will start to panic – can you see ment? Alternate anticoagulation and excessive bleed- a vicious circle? Think about your own attendings – ing that may lead to the use of blood and blood who are the most composed, professional, and level- products? Managing the hemodynamic response to headed? I’ll bet you the best anesthesiologists are the hypovolemia versus the hemodynamic response to a ones who can calm down a thoracic surgeon who just failing heart – TEE would show all in this case! Get it dissected an aorta. These are the anesthesiologists who out and start imaging the heart. command the most respect and communicate best in the OR. So if a patient with HIT comes into your OR, Practice-based learning be prepared and make sure the patient and surgeon are and improvement prepared for what potential disasters may develop. Residents must be able to investigate and evaluate their Demonstrate sensitivity and responsiveness to patient care practices, appraise and assimilate scientific patients’ culture, age, gender, and disabilities. evidence, and improve their patient care practices. Always remember, you have a life to take care Analyze practice experience and perform of, which is a unique position for a person to be in. practice-based improvement activities using a Patients are all different. Some may have more edu- systematic methodology. cation and may understand a condition and its conse- It is important to learn from your own practice quences better than others. They may have the means of these cases or your colleagues’ cases and discuss to research their own medical problems. In a condition the improvements that could be made. Asking ques- so unique as HIT, some patients may need more expla- tions and following up literature is an important way nation. Culture can play a huge roll, especially when to improve your practice-based learning. a Jehovah’s Witness appears with the declaration that you may not use blood products – your hands are com- Assimilating evidence from your own practice pletely tied, right? Well, maybe to some degree, but with the literature. there is always autologous blood salvage or transfu- sions. Assure the patient that you will do your best with Ultimately, this is a very hard task, and one that the given restrictions, instead of getting upset with the separates the experts from the amateurs. Can you look situation or the patient. There is a very important psy- at studies on HIT and, from those studies, create a bet- chosocial aspect to every case you deal with as a physi- ter method of facilitating diagnosis and/or treatment? cian, so you may as well embrace it. It is hard to find a double blind, randomized study on such a not-so-common reaction to heparin. Interpersonal and communication Professionalism skills Residents must demonstrate a commitment to car- Residents must be able to demonstrate interpersonal rying out professional responsibilities, adherence to and communication skills that result in effective infor-70 ethical principles, and sensitivity to a diverse patient mation exchange and teaming with patients, their population. patients’ families, and professional associates.
  • 80. Case 13 – Why don’t you join the HIT parade? Create and sustain a therapeutic and ethically Understand how their patient care and other sound relationship with patients. professional practices affect other health care professionals, the health care organization, and Many might say that of all physicians, anesthesiol- the larger society and how these elements of theogists have more of a problem forming relationships system affect their own practice.with patients because the majority of our interaction isunder anesthesia. However, through our preoperative We must all understand our role in the health carevisit bedside and postoperative visit, we can communi- system and our limitations. Sometimes we go abovecate all our concerns, and the patients can communi- and beyond what we may have to do to save a patient’scate theirs. Devising a plan and allowing the patient to life. In the process of treating HIT in a patient under-be educated about his or her medical issue will ensure going CABG, we act as the cardiologist, hematologist,less anxiety pre- and postop. and anesthesiologist, all the while keeping in mind our own limitations and asking for assistance, if needed. Work effectively with others as a member or leader of a health care team or other professional Practice cost-effective health care and resource group. allocation that does not compromise quality of A very important aspect is communication of all care.staff, especially when dealing with a patient who has The key here is the fact that practicing cost-effectivea unique medical condition. Many people working on medicine should not compromise patient care. Howthe case may not know the extent or ramifications of in HIT can we practice cost-effective medicine? Well,the illness. Perhaps you may not be comfortable deal- we can take into account that these patients bleeding with this patient – it happens. Don’t be a cowboy; more intraop, and patients will be receiving vari-read and communicate. Don’t be afraid to talk to the ous blood products. Keeping a mindful watch on thesurgeons because we are all in this together. amount of product you are using, placing packed red blood cells in the refrigerator that are not being used,Systems-based practice and keeping good communication between the bloodResidents must demonstrate an awareness of and bank and OR will contribute toward this. Other cost-responsiveness to the larger context and system of effective methods during your anesthetic manage-health care and the ability to effectively call on system ment can go a long way, so stop cranking up those O2resources to provide care that is of optimal value. flows! 71
  • 81. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 1. Warkentin TE, Greinacher A. Heparin induced thrombocytopenia: recognition, treatment and prevention. Chest 2004;126:311S–337S.72
  • 82. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 14 Bad lungs in the ICU Shaji Poovathor and Rany MakaryusThe case Gather essential and accurate information aboutA full-term, 24-year-old, pregnant African American their patients.woman was rushed to the operating room (OR) foremergency cesarean section secondary to fetal distress. Look at the patient. Examine her. Look at the mon-Post cesarean section, she started to bleed profusely itor. How bad is her lung (remember the pink, frothyin the abdomen. She was taken back to the OR and stuff from her ET tube?)? How high is the airway pres-ended up having a hysterectomy under general anes- sure? Order appropriate labs.thesia. However, she uncontrollably lost around 1.5 L Make informed decisions about diagnostic andof blood. She received 10 units of packed red blood therapeutic interventions based on patientcells, 10 units of fresh frozen plasmas, 2 units of cry- information and preferences, up-to-date scientificoprecipitate, and multiple boluses of crystalloids. She evidence, and clinical judgment.was left intubated and was admitted to the surgicalintensive care unit (SICU). While she was connected to Can this patient develop disseminated intravascu-the ventilator, the respiratory therapist noted a copious lar coagulation? Can this patient develop transfusion-amount of pink, frothy fluid in her endotracheal (ET) related lung injury (TRALI)? Can she develop acutetube. respiratory distress syndrome (ARDS)? Can she develop pulmonary embolism (PE)? Can she develop sepsis? The answer is yes, she could develop any onePatient care of these. Again, clinical judgment warrants looking forResidents must be able to provide patient care that is these and acting on them.compassionate, appropriate, and effective for the treat-ment of health problems and the promotion of health. Develop and carry out patient management plans. Communicate effectively and demonstrate caring Supportive measures for the lung are important. and respectful behaviors when interacting with Remember the ARDS net trial: low tidal volume, low patients and their families. airway pressure to avoid blowing off her lung, and chest X-ray every day to evaluate her lung condition. After initially attending to the patient and making An echocardiogram (EKG) to reveal her heart sta-sure that the patient is stable enough (how stable is tus is needed. What if the EKG had shown a right ven-enough is a clinical judgment; if the patient is not sta- tricular dilation (which this patient had)?ble enough, the family members still need to under- Does she need any prophylactic antibiotics?stand the unfortunate outcome), the resident needs to Evidence-based study shows no primary role forcommunicate effectively with the primary service who antibiotics in terms of prophylaxis, unless and untiloperated on her. Make sure that the family members there is solid evidence of “wrong bugs in the wrongand next of kin are fully aware. It is the joint responsi- place at the wrong time.”bility of the primary service and the SICU to keep the Administer proper sedation and pain killers sofamily members updated. What can we do? What are that she doesn’t yank off her tube. Also give vaso-the unfortunate outcomes? Could there be any other pressors, if needed, to support hemodynamics, and getalternative? Does the patient have a living will? labs to ensure that she is not bleeding, not going into, 73
  • 83. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 and not going into kidney failure and to check lytes and Work in close association with the primary service, repleting lytes, as needed, arterial blood gases, and so cardiologist (if one was involved for the EKG evalu- on. ation), SICU nursing staff, patient relation team (for closer relationships with the next of kin and family Counsel and educate patients and their families. members), and organ donation task force (now may be Now it is time to jump in and evaluate the overall the time to think of a living will, organ donation, etc.). situation. What if things don’t work? Think about the living will. Should we involve the organ donation task Medical knowledge force? Residents must demonstrate knowledge about estab- lished and evolving biomedical, clinical, and cognate Use information technology to support patient (e.g., epidemiological and social-behavioral) sciences care decisions and patient education. and the application of this knowledge to patient care. Again, look at chest X-rays, labs, ventilator param- Demonstrate an investigatory and analytic eters, spirometry, neurological examinations, abdom- thinking approach to clinical situations. inal examinations, and so on. If an EKG has shown a right ventricular dilation, what are you thinking? Several situations arise in this particular patient: Could this be an extra strain on the heart from a PE? 1. Multiple blood products – think of How is the patient’s hemodynamics? Does she have an transfusion-related lung injury versus adult alveolar arterial O2 gradient? (Look at the ABG and respiratory distress versus acute lung injury. Look the FiO2 . Does she need an increasing O2 requirement for those bilateral, fluffy, homogenous chest to keep that PaO2 up?) Should we order a computed X-rays and increasing FiO2 requirements. tomography (CT) angiogram? 2. A right ventricular strain on EKG (evidence of If your instinct says maybe, then don’t waste time right ventricular dilation) may prompt you to considering her hemodynamics and other clinical think of a PE in combination with severe judgments. Go for it. If PE is positive, we need to find hemodynamic fluctuations (vasopressor- out if anticoagulation using heparin is called for, after dependent). appropriately discussing this with the primary service. 3. With an increasing temperature and white blood Perform competently all medical and invasive cells think of sepsis. Order and look for the blood procedures considered essential for the area of culture results. practice. 4. Rising creatinine and abnormal lytes will prompt you toward ongoing kidney damage. Make sure that the patient has a central line for 5. Avoid the stress gastric ulcer. Have proton pump access and central venous pressure monitoring and inhibitors going. an arterial line for continuous beat-to-beat analysis of 6. Oozing from IV sites, hematuria, bloody sputum – blood pressure and frequent ABGs. think of DIC? Look for the platelets and fibrinogen. Provide health care services aimed at preventing health problems or maintaining health. Know and apply the basic and clinically supportive sciences that are appropriate to their Priorities are supportive ventilatory management discipline. using extremely low tidal volumes, as per the ARDS net trial, to prevent severe barotrauma. Also important are Make sure you understand all the physiology that early diagnosis of PE to prevent catastrophes, and labs, applies to these complex cases: lung parenchymal dam- including blood cultures, to discover the hiding bugs, age from blood transfusion, physiology of plateau if any, and to treat them appropriately with antibiotics. pressure, pathophysiology of ARDS, PE causes and consequences, response of the body to PE and ARDS/ Work with health care professionals, including TRALI. Following is the sequence: those from other disciplines, to provide74 patient-focused care. 1. massive blood loss 2. massive transfusion
  • 84. Case 14 – Bad lungs in the ICU3. hit to the lungs: TRALI Obtain and use information about their own4. hit to the legs or circulatory system, causing population of patients and the larger population thrombus-embolic phenomena from which their patients are drawn.5. difficulty with oxygenation and ventilation6. bad, bad, bad lungs! A study of posttransfusion patients who develop acute pulmonary edema would be beneficial, but of even more benefit would be a study that looked at thePractice-based learning prevention of TRALI in multiparous women.and improvement Apply knowledge of study designs and statisticalResidents must be able to investigate and evaluate their methods to the appraisal of clinical studies andpatient care practices, appraise and assimilate scientific other information on diagnostic and therapeuticevidence, and improve their patient care practices. effectiveness. Analyze practice experience and perform Here are some of the highlights of which we need practice-based improvement activities using a to be aware: systematic methodology. 1. early use of the gold standard CT angiogram to Again, all is not lost as far as this Core Clini- diagnose PE in high-risk cases or in cases with acal Competency is concerned! The hospital, obstetric- high index of suspiciongynecological (OB-GYN) service, anesthesiology, and 2. the ARDS net trial study with low plateau pressurethe critical care service team should all have contin- and low tidal volume, minimizing lung damageuous quality improvement committees. As previously 3. literature on deep venous thrombosis prophylaxis:mentioned, difficult cases, complications, deaths – all heparin versus fractionated heparinthese things demand a systematic analysis afterward. Were there any other alternatives to doing this case Use information technology to managein the OR or any other alternatives in managing this information, access online medical information,case in the ICU? Should the patient never have been and support their own education.allowed a sedation vacation as she had bad lungs hitwith transfusion, ARDS, and PE? Were we late in diag- In this case, it is very simply a matter of know-nosing the PE? Did we use the concept of permissive ing how to find information about this topic. Enteringhypercapnia and hypoxemia? a PubMed search with institutionalized full-text links is very useful in finding the most up-to-date infor- Locate, appraise, and assimilate evidence from mation. This would include searching for “TRALI” scientific studies related to their patients’ health and “TACO” and combining these terms with “mul- problems. tiparous” or “postpartum.” Combining these search terms would improve the relevancy of the results to the This is when we need to turn to the collective expe- patient at hand.riences of others who have taken care of patients withthis reaction. Anesthesia and medicine are ever chang- Professionalisming and expanding fields; as continuous adult learn- Residents must demonstrate a commitment to carry-ers, and for the benefit of our patients, we need to ing out professional responsibilities, adherence to eth-keep abreast of the current literature. It would be pru- ical principles, and sensitivity to a diverse patient pop-dent for the team members of this patient’s care team ulation.to look up the most recent literature on TRALI andtransfusion-associated circulatory overload (TACO): Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society1. What’s better – a continuous positive airway that supersedes self-interest; accountability to pressure (CPAP) machine, or no CPAP? patients, society, and the profession; and a2. Should the patient be placed on an oscillator? commitment to excellence and ongoing3. What monitoring devices have been proven to be professional development. 75 best in this situation?
  • 85. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 This is demonstrated by the team’s dedication to As an ICU physician, your job is to get the infor- the care of this patient during this difficult acute mation you need with a complete accounting of what situation and continuing to provide the best possible happened in the OR, presurgical comorbidities, and a care. Using background medical knowledge, building directed history and physical. on this with a review of the current literature, and Your critical care note will demonstrate your writ- applying this to the patient show ongoing professional ing skills. Examination of the patient will demonstrate development. your nonverbal finding skills. History taking from the patient’s family members will demonstrate your ques- Demonstrate a commitment to ethical principles tioning skills. pertaining to provision or withholding of clinical care, confidentiality of patient information, Work effectively with others as a member or informed consent, and business practice. leader of a health care team or other professional group. In these situations, we have to be very careful to keep the patient’s wishes in mind. Many times, This involves the following: advanced directives may restrict care that we may be r Notify the family of the seriousness of the issue. able to give as anesthesiologists. We may sometimes r Notify risk management. want to do more for the patient, but such directives r Study the living will and discuss it with family may limit care; at other times, it is the opposite. The members. key factor is that the treatments we provide must be r Involve the organ donation task force. consistent with what the patient’s wishes are or would r Notify the pastor. have been. Saying that is the easy part, but figuring it r Work in close association with nursing staff and out is where it gets a little tough! the OB-GYN service. Demonstrate sensitivity and responsiveness to pa- All should join in the process with appropriate coordi- tients’ culture, age, gender, and disabilities. nation and cooperation. In a nutshell, show respect and compassion to the Systems-based practice patient and family members irrespective of age, reli- Residents must demonstrate an awareness of and gion, culture, gender, or race. responsiveness to the larger context and system of health care and the ability to effectively call on system Interpersonal and communication resources to provide care that is of optimal value. skills Understand how their patient care and other Residents must be able to demonstrate interpersonal professional practices affect other health care and communication skills that result in effective infor- professionals, the health care organization, and mation exchange and teaming with patients, their the larger society and how these elements of the patients’ families, and professional associates. system affect their own practice. Create and sustain a therapeutic and ethically This patient has suffered a life-ending hemor- sound relationship with patients. rhage, but this could be useful for the general public. Involvement of the organ donation task force early on Wash your hands before you go in to examine the will help. We have to take the best possible care of this patient and after examining the patient. Of course, patient to ensure that her organs are best preserved. look professional and give the patient’s family your Maintain hemodynamics and avoid barotrauma/ dynamic attention. (Don’t be texting while you’re talk- volutrauma to the lungs and heparinization to avoid ing with them, for example.) further embolic phenomena and further damage. Use effective listening skills and elicit and provide Practice cost-effective health care and resource information using effective nonverbal, allocation that does not compromise quality of76 explanatory, questioning, and writing skills. care.
  • 86. Case 14 – Bad lungs in the ICU The primary concern here is to avoid further dam- wrestling with the consequences of the operation. Yourage to the other organs as the lungs are already bad and advocacy for quality patient care will manifest as youcrunched. Be aware of the hospital’s policy on notify- continue to take good care of all physiologic variablesing the organ procurement team, how much lead time (which can be tough, as the brain-dead patient canthey need (including, of course, the all-important dis- develop all kinds of instability).cussion with family), and also their protocol. Remem- Your assistance with the family will be required:ber that the other organs could be jeopardized as the 1. Get everyone in a private room.lungs are already bad. Also keep in mind that care- 2. As usual, turn your beeper and cell phone off; thisful and professional discussion is warranted as the idea is no time for interruptions.of organ donation for the immediate family members 3. Allow time for family members to vent theircould be extremely painful. emotions. Again, responsible care of the patient at this point 4. Repeat information as necessary.mandates standard cost-effective maneuvers. Main-tain low nitric oxide ppm (remember that NO is veryexpensive); avoid frequent and unnecessary labs; and Know how to partner with health care managersto the best of your ability, shift gears to the least expen- and health care providers to assess, coordinate,sive regimen, while always maintaining the optimal and improve health care and know how thesephysiologic environment for the patient’s physiologic activities can affect system performance.status. Advocate for quality patient care and assist Make sure that you keep in touch with hospi- patients in dealing with system complexities. tal administration. The whole team in the SICU and OR should maintain that link with the team outside The main group of people dealing with system the OR and ICU that was involved in this patient’scomplexities at this point are the family members, care. 77
  • 87. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 4. Petersen B, Deja M, Bartholdy R, et al. Inhalation of the ETA receptor antagonist LU-135252 selectively 1. Terragni PP, Rosboch G, Tealdi A, et al. Tidal attenuates hypoxic pulmonary vasoconstriction. Am J hyperinflation during low tidal volume ventilation in Physiol Regul Integr Comp Physiol acute respiratory distress syndrome. Am J Respir Crit 2008;294:R601–R605. Care Med 2007;175:160–166. 5. Bloch KD, Ichinose F, Roberts JD Jr, Zapol WM. 2. Parsons PE, Eisner MD, Thompson BT, et al. Lower Inhaled NO as a therapeutic agent. Cardiovasc Res tidal volume ventilation and plasma cytokine markers 2007;75:339–348. of inflammation in patients with acute lung injury. Crit Care Med 2005;33:1–6. 6. Pelage J-P, Le Dref O, Jacob D, Soyer P, Herbreteau D, Rymer R. Selective arterial embolization of the 2. Acute Respiratory Distress Syndrome Network. uterine arteries in the management of intractable Ventilation with lower tidal volumes as compared with post-partum hemorrhage. Obstet Gynecol Surv traditional tidal volumes for acute lung injury and the 2000;55:204–205. acute respiratory distress syndrome. N Engl J Med 2000;342:1301–1308.78
  • 88. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 15 A simple breast biopsy Neera Tewari and Ramtin CohanimThe case The patient refused to take PO Bicitra. After 2 mg of IV midazolam, the patient is calm, and youA 61-year-old woman is scheduled for a breast biopsy. think, “This wasn’t that bad.” In the OR, the rapidHer past medical history includes mental retardation sequence IV induction and intubation [1] are smooth,and gastroesophageal reflux disease. She lives in a and the surgery is completed without complications.home because she is unable to care for herself. She is The patient is given postoperative nausea/vomitingnonverbal. Her sister understands her nonverbal cues prophylaxis and a propofol infusion was maintainedand is able to communicate with her and calm her. intraoperatively to decrease the amount of volatile It is 7:00 a.m. on Monday, and it’s nice to be back agents used. The patient is extubated, comfortable, andat work after a relaxing weekend. You’ve had your first taken to recovery. Her sister soon joins her to keep hercup of coffee, the drugs are drawn up, the machine is calm as the anesthetic wears off.checked, the operating room (OR) is almost ready togo – and the nurses tell you that they need 15 moreminutes to set up and see the patient. You go out to Patient careholding to meet your first patient. As you draw the cur- Residents must be able to provide patient care that istain, a middle-aged woman is sitting in the stretcher, compassionate, appropriate, and effective for the treat-in street clothes, straddling and hugging your patient ment of health problems and the promotion of health.while humming in her ear. The patient is wearinga hospital gown, a hair cap, and thick mismatching Communicate effectively and demonstrate caringsocks. She sees you and shrieks (loudly!). The woman and respectful behaviors when interacting within street clothes motions to you to close the curtains. patients and their families.You do as asked, and the humming just gets louder,and now they are rocking in unison, until the patient In this case, it is very important to discuss theis again in a “calm trance.” details of the anesthetic with the patient’s sister. You The patient has no known allergies, has a history must also understand how the patient and her sisterof nausea and vomiting from prior general anesthet- communicate with each other and how you can makeics, weighs about 68 kg, and has poor dentition and it as comfortable of an experience for both the patienta MP class I airway (you couldn’t help but notice as and the family as possible. Including the family in theshe shrieked on your arrival). You explain to the sis- discussion actually helped our anesthetic plan. The sis-ter that you need to obtain intravenous (IV) access ter was able to comfort and distract the patient whileto anesthetize the patient. After a lengthy discussion the IV was inserted. Without this smooth IV insertion,considering PO (per oris) sedation, IM (intramuscu- the start of the case could have been quite involved. Thelar) darts, EMLA (eutectic mixture of local anesthetic), patient refused PO Bicitra, so attempting PO sedationmask induction, and IV induction, the sister explains [2] would have been difficult. A mask induction or anthat the patient will allow you to start an IV if you IM injection are possible but would be hard to do in ado it in the holding area, while she is present and noncompliant, anxious, combative patient. Rememberthe curtains are drawn. She explains that the patient how she reacted when you drew the curtains in hold-has had several successful blood draws. Remember- ing. It is obvious that the sister is really in tune withing your rather loud welcome, you quickly locate your the patient and is able to manage her well. It is to ourresident, present the patient, and observe while she advantage and the patient’s benefit to incorporate the 79smoothly obtains IV access. Excellent! family in her care.
  • 89. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 You will want to look at prior electrocardiograms Gather essential and accurate information about and chest X-rays. their patients. Perform competently all medical and invasive Again, more of what was said earlier. In this case, procedures considered essential for the area of it is important to obtain all the information possi- practice. ble from the family because we cannot communicate with the patient. She has gastroesophageal reflux dis- All procedures – starting IVs, intubating, main- ease (GERD), mental retardation, and a prior history taining the anesthetic, and waking up the patient – of nausea and vomiting (NV) after general anesthesia. must be done according to standards of care. Make informed decisions about diagnostic and Provide health care services aimed at preventing therapeutic interventions based on patient health problems or maintaining health. information and preferences, up-to-date scientific The patient can be given a nonparticulate antacid evidence, and clinical judgment. to prevent aspiration pneumonia. To prevent infection, We need to devise an acceptable plan for the care you must make sure that antibiotics are given 1 hour of this patient. She has a history of GERD and is non- prior to incision. verbal – is she a candidate for IV sedation? IV seda- Work with health care professionals, including tion could be a difficult option as she will not be able to those from other disciplines, to provide express pain or discomfort; likewise, it can be frighten- patient-focused care. ing to lie under surgical drapes, and she may become uninhibited or combative under a propofol infusion. You must discuss your plan with the surgeon and With her history, it may be best to proceed with gen- all OR personnel. This patient may be calm at the start eral anesthesia. There are several methods of induc- of the case (thanks to some IV midazolam), but the tion (IV, IM, mask) – which one is best for her? Is a wake-up may be a different story. Everyone must be on mask induction safe with her history of GERD? A thor- board to have a quiet and calm OR when the patient is ough discussion with the family and an understating waking up. Manpower should be available if she wakes of the patient’s history allows you to make informed up thrashing and combative. decisions about the care of this patient. As discussed earlier, IV induction looks like our best option. Medical knowledge Residents must demonstrate knowledge about estab- Develop and carry out patient management plans. lished and evolving biomedical, clinical, and cognate Once a sound anesthetic plan is devised and agree- (e.g., epidemiological and social-behavioral) sciences able to all, you must proceed as discussed and always and the application of this knowledge to patient care. be prepared for emergencies. Demonstrate an investigatory and analytic thinking approach to clinical situations. Counsel and educate patients and their families. When you first examine the patient and obtain her In our case, the patient may not understand much history, you realize that good old “propofol, succinyl- of what is going on, based on her history. It is our choline, tube” may not work here. This clinical sce- responsibility to educate the family with an open dis- nario demands that you tailor your anesthetic plan. cussion about the risks and benefits of our plans and Can you do this with some IV sedation, even though what will happen in the perioperative period. The the patient has GERD and is nonverbal? If not, how patient has a unique medical history that poses certain will you proceed with general anesthesia? How can you challenges to her care, and the family must understand avoid PONV (postoperative nausea and vomiting)? this [3]. Know and apply the basic and clinically Use information technology to support patient supportive sciences that are appropriate to their80 care decisions and patient education. discipline.
  • 90. Case 15 – A simple breast biopsy The past medical history includes GERD – you This patient is a 61-year-old woman with a historymust know how to do a rapid sequence induction. You of mental retardation. You must be sensitive to her dis-must also know how to proceed with the different types abilities. It is inappropriate to make fun of her condi-of induction. What are the drugs and doses for an IM tion! Be respectful.injection? Can you proceed with a mask induction ina patient with GERD [1]? Interpersonal and communication skillsProfessionalism Residents must be able to demonstrate interpersonalResidents must demonstrate a commitment to carry- and communication skills that result in effective infor-ing out professional responsibilities, adherence to eth- mation exchange and teaming with patients, theirical principles, and sensitivity to a diverse patient pop- patients’ families, and professional associates.ulation. Create and sustain a therapeutic and ethically sound relationship with patients. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society In this case, you have a double challenge: you must that supersedes self-interest; accountability to gain the trust of the patient and her sister. With her patients, society, and the profession; and a sister, you can communicate verbally and develop a commitment to excellence and ongoing relationship, but it is equally important to try to gain professional development. the trust of the patient with your nonverbal language. Include her in the discussion as much as possible Did you come in on time this morning? Did you set (don’t ignore her). If her sister is able to communicateup the room appropriately? Did you get a good night with her, ask for tips – they may be helpful in the OR!of rest? Did you show compassion to the patient andfamily, even if she did greet you with a deafening shriek Use effective listening skills and elicit and providewhen you first met her? This is not the time to turn information using effective nonverbal,around and run, but rather, to be calm and respectful. explanatory, questioning, and writing skills.Your patient is here for an important (maybe even life- Again, listen carefully to what the family tells you.saving) procedure, and you must give her the best care In our case, that is the only option we will have. Makeyou can. appropriate eye contact when talking to the patient and the family. Be aware of your body language. Answer all Demonstrate a commitment to ethical principles questions appropriately and in simple, lay terms. Defer pertaining to provision or withholding of clinical surgical questions to the surgeon if you are not sure of care, confidentiality of patient information, their answers – it is best not to guess. If you don’t know informed consent, and business practice. an answer, be honest and ask your attending. When you are interviewing in the holding area, Work effectively with others as a member orreview the consent with the sister, confirm the site of leader of a health care team or other professionalsurgery, and observe all HIPAA rules. It is inappropri- group.ate to reveal confidential information and discuss the Discuss the plan with the OR team. If the OR isdetails of the case while riding the elevator! delayed, discuss this with the holding area. Postoper- atively, discuss the patient’s needs with the recovery Demonstrate sensitivity and responsiveness to room staff and make yourself available for problems or patients’ culture, age, gender, and disabilities. questions. 81
  • 91. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 3. Butler M, Hayes B, Hathaway M, Begleiter M. Specific genetic disease at risk for sedation/anesthesia 1. Ng A, Smith G. Gastroesophageal reflux and aspiration complications. Anesth Analg 2000;91:837–855. of gastric contents in anesthetic practice. Anesth Analg 2001;93:494–513. 2. Petros AJ. Oral ketamine: its use for mentally retarded adults requiring day care dental treatment. Anesthesiology 1991;46:646–647.82
  • 92. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 16 Fast-track perioperative management of patients having a laparoscopic colectomy for colon cancer Brian Durkin and Sofie HussainThe case thoroughly addressed. In so doing, patients and their families are integral members of the decision-makingYour institution is interested in getting on board the team and, as such, have reported increased satisfac-fast-track surgery train that has been traveling across tion with their perioperative care. Ideally, the impor-the civilized world, as surgeons and engineers create tance of epidural anesthesia for colorectal surgery willincreasingly innovative ways to take things out of peo- be conveyed to the patients by a representative fromple without them knowing about it. Operations that each interdisciplinary department (i.e., surgery, anes-used to leave incisions measured in feet are now being thesia, nursing), and literature further explaining themeasured in millimeters, and the resulting postopera- risks and benefits of the procedure can be distributed.tive morbidity is shrinking, along with the reimburse-ment. You are in charge of your hospital’s acute pain ser- Medical knowledgevice and are responsible for placing and managing all Residents must demonstrate knowledge about estab-the epidurals used to control postoperative pain. The lished and evolving biomedical, clinical, and cog-new colorectal surgeon would like you to help take care nate (e.g., epidemiological and social-behavioral) sci-of his patients and get them out of the hospital sooner. ences and the application of this knowledge to patientHe says that where he’s from in Europe, there is this guy care.named Dr. Kehlet, and he’s always talking about multi-modal analgesia and fast-track protocols. You see, the Know and apply the basic and clinicallylonger you stay in the hospital, the more bad things supportive sciences that are appropriate to theircan happen to you. How are you going to help get this discipline.project on track and be successful? Be able to understand and articulate the risks and benefits of epidural anesthesia. Furthermore, specificPatient care to this case, the resident should be able to discussResidents must be able to provide patient care that is the pathophysiology of the postoperative patient. Forcompassionate, appropriate, and effective for the treat- example, to support the use of neuraxial blockade inment of health problems and the promotion of health. this setting, one must know the relationship between opiates and paralytic ileus and length of hospital stay. Counsel and educate patients and their families. Additionally, fluid management must be understood When seen preoperatively, the patient as well as and applied, multimodal analgesia must be appre-his or her family should be counseled on the risks ciated, and preoperative predictors of postoperativeand benefits of epidural anesthesia, particularly as it morbidity must be identified and addressed.pertains to colorectal surgery. One could explain, forexample, that although there is a risk of a postdu- Practice-based learningral puncture headache, it is far less than the chancefor postoperative incisional pain, which would com- and improvementpromise early ambulation, which has its own conse- Residents must be able to investigate and evaluate theirquences. If patients are taking blood thinners, the risks patient care practices, appraise and assimilate scientificand benefits of stopping these medications need to be evidence, and improve their patient care practices. 83
  • 93. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Locate, appraise, and assimilate evidence from refuses, for example, the resident must not show dis- scientific studies related to their patients’ health appointment or judgment. problems. Be up to date with the recent literature regard- Interpersonal and communication ing specific cases. Pertinent to this case are many skills recent articles exploring the morbidity and mortality Residents must be able to demonstrate interpersonal of patients undergoing so-called traditional colorec- and communication skills that result in effective infor- tal surgery as compared to those undergoing fast-track mation exchange and teaming with patients, their colorectal surgery. It is important that the resident be patients’ families, and professional associates. familiar with these studies and guidelines as well as those specifically targeting epidural analgesia and mul- Use effective listening skills and elicit and provide timodal anesthesia. If the resident is unaware of cur- information using effective nonverbal, rent literature, he or she must have the tools to access explanatory, questioning, and writing skills. online journals and other sources of current literature. Spend some time with the patient and his or her family, discussing treatment options. For instance, Professionalism when addressing the issue of postoperative pain and Residents must demonstrate a commitment to carry- the role of epidural anesthesia, it may help to have a ing out professional responsibilities, adherence to eth- surgical colleague present to further the conversation. ical principles, and sensitivity to a diverse patient pop- In so doing, the patient and family are met with a cohe- ulation. sive medical team. It may also behoove one to dis- Demonstrate respect, compassion, and integrity; a cuss the likelihood of a shorter hospital course with responsiveness to the needs of patients and society a fast-track approach. This could help the patient to that supersedes self-interest; accountability to consider economic factors as well as allow the res- patients, society, and the profession; and a ident to consider cost-effective health care (without commitment to excellence and ongoing any foreseeable detriment to the patient). Reassurance professional development. is also of utmost importance with respect to patient satisfaction, so be certain to listen to the patient and Despite whatever the resident may feel is the best provide contact information should further questions course of action for anesthetic care, if the patient arise.84
  • 94. Case 16 – Fast-track perioperative management of patients having a laparoscopic colectomy for colon cancerAdditional reading 2. Ender J, Borger M, Scholz M, et al. Cardiac surgery fast-track treatment in a postanesthetic care unit:1. Chase D, Lopez S, Nguyen C, et al. A clinical pathway six-month results of the Leipzig fast-track concept. for postoperative management and early patient Anesthesiology 2008;109:61–66. discharge: does it work in gynecologic surgery. Am J Ob Gyn 2008;199:541. 85
  • 95. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 17 Treatment of complex regional pain syndrome when the payer doesn’t know anything about what you are treating Marco Palmieri and Brian Durkin The case growing inpatient with her, so it’s important that you talk to her and validate her concerns. Assure her that Your patient is a 23-year-old woman who suffered a you will not just brush off her symptoms as her being severe right ankle sprain while exercising her client’s overly dramatic. dog in the park. She stepped on a rock, twisted her ankle, and ended up in the emergency room, where Gather essential and accurate information about X-rays showed no fracture – just soft tissue swelling. their patients. This happened 6 months ago, and finally, she is sent to your pain clinic for evaluation of possible reflex sym- Luckily for your and the patient’s sanity, all the lab pathetic dystrophy (now called complex regional pain work and radiology exams were done at your institu- syndrome) and medication management. Because this tion and are on the new computer system. You are able was an on-the-job injury, worker’s compensation will to review the plain films, computed tomography scan, be paying her medical bills. She lets you know that her magnetic resonance image, and three-phase bone scan job doesn’t provide insurance because she is only part- done recently as part of the workup completed by the time. This is one of three part-time jobs that she works previous physicians who were caring for her. No one while trying to get into graduate school. has been able to pinpoint a diagnosis, and all the exams Your evaluation leads you to believe that she has were “essentially normal.” complex regional pain syndrome (CRPS) type I – she has allodynia, excessive nail and hair growth, swelling, Develop and carry out patient management plans. and color changes, and she is very depressed about the whole thing. She tells you that the hydrocodone/APAP Your treatment plan will focus on three things: (1) (N-acetyl-p-aminophenol) that her primary care physical therapy, (2) pain control with medications physician is giving her “doesn’t even touch the pain.” and nerve blocks, and (3) psychological counseling. She’s taking four to five acetaminophen and seven to The patient went to physical therapy after the injury eight ibuprofen tablets per day. She tells you that since but stopped going because it made the pain worse. she has the appointment to see pain management, that You must assure her that with adequate pain control, she expects you to refill her medications. she should be able to get back to therapy and regain function in her leg. Typically, a diagnostic and, pos- Patient care sibly, therapeutic lumbar sympathetic block is done and then followed with a physical therapy session or Residents must be able to provide patient care that is two. Your office staff reminds you that you have to compassionate, appropriate, and effective for the treat- get authorization before scheduling her for any blocks, ment of health problems and the promotion of health. and they say that they’ll get right on it. Communicate effectively and demonstrate caring Medication options should focus first on neuro- and respectful behaviors when interacting with pathic pain medications and then anti-inflammatory patients and their families. medications and opioids, if needed to perform ade- quate physical therapy. You decide to start with pre- This is very critical for all patients, but especially gabalin 75 mg twice per day and titrate up to 150 mg for a patient who has been told by every health care twice per day over a week’s time. You also start ami-86 professional thus far that every test and exam has been tryptiline 25 mg at night and instruct the patient to essentially normal. Her family and friends may be increase her dose to 75 mg over the next 2 weeks.
  • 96. Case 17 – Treatment of complex regional pain syndromeFinally, you start her on lidocaine 5% patches and tell Your office staff lets you know a couple days afterher to place three over her right lower leg and foot. your initial consultation that worker’s compensationYou give her some hydrocodone/APAP so she doesn’t wants an independent medical examiner (IME) togo into withdrawal and tell her to limit her acetami- evaluate the patient. The following week, you find outnophen to less than 3–4 g/day (assuming normal liver that the IME has diagnosed “chronic regional pain syn-function). drome” and has recommended a series of three stel- From the psychological perspective, you let her late ganglion blocks. You reread this report and can’tknow that you are trying to find a psychologist who believe what you see. Did this doctor see the samespecializes in pain control, but the closest one avail- patient? Did I miss something? Wasn’t this an ankleable is about an hour away. The pain psychiatrist at injury? You call the worker’s compensation office, andyour institution is too busy and is not taking any new they tell you that they have to stand by what the IMEpatients, and the institution is not hiring anyone, ever says, and maybe you should call him yourself.(I know – it doesn’t make sense). So you must now Having been a big fan of the Hardy Boys when youwear the hat of a psychologist and counsel her appro- were a kid, you decide to do some investigating. Let’spriately. You may even try to find some cognitive- get him on the phone and work this out. You Googlebehavioral exercises or desensitization techniques that him and find several phone numbers scattered aroundmay be helpful. different locations. You also find a Web page that gives That’s the plan – start medications, get authoriza- a little biography and learn that he is a retired ortho-tion for lumbar sympathetic blocks, and get her spirits pedic surgeon who graduated from medical school inup. 1958. He was on the faculty at your institution more than 20 years ago, and now he has a little business Use information technology to support patient in retirement, in which he does independent medical care decisions and patient education. exams. Coincidentally, he has a son who is a physi- cian in New Orleans and who is an interventional pain Perhaps you can direct her and her family members specialist. After Googling yourself and finding noth-to some useful Web sites to become more informed on ing but a B movie star who shares your name, you giveher diagnosis and possible treatment options. one of his office numbers a call and leave a message explaining what must be an honest mistake. After all, Perform competently all medical and invasive he has spawned a son who ought to know the right procedures considered essential for the area of thing to do. practice. Two days later, a note is on your desk from the IME. Like we said before, part of the treatment for CRPS “I am returning your phone call to let you know that itis pain control with medications and various nerve is illegal for me to talk to you about this case.” Great.blocks. Two such blocks are stellate ganglion blocks You wonder about the choice you made going into(upper extremity) and lumbar sympathetic blocks medicine and then decide to call New Orleans. You call(lower extremity). These blocks are used to see if there the IME’s son and leave a message with his staff and lis-is a sympathetic component to the pain. It is hoped, ten to the uncomfortable silence afterward. “We’ll for-for you and your patient, that the block can be both ward this to our doctor. Ya’ll from New York, huh?”diagnostic and therapeutic, and whamo, you can nailyour diagnosis. There is little evidence-based informa-tion regarding the proper timing, number, or appro- Medical knowledgepriateness of these nerve blocks for the treatment of Residents must demonstrate knowledge about estab-CRPS; however, these blocks are used to reduce pain lished and evolving biomedical, clinical, and cognateand to enable patients to resume functional rehabilita- (e.g., epidemiological and social-behavioral) sciencestion, which is our ultimate goal. and the application of this knowledge to patient care. Work with health care professionals, including Know and apply the basic and clinically those from other disciplines, to provide supportive sciences that are appropriate to their patient-focused care. discipline. 87
  • 97. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Before you step into the room and see this patient, Interpersonal and communication you are assured that you know all the critical elements to make the appropriate diagnosis of CRPS. First off, skills the person has to have pain, duh! But seriously, accord- Residents must be able to demonstrate interpersonal ing to the International Association for the Study of and communication skills that result in effective infor- Pain, at least one symptom in each of the following cat- mation exchange and teaming with patients, their egories should be present: patients’ families, and professional associates. 1. sensory (i.e., hyperesthesia) Advocate for quality patient care and assist 2. vasomotor (temperature or skin color patients in dealing with system complexities. abnormalities) 3. sudomotor-fluid balance (edema or sweating Many patients, like ours in this case, who develop abnormalities) CRPS have to prove their diagnosis to justify treat- 4. motor (decreased range of motion or weakness, ment. You, the pain physician, must aggressively seek tremor, or neglect) out and document those objective findings on physi- cal exam. Perhaps these findings are not present at all Also, at least one sign in two or more of the following office visits; you must be diligent and help your patient categories should be present: navigate through the endless obstacles she may face as 1. sensory (allodynia or hyperalgesia) she seeks out treatment for her disease. 2. vasomotor (objective temperature or skin color abnormalities) Know how to partner with health care managers 3. sudomotor-fluid balance (objective edema or and health care providers to assess, coordinate, sweating abnormalities) and improve health care and know how these 4. motor (objective decreased range of motion or activities can affect system performance. weakness, tremor, or neglect) As the old saying goes, “if at first you don’t succeed, The diagnosis of CRPS can be difficult, and other diag- try, try again.” Make another phone call to that pain noses should be excluded such as diabetic and other specialist in New Orleans, and perhaps he can provide peripheral neuropathies, thoracic outlet syndrome, some insight to the IME as to the proper treatment entrapment neuropathies, discogenic disease, deep of CRPS. Of course, when you do so, you are sure to venous thrombosis, cellulitis, vascular insufficiency, keep all the patient’s personal information to yourself, and lymphedema. in keeping with HIPAA policy.88
  • 98. Case 17 – Treatment of complex regional pain syndromeAdditional reading 2. Cepeda M, Lau J, Carr DB. Defining the therapeutic role of local anesthetic sympathetic blockade in1. Meier P, Zurakowski D, Berde C, Sethna N. Lumbar complex regional pain syndrome: a narrative and sympathetic blockade in children with complex systematic review. Clin J Pain 2002;18:216–233. regional pain syndromes: a double blind placebo-controlled crossover trial. Anesthesiology 2009;111:372–380. 89
  • 99. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 18 OB case with cancer and hypercoagulable state Joy Schabel and Andrew Rozbruch The case reconstruction after her mastectomy. With the afore- mentioned contingencies arranged, the patient then A gravida 1 para 0 (G1P0) parturient presented at received dinoprostone for induction of labor. On 38 weeks’ gestation with a past medical history sig- arrival to L&D, the patient received an epidural to nificant for breast cancer status post (s/p) bilateral manage her labor pain and provide a safe mode of mastectomy, chemotherapy and extensive flap recon- anesthesia care in the event of a stat cesarean sec- struction, superior vena cava syndrome, expanding tion. The patient was also placed on a hydromor- brachial plexus mass, chronic pain syndrome, hyper- phone patient-controlled analgesia and fentanyl trans- coaguable disorder with bilateral internal jugular (IJ) dermal patch, as prescribed by the acute pain service, vein clots, superior vena cava (SVC) clots, and clots to manage her chronic axilla pain and opioid require- in the venous system of bilateral upper extremities. ments. Over the course of the next 32 hours, the This patient had become pregnant via in vitro fertil- patient’s labor progressed without complications, and ization (IVF). On admission to our institution, prior to the patient delivered vaginally. planned induction of labor, the patient was seen by the obstetrical anesthesia staff for consultation. The main issues of concern regarding the care of this patient Patient care were adequate intravenous (IV) access, hypercoagula- Residents must be able to provide patient care that is ble status, early epidural placement, surgical backup compassionate, appropriate, and effective for the treat- should cesarean section be necessary, effective pain ment of health problems and the promotion of health. management, and logistical coordination of necessary resources and personnel. Communicate effectively and demonstrate caring After interdepartmental discussion with anesthe- and respectful behaviors when interacting with sia, obstetrics, surgery, interventional radiology, pain patients and their families. management, labor and delivery (L&D) personnel, and main operating room (OR) staff, a plan for the care When speaking of bedside manner, either you have of this patient was established. IV access was partic- it or you don’t, right? Wrong – well, sort of. Some ularly challenging in this patient. We were unable to of us are better than others at communication, listen- use either upper extremity secondary to lymph node ing, and showing patients that we care. If you have it dissection from her mastectomy or extensive venous built in, great; if you don’t, you need to learn. Our job sclerosing from the chemotherapy; additionally, the as anesthesiologists in establishing trust and building patient had bilateral IJ clots, further limiting upper rapport with a patient is a tad more difficult than for body access. We also wanted to avoid femoral access the patient’s primary care physician or obstetrician- due to the high risk of clot formation and the need for gynecologist because we are often meeting the patient hip flexion for vaginal delivery. Prior to induction of for the first time right before she hands her life over to labor, the patient was sent for placement of a peripher- us. The patient hasn’t done any research about us, she ally inserted central (PIC) line with ultrasound guid- hasn’t had the opportunity to speak with us before – ance to ensure safe and secure access. you catch my drift. So game face on! Approaching a Coordination with general surgery and their avail- patient with respect and instilling a sense of caring and ability for backup was also arranged in the event of trust with that patient requires homework. That’s right,90 a cesarean because the patient had extensive mesh as old as you get, you still have to do your homework. reconstruction in her abdomen secondary to flap What do I mean? First, know something about your
  • 100. Case 18 – OB case with cancer and hypercoagulable statepatient before you meet her. Pick up her chart, review concerned about the clots because the catheter wouldher medical history, speak to other physicians caring be placed proximal to her SVC clots, and explainedfor the patient, and have a sense of who the patient is that this intervention would be the safest, most practi-both medically and as a person before you barge into cal plan for her. In this manner, I gained the patient’sher room and start speaking at her. Which brings me respect and trust and used good clinical judgment into my next point: don’t speak at your patients; rather, knowing my limitation of knowledge with respect tospeak to them. Most of our patients have not gone PIC lines, and I went to the appropriate resources to getthrough medical school like we have. Dumb it down a the patient sound, truthful information. Part of goodlittle. Introduce yourself, extend your hand, get down patient care is knowing your limitations and when toto the patient’s eye level, sit down next to her if you ask for help.can. We are not in a hurry, right? We have nothing elseto do, right? Wrong, but the patient does not need to Provide health care services aimed at preventingknow that. She should feel as though she is your num- health problems or maintaining health.ber one priority. So with the PIC line in place, we can go ahead and Gather essential and accurate information about have the obstetricians induce the patient, right? What their patients. if she needs that stat cesarean? All that mesh in her belly from previous surgery, that shouldn’t be a prob- Know as much about your patient as you can before lem, we’ll deal with it when the time comes. Don’tyou meet her. Your history and physical should be think so! Part of good patient care is always staying onean opportunity to confirm what you already know step ahead. Making sure that general surgery would beabout the patient and clarify some loose ends. This available for backup prior to induction of this patientwill instantly set the patient at ease and win you many was mandatory, not optional. Remember, let’s not getbrownie points. If the patient senses that you are learn- caught with our pants down.ing about her for the first time, as you are speakingto her, she may begin to have doubts, especially if the Counsel and educate patients and their families.patient is a nurse, like our patient was. Don’t get caught Although many of our patients homeschool them-with your pants down – if you always do the right selves with the Internet and seem to know a goodthing, you won’t get caught in a compromising situ- deal about what will happen to them, oftentimes,ation. they are misunderstood or misinformed. Don’t believe Work with health care professionals, including everything you read. Educating your patients not only those from other disciplines, to provide enables them to work with you in their care, but it also patient-focused care. gives you an opportunity to show how smart you are, which only serves to instill more trust and confidence Since we are doctors and we know everything, with the patient.we should dictate to our patients what the plan forthem will be. Wrong. While we are highly educated, Medical knowledgetrained professionals, we don’t know everything. If you Residents must demonstrate knowledge about estab-don’t already know that, you need help. Listen to your lished and evolving biomedical, clinical, and cog-patient’s concerns. For example, with this patient, IV nate (e.g., epidemiological and social-behavioral) sci-access proved to be a very challenging task, yet of ences and the application of this knowledge to patientutmost importance. We suggested to the patient the care.placement of a PIC line. The patient was concernedbecause of the clots she had in her superior vena cava. Demonstrate an investigatory and analyticGood point; did I think of that? Well, sort of, but I’ll thinking approach to clinical situations.just let the interventional radiology people deal withit, right? No, I listened to the patient, acknowledged Come to your cases with a plan in mind. Don’ther concerns, and consulted with the interventional leave it to your attending to dictate what you are goingradiologists. I then shared the facts of my conversa- to do with your patient. You’ll never learn anything 91tion with the patient, explained that she need not be that way. Use your cases as a vehicle to draw out
  • 101. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 important topics and learning issues. Take this case, Apply knowledge of study designs and statistical for example; it’s chock full of juicy points. Take some methods to the appraisal of clinical studies and time, identify the important elements, and run with it. other information on diagnostic and therapeutic Read, talk to others, and be prepared for your sake and effectiveness. the sake of your patient. The more you know, the better it is for all parties involved. Think for yourself. “But I read it in a paper.” Any- one can get something published. Do your homework, dig deep back to your knowledge of statistical meth- Practice-based learning ods and study design, and see if what you’re reading is and improvement worth reading. If not, move on and find a better article. Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate Professionalism scientific evidence, and improve their patient care Residents must demonstrate a commitment to carry- practices. ing out professional responsibilities, adherence to eth- Analyze practice experience and perform ical principles, and sensitivity to a diverse patient pop- practice-based improvement activities using a ulation. systematic methodology. Demonstrate a commitment to ethical principles As we say in the business, some of your worst mis- pertaining to provision or withholding of clinical takes can end up being your greatest lessons; it is hoped care, confidentiality of patient information, that you did not harm your patient. During medi- informed consent, and business practice. cal school and residency is the time to make your mistakes, but remember not to make the same mis- This complicated patient became pregnant via IVF take twice. That’s the whole idea behind practice-based with donor sperm by an IVF specialist. There was no learning and improvement. Take the time to discuss father of the baby in the picture. One may question the both what went wrong and what went right, and always ethics involved in IVF practice for a patient so criti- build on your experiences for future practice. cally ill. The obstetricians involved in the care of this patient felt that this patient would be denied the abil- Use information technology to manage ity to adopt a child because of her illnesses, but there information, access online medical information, are fewer rules and regulations for IVF. Who is going and support their own education. to care for this child in the event of likely health dete- rioration? If you don’t know, ask; better yet, look it up. As anesthesiologists, we deal with life-and-death Evidence-based medicine, kids – it’s the wave of the issues more so than social issues. IVF is typically future. Know your patient and her medical prob- considered more of a social patient issue. However, lems, and know them well. With the advent of online the IVF of this patient created a life-and-death issue resources such as PubMed and Google, it has never for her. She was already hypercoagulable, which was been easier to look something up and actually have sci- worsened with getting pregnant. IV access could only entific support for what you are saying. be obtained with radiologic assistance. What if she threw a clot to her lungs, heart, or brain? What if she Obtain and use information about their own started to hemorrhage after delivery and additional population of patients and the larger population IV access would be necessary to transfuse blood and from which their patients are drawn. fluids rapidly? We had to be ready for potential life- threatening disaster created by IVF. I doubt that “life- Talk to your friends and colleagues at other places – threatening” appeared anywhere on the IVF consent HIPAA, of course – and share war stories. Different form. It should have been listed there for this case. institutions and different geographical areas see dif- ferent pathology and do things a little differently. Go Demonstrate sensitivity and responsiveness to92 to conferences; see what’s out there. Suck it all up and patients’ culture, age, gender, and disabilities. incorporate it into your practice as you see fit.
  • 102. Case 18 – OB case with cancer and hypercoagulable state Though it is difficult to understand and support the Understand how their patient care and otherincomprehensible decision to impregnate this patient professional practices affect other health carevia IVF, what was done was done. We could only be professionals, the health care organization, andrespectful to the patient and her decision making as the larger society and how these elements of thewe anticipated the potential complexities involved in system affect their own practice.her management. Her medical diseases and limita-tions challenged our ability to care for her, but we The IVF specialist in this case should have beendid so with compassion and sensitivity to her many available to observe the extensive medical and surgicalneeds. planning necessary to keep this patient out of harm’s way. I do not think the IVF specialist was aware of the larger context of health care involved with mak-Interpersonal and communication ing this patient pregnant. Lifelong learning in systems-skills based practice is critical to the practice of medicine,Residents must be able to demonstrate interpersonal no matter the specialty. Discussion and planning withand communication skills that result in effective infor- surgery, obstetrics, anesthesiology, radiology, main ORmation exchange and teaming with patients, their and L&D staff, and the acute pain team were essentialpatients’ families, and professional associates. to be prepared for anything from a vaginal delivery to a stat cesarean section in this case. Work effectively with others as a member or leader of a health care team or other professional Advocate for quality patient care and assist group. patients in dealing with system complexities. Taking the necessary time to obtain a thorough his- The multidisciplinary care team worked together totory was crucial in this case to understand all the com- advocate for the best quality care for this patient andplicated medical and surgical issues, establish the safest her unborn child, given multiple different scenarios.management plan, and establish trust. Recent review Being prepared was essential to maximizing patientof closed claim analyses has shown poor communica- safety and minimizing patient harm.tion among health care providers to be a growing and Know how to partner with health care managersalarming trend among obstetric anesthesia malprac- and health care providers to assess, coordinate,tice claims [1]. We need to communicate openly and and improve health care and know how thesehonestly with patients and other health care teams to activities can affect system performance.maximize patient safety. The coordination of this patient’s care maximized patient safety for this patient and her unborn child.Systems-based practice What is missing in the coordination of health care inResidents must demonstrate an awareness of and this case is the involvement of the IVF specialist onceresponsiveness to the larger context and system of fertilization had taken place. One would wonder if thehealth care and the ability to effectively call on sys- IVF specialist would have changed his or her futuretem resources to provide care that is of optimal practice after being part of the delivery end of thisvalue. patient’s care scenario! 93
  • 103. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Reference 1. Davies JM, Posner KL, Lee L, Cheney FW, Domino KB. Liability associated with obstetric anesthesia: a closed claim analysis. Anesthesiology 2008;109:131–139.94
  • 104. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 19 Extubated and jaws wired shut Peggy Seidman and Ramon AbolaThe case treatment of health problems and the promotion of health.A 16-year-old male patient is under the care of thepediatric intensive care unit (PICU). He was a pedes-trian struck by a motor vehicle and has suffered a Communicate effectively and demonstrate caringtraumatic brain injury (TBI) and mandible fracture. and respectful behaviors when interacting withHe has been stabilized over the past week after endo- patients and their families.tracheal intubation, intracranial pressure (ICP) mon-itor placement, ventriculostomy, and decompressive There are no family members in the room. Thank-craniectomy. He has required high levels of sedation fully, the PICU staff made the wise decision to askand paralytics for ICP control. Mom and Dad to leave the room during extubation. He undergoes open reduction and internal fixation However, should the family be allowed to stay in theof the mandible with the oral-maxillary facial surgery room?(OMFS) service. Preoperative, his oral-tracheal tube is Family members have reported various satisfactionexchanged to a nasal-tracheal tube. The operation pro- levels when they have been allowed to be present forceeds uneventfully. His jaws are wired at the end of the their loved ones in an emergency resuscitation settingprocedure. He returns to the PICU nasally intubated. [1]. However this scenario is quite different from anOvernight, the patient’s pulmonary status is favorable. emergency resuscitation in an emergency room. In thisHe has maintained normal oxygen saturation with a situation, the patient would not benefit from familyfractional inspired oxygen (FiO2) of 35% and is sponta- being present, and it is not clear if the family wouldneously breathing with 5 mm of pressure support and benefit from being at the bedside.5 mm of PEEP. We often bring parents into the operating room The patient is following some, but not all, com- for the induction of anesthesia for the benefit of bothmands. He is evaluated by the PICU staff and the deci- the parent and the child. However, the data do notsion is made to extubate. After extubation, he quickly clearly support the benefit to the child of having abecomes hypoxic, with a SpO2 in the 80s. Chest aus- parent in the operating room. Apparently, around thecultation reveals clear lungs with course upper airway world, people are also bringing clowns into the operat-sounds. The PICU staff is unable to properly suction ing room with their pediatric patients [2, 3]. A recentthe oropharynx because of the jaw wires. Anesthesia is article in the Canadian Journal of Anesthesia states,called to the bedside. He continues to be hypoxic and “Contrary to popular belief, in most cases parentalin respiratory distress. presence does not appear to alleviate parents’ or chil- As the anesthesia resident on call, you look at dren’s anxiety. In the rare instances when it does seemthe PICU staff, who are searching for answers. The to diminish parents’ or children’s anxiety, premedicat-patient’s jaws are wired shut, and he’s not doing well. ing children with midazolam has shown to be a viableYou wonder what to do with this handy MAC 3 laryn- alternative. Other anxiety-reducing solutions, such asgoscope that you’re holding in your left hand. distracting children with video games, should also be considered” [4, p. 57].Patient care Gather essential and accurate information aboutResidents must be able to provide patient care that their patients. 95is compassionate, appropriate, and effective for the
  • 105. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Consider the following: staff has discussed with the family the possibility that 1. A quick glance at the patient reveals that he is in the patient may not tolerate extubation. There is the respiratory distress. His breathing is labored and very real possibility of reintubation and, ultimately, the noisy. patient may need a tracheostomy. 2. The monitors support this diagnosis – the patient’s Use information technology to support patient pulse ox is reading 80% with 100% oxygen care decisions and patient education. administered through a non-rebreathing mask. 3. The PICU resident gives you a quick and brief Perhaps the use of information technology and summary of the patient’s history and the events online resources is not so useful in the emergency this morning that have led to the present situation. situation. After this episode, a review of the perti- nent literature regarding anesthesia management for Make informed decisions about diagnostic and oral-maxofacial surgery is most useful. “Periopera- therapeutic interventions based on patient tive Anesthetic Management of Maxillofacial Trauma information and preferences, up-to-date scientific Including Ophthalmic Injuries” [5] sounds like a good evidence, and clinical judgment. place to start. Let’s see. The patient was breathing fine with a Perform competently all medical and invasive breathing tube. We have now removed the breath- procedures considered essential for the area of ing tube, and patient is no longer doing fine. You try practice. to remember the anesthesia attending who asked you how long the brain can tolerate not receiving oxygen. A competent anesthesiologist will be able to per- Four minutes? Maybe it was 5 minutes? (For those who form direct laryngoscopy and oral intubation in the like mnemonics, remember Seidman’s rule of 7s: 70 presence of a difficult airway. He or she would also be days to starve to death, 7 days to dehydrate to death, skillful in performing nasal intubation for the origi- 7 minutes of no O2 until death.) Is that time less nal surgery. An anesthesiologist must also assess and because the patient suffered a traumatic brain injury? determine a proper time for extubation. The anesthesi- Wait! Why are you wasting your time? You need to ologist must be prepared for failed extubation and have reestablish an airway quickly! ready a plan should this occur. An anesthesiologist needs to be able to assess and manage the emergency airway, which includes deter- Work with health care professionals, including mining important equipment and personnel that need those from other disciplines, to provide to be readily available. patient-focused care. Develop and carry out patient management plans. The coordination of anesthesia, PICU nursing and physician staff, and oral-maxo-facial surgery is essen- Your plan: oral intubation. We’ll need to cut those tial to providing the optimal care for this patient, espe- jaw wires to get the tube in there. Thankfully, the cially in the emergency situation. Future consultation OMFS service have placed wire cutters at the head of with the pediatric surgery or otolaryngology service the patient’s bed, as is standard for care for this type of to evaluate for placement of a tracheostomy may be patient for exactly this reason. It’s always useful when warranted. things are where they are supposed to be. The OMFS service showed the PICU staff how and where to clip the wires during evening rounds last night, and no one Medical knowledge actually thought that this information may be needed. Residents must demonstrate knowledge about estab- You move toward the head of the bed and prepare for lished and evolving biomedical, clinical, and cognate direct laryngoscopy. (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Counsel and educate patients and their families. Demonstrate an investigatory and analytic96 No time to educate the patient and his family dur- thinking approach to clinical situations. ing this emergency. However, you hope that the PICU
  • 106. Case 19 – Extubated and jaws wired shut Respiratory distress after extubation occurs. You 4. management of ICPs in the head trauma patientneed to quickly consider a differential diagnosis as to 5. ventilator management for the ICU patientthe current situation. Postoperatively, failed extuba-tion could be related to several factors: Practice-based learning1. drugs: too many sedative/hypnotics on board to adequately maintain an airway, inadequate and improvement reversal of muscle relaxation Residents must be able to investigate and evaluate their2. pulmonary: pulmonary edema, pneumothorax patient care practices, appraise and assimilate scientific (hey, we weren’t operating anywhere near the evidence, and improve their patient care practices. lungs, buddy), asthma/bronchospasm, cardiac problems (right ventricular failure, pulmonary Analyze practice experience and perform edema from congestive heart failure?) practice-based improvement activities using a systematic methodology.3. airway obstruction from posterior pharyngeal problems or laryngospasm, upper airway Debriefing and discussion sessions about critical secretions unable to clear events are important to promote learning and educa- tion. Debriefing sessions can come in a variety of dif-This list is obviously not nearly as exhaustive as it ferent forms: a formal meeting between departments,should be. The anesthesiologist must also be knowl- a discussion between the attending and residents, oredgeable about determining the appropriateness of even a discussion between physicians and nursingextubation. Extubation criteria in the operating room staff. There are a variety of different perspectives aboutmay have some difference to criteria in the ICU setting. the events, the critical decisions, the implications ofHowever, some basic (and not so basic) principles fol- those decisions, and lessons for future patient care.low:1. Is the patient awake or alert enough to protect his Locate, appraise, and assimilate evidence from own airway? scientific studies related to their patients’ health2. Is the patient hemodynamically stable? problems.3. Has the initial reason for intubation been resolved? Our PICU has developed an algorithm for the sur- gical and medical treatment of TBI patients and the4. Does the patient demonstrate adequate management of intracranial pressure. This algorithm oxygenation and ventilation during a spontaneous was designed after reviewing the pertinent literature breathing trial or during a T piece trial? and clinical trials that relate to this topic [6]. Algo-5. Is the patient strong enough to remove ventilator rithms, if designed well, should allow for the imple- support – does he demonstrate an adequate mentation of so-called best practices. Critical eval- negative inspiratory force or an adequate vital uation of the data from which these algorithms are capacity? Will he be able to maintain effort of designed is important to determine the validity of respiration in face of nutrional status? Will he these recommendations and management steps [6]. fatigue after time? Our guidelines for the management of TBI patients6. Does the patient demonstrate a favorable rapid, include some of the following: shallow breathing index? PICU Management of High ICP/Low Cerebral Perfu- sion Pressure (CPP) Know and apply the basic and clinically First-Tier Therapies supportive sciences that are appropriate to their discipline. 1. administer appropriate sedation/analgesia in patients with secured airways The medical knowledge that is needed in providing 2. elevate head of bed 30◦ and in midlineadequate care for this patient is extensive: 3. manage patient’s temperature aggressively to1. ICU care avoid hyperthermia and increased cerebral2. approach to the trauma patient metabolic rate 973. approach to the patient with TBI 4. provide seizure prophylaxis
  • 107. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 5. maintain normal glucose levels 2. Do the therapeutic recommendations show a 6. treat acute increase in ICP or decrease in CPP significant improvement to change patient with sedation, mannitol, or 3% saline management? 7. treat acute increases in ICP with mild 3. Have our own practice experiences been in hyperventilation (PACO2 or ETCO2 between 30 agreement with clinical studies? and 35) while obtaining one of the preceding therapies Professionalism Second-Tier Therapies Residents must demonstrate a commitment to car- 1. surgical: neurosurgery to consider placement of rying out professional responsibilities, adherence to an extraventricular drain ethical principles, and sensitivity to a diverse patient 2. medical: hyperventilation with goal pCO2 of population. 30–35 if ICPs have been unsuccessfully managed with sedation, osmotherapy, and ventricular Demonstrate respect, compassion, and integrity; a drainage responsiveness to the needs of patients and society 3. medical: if these measures do not control ICPs, that supersedes self-interest; accountability to patient will be placed in a pentobarbital coma patients, society, and the profession; and a with continuous electroencephalography until commitment to excellence and ongoing burst suppression is achieved professional development. Third-Tier Therapies Physician A is a participant in this clinical scenario. 1. surgical: if continued elevated ICPs, neurosurgery Physician A begins asking who’s to blame for this situ- to evaluate for possible decompressive ation. Who is the responsible party who caused further craniectomy harm to this patient? Physician A sneers at the accused, 2. medical: consideration of use of 3% saline infusion stating that the case should have been handled differ- ently and that Physician A should have been called Although these recommendations are guidelines that sooner. Physician A stammers that it has always been the PICU staff uses to manage head trauma patients, the policy that these extubations should be handled in essential to the idea of practice-based learning is this manner to a resident and an attending who are to (1) understand the clinical foundation on which both unaware of any such policy. In a condescending these guidelines were made and (2) critically evaluate tone, Physician A says, “I hope that you’ve learned your these recommendations for areas in which change may lesson.” improve patient outcome. One such idea is consider- Physician B is a participant in this clinical scenario. ing the use of decompressive craniectomy as an early He or she gathers information from the various groups surgical therapy for these patients. Another example is involved to obtain a clear picture of what happened. He that hyperventilation was a routine practice in the past or she discusses with the various medical services their for these patients; however, this practice has fallen out opinion of the situation, what decisions were made, of favor. Decreased ICPs secondary to hyperventila- and how those decisions influenced the results. Physi- tion only last 6–12 hours, and there are concerns about cian B tries to identify reasons for why an unintended decreasing cerebral blood flow to an injured brain with outcome occurred, not who is the responsible party. vasoconstriction. Physician B seeks to identify ways to improve both his or her own clinical practice and the clinical practice of Apply knowledge of study designs and statistical the health care unit. methods to the appraisal of clinical studies and other information on diagnostic and therapeutic Demonstrate sensitivity and responsiveness to effectiveness. patients’ culture, age, gender, and disabilities. Critical evaluation of clinical studies is important: Children are not little adults. This is a phrase98 1. Does the study group adequately represent the recited time and time again by our pediatric col- characteristics of my current patient? leagues.
  • 108. Case 19 – Extubated and jaws wired shut Ultimately, our patient failed extubation secondary Essential to medical practice is being able to pro-to his TBI. His pulmonary status appeared to be opti- vide families with unpleasant information and to bemized, but his TBI is the reason for being unable honest about events that occurred during their med-to properly protect his airway and clear his secre- ical care. Who is the unfortunate resident or physi-tions. This is supported by the clinical observation cian who has to tell this patient’s family that (1) hethat the patient was not following commands prior to did not do well after we tried to take out the breath-extubation. ing tube, (2) we have to bring him back to the operating In the adult patient, our hospital will routinely room, and (3) we had to reintubate the patient – essen-place tracheostomy tubes early in a patient’s hospital tially everything being a step in the wrong direction?course if it appears that the patient will need prolonged Because you are the emergency consultant without amechanical ventilation. This allows for a decrease in relationship with the family, the ICU team will needsedation and mobilization of the patient out of bed, if to do this, and they are the most appropriate medicalpossible. The question is, why not place a tracheostomy service to inform the family. Often, it is best for thein our 16-year-old PICU patient during this first week, physician who has developed a relationship with thewhen he has demonstrated that he will likely require family to meet with the family to discuss bad news. Asprolonged ICU care? an anesthesiologist, meeting with a family postopera- Although practices differ between hospitals, our tively is enhanced by the presence and support of thePICU will typically try to avoid placing a tracheostomy surgeon, who has developed a patient-physician rela-tube unless it is absolutely necessary because trachs tionship prior to the day of surgery.in children can be very difficult for the families to Communication is key to a healthy and workingdeal with. This has been the observation of our PICU relationship between the medical staff, the patient, andstaff, and it represents an example of how the prac- the family. Discussion with patients and families aheadtice of medicine requires the clinician to be sensitive of time about what to expect, plus the possible com-to the patient’s age and also the family members, who plications, is essential to help guide patients throughbecome patients themselves, in a way. medical care. Looking at things from a medicolegal perspective, communication may be beneficial in pre- venting medical malpractice litigation [7].Interpersonal and communication skillsResidents must be able to demonstrate interpersonal Work effectively with others as a member orand communication skills that result in effective infor- leader of a health care team or other professionalmation exchange and teaming with patients, their group.patients’ families, and professional associates. Essential in any emergency situation is the devel- opment of a team leader and team players. The team Create and sustain a therapeutic and ethically leader provides the guidance and plan for care, and sound relationship with patients. the team members are just as essential to complete the One of the most difficult aspects of the medical tasks and provide feedback to the team leader aboutpractice is providing patients and families with bad the situation. Team building is essential for a group ofnews. Similar to history taking or physical exam, giv- people to respond in an organized fashion to an emer-ing bad news requires practice. gency situation. Think of code blues and cardiac arrests In this current case, our patient did poorly after for which there was complete chaos, with no order andextubation. His wires, which were cut, were then noted people running around like chickens without heads.to be located in both his stomach and pharynx, as they This is a place where simulation can help by allowingwere not accounted for during the airway emergency teams to work together in the safety of simulation.after extubation. The patient needed to be broughtback to the operating room and placed under general Systems-based practiceanesthesia for endoscopy and direct laryngoscopy to Residents must demonstrate an awareness of andextract these jaw wires and remove them as an infec- responsiveness to the larger context and system oftion risk and to prevent them from getting buried into health care and the ability to effectively call on system 99mucosa or other tissues. resources to provide care that is of optimal value.
  • 109. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Know how types of medical practice and delivery therapy, and pharmacy – allowing for optimization of systems differ from one another, including care and keeping all services in agreement. methods of controlling health care costs and allocating resources. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these One aspect of ICU care that is relatively new is activities can affect system performance. the ICU checklist. The checklist is a systems-based list that ensures important goals and objectives of the Important after any critical event is communica- ICU patient on a daily basis such as number of antibi- tion between members of the health care team in a otic days, days since central lines have been placed, professional manner to provide optimal care for future or nutritional and feeding management. Checklists situations. The purpose of these meetings and discus- allow for important aspects of patient care not to sions is to identify systems-based mistakes. Typically, be missed on a daily basis. ICU checklists may also no error in medicine occurs in isolation. Pointing fin- evaluate a patient’s need for continued ICU, which gers and trying to find who is to blame are typically not may significantly impact the cost of the patient’s very productive means of improving future care. care. After this case, it was decided that similar cases In addition to the ICU checklist are interdis- should coordinate PICU staff, OMFS, and anesthesia, ciplinary rounds, which facilitate communication who are to be readily available at bedside for quick and between the various medical services of ICU patients – efficient airway management in the event of a failed the medical staff, nursing staff, nutrition, respiratory trial of extubation.100
  • 110. Case 19 – Extubated and jaws wired shutReferences anesthesia induction and parent/child anxiety. Can J Anaesth 2009;56:57–70.1. Myers TA, Eichhorn DJ, Dezra J, et al. Family presence during invasive procedures and resuscitation. Top 5. Shearer VE, Gardner J, Murphy MT. Perioperative Emerg Med 2004;26:61–73. anesthetic management of maxillofacial trauma including ophthalmic injuries. Anesth Clin North Am2. Vagnoli L, Caprilli S, Robiglio A, et al. Clown doctors 1999;17:141–153. as a treatment for preoperative anxiety in children: a randomized, prospective study. Pediatrics 6. Carney NA, Chestnut R, Kochanek PM. Guidelines for 2005;116:e563–e567. the acute medical management of severe traumatic brain injury in infants, children and adolescents.3. Golan G, Tighe P, Dobija N, et al. Clowns for the Pediatr Crit Care Med 2003;4(Suppl):S1. prevention of preoperative anxiety in children: a randomized controlled trial. Paediatr Anaesth 7. Sack K. Doctors say “I’m sorry” before “see you in 2009;19:262–266. court.” The New York Times 2008 May 18;A1.4. Chundamala J, Wright JG, Kemp SM. An evidence-based review of parental presence during 101
  • 111. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 20 Code Noelle A tale of postpartum hemorrhage Rishimani Adsumelli and Ramon Abola The case Anesthesia colleagues join the operating room to assist in volume resuscitation. The patient becomes A 45-year-old woman, gravida 4 para 3, presents at anxious and inconsolable secondary to the emergency 38 weeks’ gestation for cesarean section. The patient situation or secondary to the acute loss of blood. The has had three previous cesarean sections. Obstetrical father is escorted from the operating room. The patient colleagues inform you that she has placenta previa is induced with ketamine and succinylcholine and is and strong possibility for placenta accreta. The patient intubated for general anesthesia. is originally from Pakistan and speaks only Punjabi and had general anesthesia without complications for her previous three cesarean sections, which were per- Patient care formed in Pakistan. Nursing staff has had a difficult Residents must be able to provide patient care that is time placing an appropriately sized peripheral IV. The compassionate, appropriate, and effective for the treat- patient’s airway examination is unremarkable and her ment of health problems and the promotion of health. body mass index is within normal limits. After discussion with colleagues about the risks Communicate effectively and demonstrate caring and benefits of regional versus general anesthesia for and respectful behaviors when interacting with this case, a decision is made to recommend regional patients and their families. anesthesia with spinal anesthesia. The patient is reluc- tant about having a spinal and inquires about general When the patient expresses her shock that, when anesthesia. Fortunately, one of the obstetrician resi- general anesthesia was successfully performed with- dents also speaks Punjabi and facilitates communica- out any complications in her home country of Pak- tion. Discussion takes places, informing the patient istan, why the sophisticated American anesthesiolo- about the reasons for preferring regional anesthesia, gists are so concerned about dangerous complications, and the patient agrees to this anesthetic plan. Arrange- it is important not to ignore her very pertinent obser- ments are made for blood salvage equipment for use in vation. It was important to convey that even we can the operating room. do GA safely if we need to, but we prefer the regional The patient is brought to the operating room and because it is at least a tad safer [1,2]. Communicating spinal anesthesia is administered successfully. There the various nuances via appropriate communicators is is routine delivery of a healthy infant. However, after very important. Here, having the obstetric resident as delivery of the placenta, a peek over the field reveals a an interpreter was very helpful. uterus sitting in a large pool of blood that is steadily growing faster than anyone would like. The patient Gather essential and accurate information about becomes tachycardic and hypotensive as she’s losing their patients. quite a bit of blood (up to 700 cc/min, to be exact). The obstetricians inform you that they suspect that Medical information is important, such as previous the patient does in fact have an accreta and plan for uncomplicated GA, other comorbid conditions, blood an emergency hysterectomy. “Code Noelle” is called – product availability, and not-so-easy IV access (nurses hospital mobilization for postpartum hemorrhage – couldn’t get IV, even though the patient was not obese). which coordinates anesthesia, obstetrics, and the102 blood bank. Medical therapy is attempted to slow the Make informed decisions about diagnostic and hemorrhage, with minimal improvement. therapeutic interventions based on patient
  • 112. Case 20 – Code Noelle information and preferences, up-to-date scientific r competency in administering general anesthesia evidence, and clinical judgment. in a pregnant woman; GA was given when she was hypotensive Prepare for a possible need for interventional radi- r competency in obtaining IV access, bothological procedures such as uterine artery emboliza- peripheral and centraltion [3] and cell saver use. (The worry that a cell r competency in placing an arterial linesaver might produce amniotic fluid embolism has been r competency in using the pharmacotherapyunfounded. Moreover, if you salvage the blood afterthe placenta is removed, there is no worry at all [4,5].) If you feel that the patient is extremely nervous and Provide health care services aimed at preventingthat GA can be done safely, you could even choose gen- health problems or maintaining health.eral anesthesia instead of regional. It all depends onyour judgment after careful consideration of risks and Pertinent points include the following:benefits. r preparation for counteracting massive blood loss and maintaining hemodynamic stability Develop and carry out patient management plans. r measures to prevent aspiration such as naught per A regional anesthesia with GA backup is planned. oris status, use of H2 blockers and Bicitra, andPrepare for major blood loss with good IV access, rapid sequence induction r timely antibiotic administrationblood products, a cell saver, an arterial line, and centralvenous access, if needed. Work with health care professionals, including Counsel and educate patients and their families. those from other disciplines, to provide The following considerations should be made: patient-focused care.r discussion regarding the possible need for blood This case is a true reflection of a multidisciplinary transfusion and hysterectomyr honest discussion about the possible need for approach: r dialogue with obstetrics interventional radiology help and even intensive r discussion with the blood bank, labor and delivery care unit (ICU) admissionr discussion of the possible need for postop nurses, and other support staff r discussion with the interventional radiology team ventilation and surgical ICU team Use information technology to support patient care decisions and patient education. Medical knowledge Residents must demonstrate knowledge about estab- The pertinent issues in this case are as follows: lished and evolving biomedical, clinical, and cog-r the advantages of regional versus GA nate (e.g., epidemiological and social-behavioral) sci-r the useful role of interventional radiology ences and the application of this knowledge to patient procedures care.r recent pharmacological modalities for uterine atony Demonstrate an investigatory and analyticr the use of a cell saver thinking approach to clinical situations. The pertinent points in our case are as follows: Perform competently all medical and invasive r Is a well-conducted GA really so harmful? What is procedures considered essential for the area of practice. the current thinking? r Is it better to do preemptive radiological The following should be considered: procedures?r competency in performing and conducting r Am I really prepared for possible blood loss of 103 regional anesthesia 700 cc/min?
  • 113. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 r in general, having good exposure to blood Know and apply the basic and clinically product therapy supportive sciences that are appropriate to their r application of the knowledge gained from other discipline. areas of anesthesia in her situation (at times, The following should be considered: knowledge from other areas takes time to trickle r thorough knowledge of blood therapy and down to obstetric anesthesia) r additionally, debriefing and discussion between complications such as transfusion-related acute anesthesia residents and attendings about case lung injury r appropriate use of products management, critical events, and lessons from the r knowledge of pharmacotherapy of uterotonics case aid in generating new information r resident self-reflection on the role of their r role of recombinant factor VII individual management of the patient, self-reflection on learning and prediction of their Practice-based learning performance in this situation if they had been the attending, and aid in continuing practice-based and improvement learning Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and Analyze practice experience and perform other information on diagnostic and therapeutic practice-based improvement activities using a effectiveness. systematic methodology. This involves the following: This is based on the following: r knowledge of the statistics needed to evaluate the r your own experience of exposure to such cases in power of the studies the past r ability to analyze statistical significance r your own reflection of how to improve care r departmental quality control reviews of these Use information technology to manage cases and debriefings that follow r knowledge of the departmental protocols that information, access online medical information, and support their own education. were formulated based on the debriefings This involves the following: Locate, appraise, and assimilate evidence from r ability to use search engines to get information scientific studies related to their patients’ health r knowledge of departmental online resources problems. This is based on the following: Professionalism r lectures on this topic that you attended Residents must demonstrate a commitment to carry- r literature searches ing out professional responsibilities, adherence to ethi- r departmental online resources cal principles, and sensitivity to a diverse patient popu- lation. Obtain and use information about their own Demonstrate respect, compassion, and integrity; a population of patients and the larger population responsiveness to the needs of patients and society from which their patients are drawn. that supersedes self-interest; accountability to Consider the following: patients, society, and the profession; and a r having knowledge of newer modalities of airway commitment to excellence and ongoing104 professional development. management in case of difficult intubation
  • 114. Case 20 – Code Noelle This involves the following: r overcoming language barriersr respectful communication regarding the pros and r effective communication with Dad when he needs cons of GA to leave the room and continuing ther respectful communication about the need for an communication about patient status and new arterial line and large-bore IV when still awake developmentsr overcoming language barriers to connect with the patient Use effective listening skills and elicit and provider preparing with necessary skills such as advanced information using effective nonverbal, cardiac life support and neonatal advanced life explanatory, questioning, and writing skills. supportr attending departmental grand rounds and This involves the following: continuing use of medical education resources r judging that there is a severe uterine atony and massive hemorrhage by the expression on the Demonstrate a commitment to ethical principles obstetrician’s face pertaining to provision or withholding of clinical r knowing that there is significant hypotension care, confidentiality of patient information, when the patient looks spaced out informed consent, and business practice. This involves the following: Work effectively with others as a member orr ethicality of refusing the care [6] if the patient is leader of a health care team or other professional adamant about GA group.r misplaced worry about additional cost because of This involves the following: the cell saver and all the hotline sets because there is a possibility that she may not need them r effective communication about the patient’s status, need for GA and blood products, and need Demonstrate sensitivity and responsiveness to for more personnel r calling code Noelle when extra help is needed patients’ culture, age, gender, and disabilities. This involves the following:r understanding that because of her background, Systems-based practice she may be extremely uncomfortable if not Residents must demonstrate an awareness of and covered responsiveness to the larger context and system ofr might be more comfortable with women health care and the ability to effectively call on systemr care not to be condescending of the medical care resources to provide care that is of optimal value. in her country Understand how their patient care and otherInterpersonal and communication professional practices affect other health care professionals, the health care organization, andskills the larger society and how these elements of theResidents 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 This involves the following:patients’ families, and professional associates. r understanding of the hospital rules and Create and sustain a therapeutic and ethically regulations for narcotic use r thorough understanding of the impact of a sound relationship with patients. skeleton staff of nurses and other support This involves the following: personnel after 3:00 p.m. [7]r honest informed consent and explanation of the r availability of help from other physicians such as 105 rationale behind the use of invasive monitoring interventional radiologists and gynecologists
  • 115. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Practice cost-effective health care and resource The pertinent issue in our case is finding the right allocation that does not compromise quality of person to translate for the patient. care. Know how to partner with health care managers This involves the following: and health care providers to assess, coordinate, r having a rapid infuser available but not ready and improve health care and know how these r cost differences between bupivacaine and activities can affect system performance. ropivacaine The pertinent issue in our case is that in our hos- r cost comparison of various inhalational pital, systems-based multidisciplinary protocols have anesthetics been developed for risk stratification, effective treat- ment, and rapid mobilization of resources by calling Advocate for quality patient care and assist code Noelle. Knowledge of the resources that will be patients in dealing with system complexities. mobilized by the code and when to activate this code is important.106
  • 116. Case 20 – Code NoelleReferences combined with leucocyte depletion filtration to remove amniotic fluid from operative blood loss at1. Gulur P, Nishimori M, Ballantyne J. Regional caesarean section. Int J Obstet Anesth 1999;8:79– anaesthesia versus general anaesthesia, morbidity and 88. mortality. Best Pract Res Clin Anaesthesiol 2006;20:249–263. 5. King M, Wrench I, Galimberti A, et al. Introduction of cell salvage to a large obstetric unit: the first six2. Afolabi BB, Lesi F, Merah N. Regional versus general months. Int J Obstet Anesth 2009;18:111–117. anaesthesia for caesarean section. Cochrane Database Syst Rev 2006;18:CD004350. 6. Chervenak F, McCullough L, Birnbach D. Ethics: an essential dimension of clinical obstetric anesthesia.3. Hong TM, Tseng H, Lee R, et al. Uterine artery Anesth Analg 2003;96:1480–1485. embolization: an effective treatment for intractable obstetric haemorrhage. Clin Radiol 2004;59:96–101. 7. Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US4. Catling S, William S, Fielding A. Cell salvage in hospitals. Am J Med 2007;120:422–428. obstetrics: an evaluation of the ability of cell salvage 107
  • 117. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 21 Are you sure there’s a baby there? A tale of the morbidly obese parturient Ellen Steinberg and Ramon Abola The case a controlled fashion; emergency cesarean section may result in fetal or maternal compromise. A 32-year-old gravida 1 para 0 (G1P0) presents to labor and delivery for induction of labor for a large- 8. Cesarean section is performed under epidural for-gestational-age fetus. The patient is at 39 weeks’ anesthesia; emergency and difficult airway gestation. Past medical history is significant for mor- equipment is available in the operating room. bid obesity. She is 5 foot 6 inches but weighs 400 9. The cesarean section proceeds uneventfully under pounds. She presents to the floor for induction in the regional anesthesia. early evening, a similar practice for most inductions as patients should then be in active labor during the day- time hours. Anesthesia staff is present 24 hours, how- Patient care ever, with less help available during the evening hours. Residents must be able to provide patient care that is During your evening huddle – a meeting between compassionate, appropriate, and effective for the treat- obstetrics (OB), nursing, and anesthesia services – this ment of health problems and the promotion of health. patient’s case is discussed. The patient is also a so- called difficult patient, demanding of the nursing staff, Communicate effectively and demonstrate caring and lacks insight into the severity of her situation. She and respectful behaviors when interacting with is unhappy that she is being treated differently than the patients and their families. other expectant mothers on the floor. Discussion between OB and anesthesia determines Communication between the staff and patient is that appropriate management will be as follows: (1) of the utmost importance in the medically challeng- placement of an epidural (prior to induction) available ing and difficult patient. As health care practition- for use for emergency cesarean section for maternal ers, we have to be able to convey our concerns to the or fetal distress, (2) induction of labor, and (3) vaginal patient. Educating patients about these concerns helps delivery – a reasonable plan. the patient understand the prescribed care plan. The reality: The patient’s body habitus, in our case, complicates 1. Nursing staff is unable to obtain intravenous (IV) medical care: access. r difficult IV access 2. Anesthesia requires IV access prior to epidural r potential difficult airway management if general placement in case of emergency. anesthesia is needed (mask ventilation in a 3. Central venous access is placed secondary to 400-pound, pregnant patient who will rapidly inadequate peripheral access. desaturate secondary to decreased functional 4. Epidural is placed after multiple attempts, with residual capacity, with increased metabolic success after a second anesthesia team attempts demand and an excess of soft tissue in the airway, epidural placement. does not sound pleasant) 5. Induction of labor is initiated. r potentially difficult placement of regional 6. Patient fails induction of labor. anesthesia (Do you know where the midline is?) 7. OB and anesthesia staff agree that the best r difficulty in accurate monitoring – both fetal and108 approach will be to perform a cesarean section in maternal
  • 118. Case 21 – Are you sure there’s a baby there?r increased comorbid conditions during pregnancy internal jugular triple lumen catheter was placed (hypertension, diabetes [1]). under ultrasound guidance. There is currentr potentially difficult cesarean section debate about increased safety, success rate, andr increased risk of infection after cesarean section time to placement [3]. An article from Interactive [2] and Cardiovascular Thoracic Surgery concludes that “in patients with a potentially difficult central line insertion, the ultrasound technique reduces Gather essential and accurate information about complications and time to insertion. However, in their patients. those patients where no difficulty is predicted, A quick review of this patient reveals a morbidly there is no evidence that the ultrasound techniqueobese patient, G1P0, with an intrauterine pregnancy at confers any advantage” [3, p. 527].term. There is no significant past medical history, and 3. Placement of epidural anesthesia prior tothere have been no significant problems during this induction of labor should be completed. Shouldpregnancy. The patient has had no previous surgeries. the patient develop the need for a stat cesareanMedications include prenatal vitamins. section (i.e., nonreassuring fetal heart tracing), Physical exam reveals a blood pressure of 110/70, having epidural anesthesia in place would allowP 76, SpO2 96% on room air. The patient appears to be for rapid administration of surgical-levelin no acute distress. Her airway exam reveals a good anesthesia, without instrumentation of themouth opening and a Mallampati class II airway, with patient’s airway.good neck extension. Thyromental distance appears 4. Then, induction of labor for ato be greater than three finger breadths; however, the large-for-gestational-age fetus should bepatient’s neck circumference is quite large. You suspect performed.that the patient would easily exhibit airway obstruc- 5. Should general anesthesia become necessary,tion with too much sedation. Auscultation of the chest difficult airway equipment, including differentand heart are difficult secondary to the patient’s body laryngoscope blades, a laryngeal mask airway, anhabitus. You note the multiple attempts that the nurses intubating laryngeal mask airway, gum elastichave made in placing an IV. bougie, and other airway tools should be readily Laboratory studies are reviewed, revealing an available.appropriate hematocrit of 36, a platelet count of 140,and normal coagulation studies. Gathering the essen-tial information is important to developing an appro- Perform competently all medical and invasivepriate management plan for this patient. procedures considered essential for the area of practice. Develop and carry out patient management plans. Invasive procedures performed during this case A useful tool in medical practice is to predict what include (1) establishing IV access in a difficult patient,will or what could possibly happen during the care of a (2) placement of an epidural catheter, (3) placement ofpatient. Planning for all possible outcomes allows one central venous access for a patient with poor periph-to better prepare for an emergency. The management eral access, and (4) airway management in the obeseplan for this patient was as follows: patient should general anesthesia be needed. Essential for the anesthesiologist is determination of the appro-1. Placement of IV access prior to epidural priateness of each invasive procedure. anesthesia should be performed. During a regional anesthetic procedure, IV access Work with health care professionals, including administers essential IV fluids or emergency those from other disciplines, to provide medications for resuscitation. Complications with patient-focused care. neuraxial anesthesia include hypotension from sympathectomy, high spinal block, and local Labor and delivery requires coordinating the ser- anesthesia toxicity from intravascular injection. vices of anesthesia, obstetrics, and nursing staff to pro-2. As placement of peripheral IV access was vide optimal care. Each area of expertise provides a dif- 109 unsuccessful, a central line was placed. A right ferent perspective about the current problem, and by
  • 119. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 communication and discussion, the best medical plan Regional anesthesia provides an attractive anes- should be established. thetic plan for these patients as it allows for surgery without manipulation of the airway. A postoperative concern for this patient is pain management, and Medical knowledge regional anesthesia allows one to minimize systemic Residents must demonstrate knowledge about estab- analgesics that may depress respiratory function. lished and evolving biomedical, clinical, and cognate The anesthesiologist must be informed about (e.g., epidemiological and social-behavioral) sciences obstetrics to facilitate decisions regarding patient care. and the application of this knowledge to patient care. Knowledge of the indications for a cesarean section allows the anesthesiologist to be an advocate for good Know and apply the basic and clinically patient care. Questioning a colleague about the indi- supportive sciences that are appropriate to their cation for this procedure may allow a patient not to discipline. have an unnecessary procedure. Knowledge of the procedure itself is important. In the morbidly obese With any parturient, the anesthesiologist needs to patient, a cesarean section is not a simple procedure: be mindful of the physiological changes in pregnancy (1) how much tissue is there between the skin and and how this will affect their management. Knowl- the uterus? (2) Can you find the uterus to apply fun- edge of increased blood volume and increased edema dal pressure when extracting the fetus? (3) An opera- is important as this will result in increased airway tive delivery can have increased complications of poor edema, fragile mucosa, and more difficult airway man- wound healing and wound infection. This is surgery agement. Lung volumes are decreased secondary to that would benefit from as much expertise and assis- the gravid uterus, with a decreased functional resid- tance as is available. A stat cesarean section in this ual capacity. The pregnant patient will become hypoxic patient may likely have complications. Alternatively, faster with apnea than the nonpregnant patient. Addi- vaginal delivery may not be a better option. These tionally, the pregnant patient has an increased risk patients have an increased rate of large-for-gestational- of aspirating gastric contents because progesterone age fetuses, and there is a higher risk of shoulder relaxes the lower esophageal sphincter tone and there dystocia. is increased pressure on the abdomen by the gravid uterus [4]. Obesity increases the probability of difficult airway Practice-based learning management, certainly making ventilation more diffi- and improvement cult and possibly making intubation more difficult [5]. Proper patient positioning for intubation is important. Residents must be able to investigate and evaluate their The morbidly obese patient demonstrates (1) a patient care practices, appraise and assimilate scientific decreased functional residual capacity and (2) a evidence, and improve their patient care practices. decreased closing capacity, both of which will result in faster oxygen desaturation with apnea. Increased Analyze practice experience and perform chest wall weight results in increased airway resistance practice-based improvement activities using a and higher peak airway pressures during positive pres- systematic methodology. sure ventilation. Patients with morbid obesity have a high incidence of sleep apnea, which can be associ- Essential to anesthesia learning is to review the ated with pulmonary hypertension and, ultimately, cor events of this case, the decisions that were made, the pulmonale. patient outcome, and if alternatives to therapy should These patients may have associated medical condi- have been done. tions that complicate both their anesthetic and obstet- On our obstetric anesthesia service, we perform ric management, including hypertension, diabetes, a daily debriefing with residents and attendings that and coronary artery disease. These patients are at reviews the day’s critical events, teaching points, and an increased risk of developing gestational hyperten- lessons for future care. It is a system that reviews clin-110 sion, preeclampsia, gestational diabetes, and fetal birth ical experience to help shape learning and future deci- weight greater than 4,000 g [6]. sion making.
  • 120. Case 21 – Are you sure there’s a baby there? Locate, appraise, and assimilate evidence from in loss of the airway, hypoxia, cardiac arrest, and loss scientific studies related to their patients’ health of both the mother and the fetus. The physician must problems. remain mindful of this problem and perform the ethi- cal principle of nonmaleficence. This is not to say that Reviewing pertinent literature before and after this an urgent cesarean section cannot be performed, but itcase about the obstetric management of the morbidly should not be done in a matter that may jeopardize theobese patient allows one to ensure that one is perform- life of the mother.ing evidenced-based medicine and adhering to goodpractice principles. Reviewing literature may also pro- Interpersonal and communicationvide ways to improve patient care, for example, wouldthe use of ultrasound guidance improve success in skillsepidural placement [7]? Residents must be able to demonstrate interpersonal and communication skills that result in effective infor- Apply knowledge of study designs and statistical mation exchange and teaming with patients, their methods to the appraisal of clinical studies and patients’ families, and professional associates. other information on diagnostic and therapeutic effectiveness. Create and sustain a therapeutic and ethically sound relationship with patients. Reviewing the medical literature about the com-plications noted in the morbidly obese parturient as Communication skills were essential in dealingwell as performing a critical review of this information with this difficult patient. The medical staff neededfor its validity will allow the medical team to prepare to develop a trusting relationship with this patientpatients for what they should expect in their care. The in a very short amount of time. Trust is importantcare of the morbidly obese paturient has a high likeli- from this patient, particularly as several invasive pro-hood of complications, both for the mom and for the cedures needed to be performed – central line accessfetus. and epidural placement. Work effectively with others as a member orProfessionalism leader of a health care team or other professionalResidents must demonstrate a commitment to car- group.rying out professional responsibilities, adherence toethical principles, and sensitivity to a diverse patient One practice that we have implemented on laborpopulation. and delivery is the huddle, which is to occur twice a day. The nursing, anesthesia, and obstetric staff meet Demonstrate a commitment to ethical principles briefly to discuss the patients on the unit, any poten- pertaining to provision or withholding of clinical tial problems, and planned medical care. This also care, confidentiality of patient information, provides an opportunity for each medical service to informed consent, and business practice. express its concerns about individual patients. One of the most difficult aspects of obstetrical careis that we are caring for two patients: both the mom Systems-based practiceand the fetus. A principle to review is that fetal well- Residents must demonstrate an awareness of andbeing is dependent on maternal well-being. If maternal responsiveness to the larger context and system ofhealth is jeopardized, then the outcome of the fetus is health care and the ability to effectively call on systemjeopardized. However, this relationship does not nec- resources to provide care that is of optimal value.essarily apply in reverse. Consider the following scenario: our morbidly Understand how their patient care and otherobese patient is on labor and delivery with continu- professional practices affect other health careous fetal monitoring. The fetus demonstrates nonre- professionals, the health care organization, andassuring fetal heart tracing, and the decision is made the larger society and how these elements of theto perform a stat cesarean section. Performing an ill- system affect their own practice. 111prepared general anesthetic in this patient may result
  • 121. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 This case highlights some of the challenges of care uate the airway, (2) evaluate possible peripheral IV with a morbidly obese pregnant patient during deliv- access, and (3) provide patient education about anes- ery. A task force was formed to evaluate several of the thetic management at the time of delivery. Educating issues surrounding this case. The task force looked at patients about the placement of an epidural catheter ways to improve system practices for these patients. early in labor allows them to understand the benefits of What quality improvement measures can be done the medical plan. The outpatient setting also allows for to optimize patient care? Several policies have been more time in a lower-stress environment for questions implemented. and concerns to be properly addressed. An anesthetic We have compiled the data from the medical liter- plan can be formulated prior to presentation on labor ature that assess the complication rates and outcomes and delivery. of pregnancy in the morbidly obese patient. This infor- As noted in this case, given the difficulty of IV mation has been given both to health care providers access, our staff has become more aggressive at hav- and to patients. This education highlights the risks, ing peripherally inserted central catheter lines placed dangers, and outcomes of the morbidly obese patient by interventional radiology before admission to labor during pregnancy. Better educating patients should and delivery. allow them to modify their expectations should they Improving the health care system and using a decide to become pregnant. multidisciplinary approach to these patients should Assessing a patient prior to presentation at labor improve patient care. and delivery allows for anesthesia providers to (1) eval-112
  • 122. Case 21 – Are you sure there’s a baby there?Additional reading 4. Birnbach D, Browne I. Anesthesia for obstetrics. In: Miller R, editor. Miller’s anesthesia. 6th ed.1. Castro LC, Avina R. Maternal obesity and pregnancy Philadelphia: Elsevier Churchill Livingston; 2005: outcomes. Curr Opin Obstetr Gynecol 2307–2344. 2002;14:601–666. 5. Popescu WM, Schwartz JJ. Perioperative2. Schneid-Kofman N, Sheiner E, Levy A, Holcberg considerations for the morbidly obese patient. Adv G. Risk factors for wound infection following Anesth 2007;25:59–77. cesarean deliveries. Int J Obstetr Gynecol 2005;90: 10–15. 6. Weiss JL. Obesity, obstetric complications and cesarean delivery rate – a population-based screening3. Espinet A, Dunning J. Does ultrasound-guided central study. Am J Obstetr Gynecol 2004;190:1091–1097. line insertion reduce complications and time to placement in elective patients undergoing cardiac 7. Ali ME, Laurito C. Ultrasound guidance for epidural surgery. Interact Cardiovasc Thorac Surg catheter placement: a coming of age? J Clin Anesth 2004;3:523–527. 2005;17:235–236. 113
  • 123. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 22 Smoking, still smoking, and won’t quit Deborah Richman and Rany Makaryus The case Patient care “Joe the plumber” is a 44-year-old male who presented Residents must be able to provide patient care that is to preoperative services with low back pain because of compassionate, appropriate, and effective for the treat- a herniated disc at L5/S1, going for a discectomy. He ment of health problems and the promotion of health. had been having severe radiating pain, especially down his right leg, and was treating this pain with all the Communicate effectively and demonstrate caring Vicodin he could get his hands on! He did not have any and respectful behaviors when interacting with paraesthesias or weakness. As a self-employed contrac- patients and their families. tor, and with no other medical problems besides hyper- Joe the plumber is a model U.S. citizen! He defi- tension (HTN) and gastroesophageal reflux disease, he nitely deserves respect! This is a difficult situation, in just wanted to get this surgery done so he could get which we must understand the difficult dilemma this back to work and pay his bills again. Since he’s had patient is in and respect his decision in going forward surgery before (a laparotomy about 20 years ago, with with surgery, even though his medical condition is not no problems), of course, he would have no problems optimized. Part of the problem is that he may not be with this surgery, right? able to afford the surgery if he puts all his hard-earned On further questioning and a review of systems, it money into medical optimization. was discovered that he also smokes just a little – only about two packs per day for 30 years! On top of this, Gather essential and accurate information about he also has a chronic cough, worse in the morning and their patients. productive of brown sputum, as well as a wheeze. He denied having frequent urinary tract infections, pneu- A great deal of time was spent trying to gain infor- monia, or bronchitis. He doesn’t take any pulmonary mation from this patient to establish a working diag- medications because he doesn’t have insurance. He nosis and optimize this patient with as little further was also suspect for obstructive sleep apnea, being that testing as possible so as not to impart much cost to the he snores, has daytime tiredness, has been observed to patient. Careful assessment of his pulmonary function stop breathing in his sleep, and has a history of HTN. and stability of his presumed chronic obstructive pul- He can’t, however, afford a sleep study because his monary disease (COPD) are mainly done on history darned health insurance, which, again, doesn’t exist, and physical exam. can’t pay! On the positive side, though, he is a contractor and Make informed decisions about diagnostic and works hard with great effort and tolerance. He is self- therapeutic interventions based on patient employed; he can’t work because he’s in too much pain, information and preferences, up-to-date scientific and he can’t afford not to work because he has way too evidence, and clinical judgment. many bills to pay. This is where being a clinician, and individualizing His only medication at this time is Vicodin. A phys- medical care for each patient, becomes very important. ical exam revealed that he is 5 feet 11 inches tall, weigh- Ideally, this patient should do the following: ing in at 225 pounds, with a blood pressure of 158/92 and with bilateral wheezes – mainly in the upper air- r see a pulmonologist for optimization way – that improve with coughing and in an open- r be encouraged to quit smoking and have his114 mouth sniffing position, but not completely. The rest surgery scheduled for 8 weeks after he quits of the physical exam was noncontributory. r have his sleep apnea evaluated and treated
  • 124. Case 22 – Smoking, still smoking, and won’t quitHowever, for him, it may be much more beneficial to tive in detecting this disease in the preoperative popu-go ahead with surgery, simply assuming that he won’t lation.quit smoking and that he has severe sleep apnea, andto provide anesthesia with these facts and assumptions Perform competently all medical and invasivein mind. procedures considered essential for the area of practice. Develop and carry out patient management Chest X ray, pulmonary function tests, and blood plans. gases are not proven to change management or out- The patient’s plan includes smoking cessation, come in these patients and are not indicated.incentive spirometry education preoperatively, and Provide health care services aimed at preventingbeta agonist nebulizer prior to surgery; combined local health problems or maintaining health.and general anesthesia; and postoperative monitor-ing, incentive spirometry, and deep venous thrombosis Teach the patient preoperatively how to use theprophylaxis. incentive spirometer and send him home with one. The physician should keep careful documentation Offer a prescription for nicotine patches. If sputumof these plans and the reasoning behind them. Com- is infected (green or yellow), have the patient take anmunication with the anesthesia and surgical teams antibiotic for at least 48 hours prior to surgery, withwho will be providing care for this patient should be the goal of preventing pulmonary complications post-maintained to ensure the best possible care for this operatively.patient. Work with health care professionals, including Counsel and educate patients and their those from other disciplines, to provide families. patient-focused care. This patient needs to be educated on multiple Hold discussions with the surgical team, the oper-health care concerns. First and foremost is education ating room (OR) anesthesia team, the postanesthesiaon the negative effects of smoking, especially in such care unit team, pulmonary experts, and the patient tolittle – oh, sorry, I mean large . . . oh, sorry, I mean enor- provide the best possible anesthesia care.mous – amounts! Also important to discuss with this patient is the Medical knowledgefact that taking Vicodin for pain should be done in Residents must demonstrate knowledge about estab-moderation – not only because of the possibility of lished and evolving biomedical, clinical, and cognateopioid toxicity, but also because of the adverse hepatic (e.g., epidemiological and social-behavioral) scienceseffects of acetaminophen. Sometimes it would be bet- and the application of this knowledge to patient care.ter to provide the patient with opioid medications sep-arately from the acetaminophen. Demonstrate an investigatory and analytic Finally, if it is decided to go ahead without further thinking approach to clinical situations.optimization, the patient needs to be aware of the extra Think about how to treat chronic bronchitis/risks he is taking on – specifically postoperative pul- COPD. Think about how to treat OSA.monary complications, and worse, the risk of beingcanceled on the day of surgery by the anesthesiologist Know and apply the basic and clinicallydue to lack of optimization. supportive sciences that are appropriate to their discipline. Use information technology to support patient care decisions and patient education. Preop use of nebulizers and/or albuterol – to use or not to use? If you gave the patient an inhaler, would his This patient’s probable diagnosis of obstructive inhaler technique be adequate enough to get the drugsleep apnea (OSA) would not have been discovered delivered, or would most be drifting into the ozone?had the STOP screen questionnaire not been used, Also, consider the advantages and disadvantages of 115which, in the literature, has been proven to be effec- preoperative steroids.
  • 125. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 How long should the patient stop smoking for? Have studies shown that screening for OSA is effec- Six hours (CO effects)? Twenty-four hours (sympa- tive in preventing complications? What about these thetic effects of nicotine withdrawal)? Two weeks study designs and/or statistical methods supports that (return of ciliary function)? Eight weeks (decreased assertion? postoperative pulmonary complications)? Ten years (return to nonsmoking population risk of coronary Use information technology to manage artery disease and lung cancer)? Or my personal information, access online medical information, favorite – whenever you stop is good, excellent, and and support their own education. wonderful! Much information about COPD, OSA, smoking cessation, local support groups, and so on is available Practice-based learning online and in pamphlets that can be handed out to patients. and improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific Professionalism evidence, and improve their patient care practices. Residents must demonstrate a commitment to carry- ing out professional responsibilities, adherence to eth- Analyze practice experience and perform ical principles, and sensitivity to a diverse patient pop- practice-based improvement activities using a ulation. systematic methodology. Demonstrate respect, compassion, and integrity; a Consider carefully why this patient is different responsiveness to the needs of patients and society from a 75-year-old with the same history and if that supersedes self-interest; accountability to that patient could be sent to surgery without further patients, society, and the profession; and a workup – it’s all about the risk–benefit ratio. Remem- commitment to excellence and ongoing ber age and closing capacity. professional development. In this case, responding to the needs of the patient Locate, appraise, and assimilate evidence from is top priority – the need to have surgery to regain scientific studies related to their patients’ health the ability to make a living is most important for this problems. patient and thus needs to be most important for the Look up management of COPD, preop optimiza- clinician, as well. tion for smokers, advantages of quitting tobacco use, Demonstrate a commitment to ethical principles and so on. Also look up the usefulness of the STOP pertaining to provision or withholding of clinical screen, what to do with the screen, what is a positive care, confidentiality of patient information, screen, and the importance of identifying patients informed consent, and business practice. with OSA. Respecting the patient’s decision to go ahead with Obtain and use information about their own surgery without medical optimization, while he con- population of patients and the larger population tinues to smoke, is important, as is the ethical principle from which their patients are drawn. to the patient of “first, do no harm . . . ” This patient needs individualized care, and this Demonstrate sensitivity and responsiveness to must be drawn from known information on how to patients’ culture, age, gender, and disabilities. deal with patients with similar disease processes. Keeping these factors in mind, making the deci- Apply knowledge of study designs and statistical sion to go with surgery on this patient, while giving methods to the appraisal of clinical studies and the patient all the important information and medi- other information on diagnostic and therapeutic cal education for surgical optimization, is the result116 effectiveness. of being sensitive to the patient’s disabilities, lack of insurance, and need for employment.
  • 126. Case 22 – Smoking, still smoking, and won’t quitInterpersonal and communication Understand how their patient care and otherskills professional practices affect other health care professionals, the health care organization, andResidents must be able to demonstrate interpersonal the larger society and how these elements of theand communication skills that result in effective infor- system affect their own practice.mation exchange and teaming with patients, theirpatients’ families, and professional associates. Deciding that this guy is OK to do might fit your clinical judgment and moral values – you’ve spoken Create and sustain a therapeutic and ethically with a real person, not a cold chart that looks sick or an sound relationship with patients. anxious supine patient without his teeth. But if the sur- geon and anesthesiologist of the day do not agree with Take care of the patient as a person, not as another your opinion – the OR stands, the surgeon fumes, andsubject of medical treatment. your colleague thinks you are an idiot (the feeling will Use effective listening skills and elicit and provide probably be mutual) – there is going to be downtime information using effective nonverbal, in the OR (mega bucks). explanatory, questioning, and writing skills. If your judgment is not sound, the patient may suf- fer postop pneumonia, increased length of stay, tests, Listening to the patient brought out the fact that consults, and more mega bucks! And the state just cuthe lacks insurance, yet needs this surgery. Using inex- our budget again.pensive tests and interventions, for example, the STOPscreen and incentive spirometry, to assess and manage Practice cost-effective health care and resourcethis patient provided necessary medical information allocation that does not compromise quality ofand allowed the patient to make appropriate medical care.decisions. Providing this patient with surgery that will em- power him to return to work and regain a functional Work effectively with others as a member or lifestyle is very important – all the while using effec- leader of a health care team or other professional tive health care, while maintaining the least possible group. cost to the patient, is key in this case. Communication with the surgical team and the Advocate for quality patient care and assistanesthesiologist providing the patient’s care is huge – patients in dealing with system complexities.the anesthesiologist of the day would not be wrongto cancel our friend Joe the plumber. Find the right Helping this patient gain the benefits of surgery,guy or gal, give him or her a head’s up, and let him without giving him undue financial stress, is importantor her think it over, bounce it off the boss/spouse/dog, here.and make an informed decision to anesthetize thispatient because of the unique circumstances of Know how to partner with health care managers2009. and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.Systems-based practiceResidents must demonstrate an awareness of and The patient’s surgery and recovery period wereresponsiveness to the larger context and system of uneventful. He was discharged home on postop dayhealth care and the ability to effectively call on system 1 and has significant improvement in his symptoms,resources to provide care that is of optimal value. enabling him to return to work . . . and smoking. 117
  • 127. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144: 1. Qaseem A, Snow Q, Fitterman N, et al. Risk 581–595. assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing 5. Warner DO. Perioperative abstinence from cigarettes: noncardiothoracic surgery: a guideline from the physiological and clinical consequences. American College of Physicians. Ann Intern Med Anesthesiology 2006;104:356–367. 2006;144:575–580. 6. Egan TD, Wong KC. Perioperative smoking cessation 2. Pasquina P, Tram`r MR, Granier J, Walder B. e and anesthesia: a review. J Clin Anesth 1992;4: Respiratory physiotherapy to prevent pulmonary 63–72. complications after abdominal surgery: a systematic 7. Practice guidelines for the perioperative management review. Chest 2006;130:1887–1899. of patients with obstructive sleep apnea: a report by 3. Wong D, Weber E, Schell M, Wong A, Anderson C, the American Society of Anesthesiologists Task Force Barker S. Factors associated with postoperative on Perioperative Management of Patients with pulmonary complications in patients with severe Obstructive Sleep Apnea. Anesthesiology chronic obstructive pulmonary disease. Anesth Analg 2006;104:1081–1093. 1995;80:276–284. 8. Chung F, Yegneswaran B, Liao P, et al. STOP 4. Smetana GW, Lawrence VA, Cornell JE. Preoperative questionnaire: a tool to screen obstructive sleep apnea. pulmonary risk stratification for noncardiothoracic Anesthesiology 2008;108:812–821.118
  • 128. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 23 Pseudoseizures following office extubation Ralph Epstein and Andrew DrollingerThe case daughter exhibited this behavior previously in a medi-This is a case of a 19-year-old female college student cal office. Not knowing if the patient was actually hav-presenting to a private dental office for comprehen- ing a seizure, intravenous (IV) access was obtained viasive dental care under general anesthesia. Her medi- a 20-gauge catheter and with D5-1/2 as the IV fluid.cal history includes depression, panic disorder, “prob- The patient was administered midazolam 10 mg overlems with mental health,” needle phobia, anemia, latex 10 minutes with no change in her seizurelike behavior.allergy, and seasonal allergies. She takes sertraline for Diazepam 5 mg was then administered, also with nodepression, lorazepam for anxiety, and amoxicillin for changes noted. Her BIS was noted to be in the 70s, asdental infection. expected after the administration of benzodiazepines. At a recent dental appointment under general anes- It was noted that this seizurelike behavior wouldthesia by the same anesthesiologist, blood studies were start and stop and increase and decrease in inten-obtained, including complete blood count (CBC) with sity, particularly with her mother’s involvement. Aboutplatelets and differential and a thyroid panel. All results 20 minutes into this event, when she was called by thewere found to be within normal limits. Evaluation of wrong name, she opened her eyes slightly and jokinglyher airway classified her as Mallampati class I, with full became upset that such a mistake was made, and thenrange of motion of her neck and with adequate thyro- slipped back into shaking and shuttering.mental distance. At 8:20 p.m., emergency medical services (EMS) Owing to the patient’s needle phobia, general anes- were called to transport the patient to the local emer-thesia was initiated via mask induction with sevoflu- gency department. This decision was made collec-rane, nitrous oxide, and oxygen. A 7.0 nasal endo- tively, including with the mother. The patient wastracheal tube was inserted atraumatically through the transported to the emergency department via ambu-patient’s left naris. Monitoring included electrocardio- lance. All the involved dentists went to the emergencygram, blood pressure, heart rate, pulse oximetry, pre- department to provide necessary information to thetracheal auscultation, capnography, temperature, and emergency department physician and to provide sup-bispectral index (BIS). Anesthesia was maintained by port to the patient and her mother.propofol and dexmedetomidine infusion, and her den- After about 1 hour in the emergency department,tal work, which included root canal on nine teeth, the physician, in hearing the distance of the patient,was completed as expected. The anesthetic course was recommended sedation with propofol and reintuba-smooth, with no aberrations. At the completion of tion to take a brain magnetic resonance image (MRI).treatment, infusions were discontinued, and she was The mother was opposed to the reintubation and, fol-extubated without complications (6:50 p.m.). lowing the advice of the anesthesiologist, she left the At 7:00 p.m., the patient’s mother, a physician, was treatment room to call her husband, also a physi-brought into the recovery area with the patient being cian. Approximately 3 minutes after the mother left theawake, responsive, and resting comfortably. At 7:20 room, the patient opened her eyes, woke up, and thep.m., the patient’s behavior began to change. She started seizurelike behavior stopped. A brain MRI was takenshaking and shuttering and was no longer respon- and the patient was admitted overnight. The brain MRIsive. Her blood pressure was 113/70, with a pulse of was read out without any positive findings.88 and oxygen saturation at 98%. A BIS monitor was When the IV started by the anesthesiologist inplaced, and a reading of greater than 90 was noted. the private office was removed the next morning, theAt this point in time, the mother reported that her patient exhibited 5 minutes of the seizurelike activity. 119
  • 129. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 The same seizurelike activity occurred later in the Perform competently all medical and invasive afternoon, when the IV started in the emergency procedures considered essential for the area of department was removed. practice. Later follow-up indicated that the patient had a video electroencephalogram (EEG) performed. Dur- General anesthesia was performed as planned ing the video EEG, the patient exhibited four episodes and without incident. After pseudoseizures began, IV of the seizurelike activity. The official impression from access was obtained and benzodiazepines were admin- the neurophysiologist conducting the video EEG was istered. as follows: r four nonepileptic events Work with health care professionals, including r EEG normal those from other disciplines, to provide r large beta may be secondary to Ativan patient-focused care. The mother reports that the primary neurologist has Everyone who was involved in patient care escorted made a diagnosis of pseudoseizures. the patient to the emergency department to provide all necessary information to the emergency department physician. Patient care Residents must be able to provide patient care that Medical knowledge is compassionate, appropriate, and effective for the Residents must demonstrate knowledge about estab- treatment of health problems and the promotion of lished and evolving biomedical, clinical, and cog- health. nate (e.g., epidemiological and social-behavioral) sci- ences and the application of this knowledge to patient Communicate effectively and demonstrate caring care. and respectful behaviors when interacting with patients and their families. Demonstrate an investigatory and analytic The decision was made early on to involve the thinking approach to clinical situations. patient’s mother. The patient’s behavior was immediately suspected Gather essential and accurate information about to be seizure and was treated accordingly. their patients. Vital signs and BIS were recorded, and seizure Practice-based learning activity was highly suspected. and improvement Residents must be able to investigate and evaluate their Make informed decisions about diagnostic and patient care practices, appraise and assimilate scientific therapeutic interventions based on patient evidence, and improve their patient care practices. information and preferences, up-to-date scientific evidence, and clinical judgment. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health Suspected seizure activity was treated accordingly. problems. Develop and carry out patient management plans. This patient presented with a psychological history The patient was treated for seizures and trans- of anxiety and depression. ported to the emergency department via EMS within an appropriate time frame. Professionalism Counsel and educate patients and their families. Residents must demonstrate a commitment to car- rying out professional responsibilities, adherence to120 The patient’s mother was included in the decision- ethical principles, and sensitivity to a diverse patient making process. population.
  • 130. Case 23 – Pseudoseizures following office extubation excellence and ongoing professionalDemonstrate respect, compassion, and development.integrity; a responsiveness to the needs ofpatients and society that supersedes self- Everyone involved in the patient’s care went to theinterest; accountability to patients, society, emergency department and stayed until her care was and the profession; and a commitment to complete. 121
  • 131. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 3. Parry T, Hirsch N. Psychogenic seizures after general anaesthesia. Anaesthesia 2007;47:534. 1. Ng L, Chambers N. Postoperative pseudoepileptic seizures in a known epileptic: complications in 4. Taylor DC. Pseudoseizures and the predicament: recovery. Br J Anaesth 2003;91:598–600. pseudoseeing is pseudobelieving. Epilepsy Behav 2001;2:78–84. 2. Allen G, Farling P, Ng L, Chambers N. Anaesthesia and pseudoseizures. Br J Anaesth 2004;92:451–452.122
  • 132. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 24 What happened to the ETT tip? Ralph Epstein and Tate MontgomeryThe case 2 hours and 30 minutes. All vital signs, respiratoryA 16-kg, 2-year, 6-month-old male presented to the sounds and ETCO2 , SpO2 , temperature, and BIS read-dental office with multiple carious, nonrestorable ings were within normal limits.teeth. His past medical history and family history When the dentist finished, she removed the throatwere noncontributory. On examination, it was deter- pack and allowed the anesthesiologist to extubate themined that he would require a more extensive exam- patient. It was done atraumatically, although someination, radiographs, multiple restorations, cleaning, secretion or something came out with the tube. Theand extractions. It was decided that because of age and tube was placed on a tray to the right, and all atten-behavior, the treatment would be done with the patient tion was returned to the patient. He was recoveringunder general anesthesia in the dental office. Prior to very well. On glancing to the right, the anesthesiolo-the date of treatment, the anesthesiologist evaluated gist noticed that the tip of the NRAE was abnormal andthe patient and determined that he was a good candi- that part of it was missing. A direct laryngoscopy wasdate for office-based general anesthesia. performed and there was no sign of a foreign body. The The child was seen preoperatively by his pediatri- patient continued to have an oxygen saturation of 98%.cian and was found to be healthy, with no contraindi- His lungs were clear to auscultation and he was thencations to general anesthesia. Prior to the start of anes- transferred to another room to continue recovery andthesia, the patient was evaluated by the anesthesiolo- monitoring. The operatory was thoroughly inspectedgist and found to be in good condition for office-based and cleaned in an attempt to find the missing tip fromgeneral anesthesia on this date. The patient was given the NRAE, but nothing was found.15 mg oral midazolam in the waiting room. Twenty The entire situation was explained to the parents.minutes later, he was taken to the treatment room Following consultation with a pediatric radiologist atand general anesthesia was induced by sevoflurane and University Hospital 1 mile away, the patient was trans-nitrous oxide/oxygen. Intravenous access was obtained ported by the anesthesiologist to the hospital, withoutwith a 22-gauge Jelco catheter in the right anticubital discontinuing his IV. A pediatric radiologist reviewedfossa. Standard ASA monitors were placed as well a BIS the patient’s chest PA and a lateral and found an areamonitor and a precordial stethoscope. of prominent markings in the right upper lobe due Both nares were prepared with oxymetazoline to atelectasis or infiltrate, no air trapping, and nodrops, and nasal airways 20–26, which were lubricated opaque foreign body. A pediatric mag study was alsowith 2% lidocaine jelly, were successively placed in done, and there was atelectasis or infiltrate in the rightthe right naris. To decrease the trauma to the naris, upper lung field; no radiopaque foreign body and noan uncuffed Mallinckrodt 4.5 nasal RAE was removed nonopaque foreign body surrounded by air was found.from its package and placed in very hot water. Imme- Intravenous access was discontinued, and the patientdiately prior to insertion of the NRAE in the right was transported to the private office of the chief of oto-naris, the tube was lubricated with 2% lidocaine jelly laryngology.that was on a 4 by 4 inch gauze. The patient was intu- The patient was inspected via anterior rhinoscopy,bated on the first attempt, and it was atraumatic. The direct fiber-optic nasal endoscopy, and laryngoscopytube was secured, eyes were taped, and the head was with phenylephrine. There was no evidence of a foreignwrapped in the usual manner for a dental procedure. body, abrasion, or any airway compromise. The patientThe dentist placed one throat pack. Maintenance anes- was then sent home, and instructions were given tothesia was sevoflurane and nitrous oxide/oxygen for the parents that if anything abnormal occurred with 123
  • 133. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 regard to his breathing, they should inform the anes- Make informed decisions about diagnostic and thesiologist and immediately go to the emergency therapeutic interventions based on patient department. The patient was followed by his pedia- information and preferences, up-to-date scientific trician, radiographs were retaken 3–4 days posttreat- evidence, and clinical judgment. ment, and he was evaluated in the office 6 days later. The patient did well, and the parents never reported It was decided to first transport the patient to the any problems. hospital for further examination, and when satisfac- Mallinckrodt was informed of the situation via e- tory results were not found, the patient was then trans- mail, and digital photographs of the tube were sent. ferred to a specialist to further determine what could After several months, by letter, Mallinckrodt explained be done to ensure that the best care was provided. that the tubes are manufactured in one piece. The Mur- phy eye is then punched after the tube is formed. They Develop and carry out patient management plans. explained that the tube was probably punched twice The postoperative management was handled as and not detected by their quality control procedures. described previously. This defect was reported to both the quality and manu- facturing departments, and they requested that correc- Counsel and educate patients and their families. tive action be implemented to avoid the reoccurrence of this problem. Most information was given to the parents because This was a situation that was challenging to manage of the patient’s age. The parents were informed about because it occurred in a private office, where all means everything and were very cooperative. where not immediately available to address the con- cerns of an incomplete tube discovered on extubation. Use information technology to support patient All information was disclosed to the parents, and they care decisions and patient education. were assisted and informed throughout the entire pro- It was explained to the parents that everything was cess. We are reminded by this incidence that we must done to find the missing piece of the endotracheal tube. always be ready to manage unexpected situations in a In the past, the most that might have been done would professional and ethical manner. I currently check not have been to take a chest X-ray, but with the aid of the only the cuff on my endotracheal tubes, but the entire specialist, much more was done to maintain the health tube every time I intubate! Will you now? of the patient. Patient care Perform competently all medical and invasive procedures considered essential for the area of Residents must be able to provide patient care that is practice. compassionate, appropriate, and effective for the treat- ment of health problems and the promotion of health. The anesthesiologist transferred the patient to two different and independent health care providers to Communicate effectively and demonstrate caring reevaluate and confirm that nothing was abnormal. and respectful behaviors when interacting with patients and their families. Medical knowledge It was necessary for the anesthesiologist to care- Residents must demonstrate knowledge about estab- fully explain, in full detail, in a manner that the parents lished and evolving biomedical, clinical, and cognate could understand, what happened and what was going (e.g., epidemiological and social-behavioral) sciences to need to be done. and the application of this knowledge to patient care. Gather essential and accurate information about Demonstrate an investigatory and analytic their patients. thinking approach to clinical situations. As the patient was so young, it was necessary to dis- Before the patient was transferred to the hospital,124 cuss with the parents the health of the child and to ask the room was thoroughly searched to see if the missing appropriate questions. piece could be found. After the situation occurred, the
  • 134. Case 24 – What happened to the ETT tip?manufacturer was contacted to further explain what Throughout this entire case, the parents were fullyhappened. informed and involved to make sure they knew that the best health care available was provided to their child.Practice-based learningand improvement Interpersonal and communicationResidents must be able to investigate and evaluate their skillspatient care practices, appraise and assimilate scientific Residents must be able to demonstrate interpersonalevidence, and improve their patient care practices. and communication skills that result in effective infor- mation exchange and teaming with patients, their Locate, appraise, and assimilate evidence from patients’ families, and professional associates. scientific studies related to their patients’ health problems. Create and sustain a therapeutic and ethically sound relationship with patients. The manufacturer was contacted to determine ifthis has been a problem and to see what would be done The family was kept informed of the status ofto ensure that this did not happen again. their child during the posttreatment evaluation pro- cess. Multiple postoperative phone calls were made to Obtain and use information about their own answer questions and to make sure the child had no population of patients and the larger population further complications. from which their patients are drawn. Work effectively with others as a member or This was an unexpected issue that was not specific leader of a health care team or other professionalto this patient’s population; however, it could occur to group.anyone undergoing intubated general anesthesia. The entire staff was involved in attempts to find the missing piece and to determine a plausible causeProfessionalism for the issue. Multiple other health care providersResidents must demonstrate a commitment to car- were consulted, but the anesthesiologist took therying out professional responsibilities, adherence to lead, gathered information from all possible resources,ethical principles, and sensitivity to a diverse patient and made leadership decisions for the benefit of thepopulation. patient. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society Systems-based practice that supersedes self-interest; accountability to Residents must demonstrate an awareness of and patients, society, and the profession; and a responsiveness to the larger context and system of commitment to excellence and ongoing health care and the ability to effectively call on system professional development. resources to provide care that is of optimal value. Because this patient required unexpected addi- Understand how their patient care and othertional care, other patients had to be rescheduled to professional practices affect other health careanother day. Total productivity for the day was de- professionals, the health care organization, andcreased, which resulted in a decrease of income for the the larger society and how these elements of theoperating dentist and the anesthesiologist. system affect their own practice. Demonstrate a commitment to ethical principles This case demonstrates how office-based general pertaining to provision or withholding of clinical anesthesia care affects multiple health care practition- care, confidentiality of patient information, ers and institutions and also how dependent we are informed consent, and business practice. on multiple providers to ensure the best care for our 125 patients.
  • 135. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Practice cost-effective health care and resource ent specialists. The complexities of accessing specialty allocation that does not compromise quality of consultant care were far from normal. While attend- care. ing to the recovery of the child, multiple phone con- sultations outside the treatment facility were required This case demonstrates that when providing cost- to schedule and organize the best treatment for the effective office-based general anesthesia and being pre- patient. sented with the most unexpected of complications, the Know how to partner with health care managers patient’s quality of care was not compromised. and health care providers to assess, coordinate, and improve health care and know how these Advocate for quality patient care and assist activities can affect system performance. patients in dealing with system complexities. The private office had predetermined where a The anesthesiologist was with the patient through- patient would be transported if it were ever necessary. out the multiple visits he received. He was there to This way, there was no time wasted when it was actu- explain the results that were obtained from the differ- ally necessary.126
  • 136. Case 24 – What happened to the ETT tip?Additional reading 3. Wang PC, Tseng GY, Yang HB, et al. Inadvertent tracheobronchial placement of feeding tube in a1. Pritt B, Harmon M, Schwartz M, et al. A tale of three mechanically ventilated patient. J Chin Med Assoc aspirations: foreign bodies in the airway. J Clin Pathol 2008;71:365–367. 2003;56:791–794. 4. Krzanowski TJ, Mazur W. A complication associated2. Lampl L. Tracheobronchial injuries: conservative with the Murphy eye of an endotracheal tube. Anesth treatment. Interact Cardiovasc Thorac Surg Analg 2005;100:1854–1855. 2004;3:401–405. 127
  • 137. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 25 Jerry and Terry want one more baby Rishimani Adsumelli and Vishal Sharma The case perform abdominal hysterectomy. During the surgery, the patient develops hypotension and bradycardia. The A 39-year-old gravida 10 para 9 (G10P9) is admitted patient is transfused 5 units of packed red blood cells, for treatment and evaluation to the obstetrics floor for 2 units of platelets, and 2 units of fresh frozen plasma. abdominal pain. The obstetricians are telling you that Her lowest hemoglobin was 6.7 and her hematocrit was the patient probably has placenta accreta and placenta 24. The patient is transported to the recovery room, previa on ultrasound. Furthermore, the obstetricians where she recovers from her surgery. She has no other relate to you that the baby has no heart rate and no complications and is eventually discharged after 5 days movement is visualized on ultrasound at 36 weeks’ ges- of hospitalization. tation. The patient has no significant past medical his- tory. Her obstetric history is extensive, including five vaginal births and four previous cesarean sections. Her Patient care cesarean sections were complicated by uterine atony Residents must be able to provide patient care that is after each procedure, requiring blood transfusions and compassionate, appropriate, and effective for the treat- an intensive care unit stay for the last one. It is rec- ment of health problems and the promotion of health. ommended to the patient that she undergo bilateral uterine artery embolization as well as abdominal hys- Communicate effectively and demonstrate caring terectomy to remove the dead fetus and to prevent and respectful behaviors when interacting with postpartum hemorrhage from previa and accreta. The patients and their families. patient is devastated at the loss of her child and is refus- ing all medical care. She just wanted to be given some Although the patient wanted only sedation and sedation and sleep. wasn’t willing to discuss any other medical manage- After extensive discussion with the patient and the ment, it was not an option for the medical team. We obstetrician, it is determined that an initial attempt to couldn’t sedate unless consents were signed for man- perform a cesarean section will be made; if, however, agement. the patient begins to have bleeding of any kind, no fur- Faced with this situation, the only option was to ther attempts will be made to deliver the placenta, and give her some time for this devastating event to sink the patient will then undergo abdominal hysterectomy. in, while continuing discussions with her husband. We The patient is brought to the operating room and showed empathy by having different staff try to get an epidural catheter is placed successfully with a across to her, even a pastor. After 2 hours, one of the T5 thoracic level obtained using 2% lidocaine with labor and delivery nurses managed to convince her 1:200,000 epinephrine, approximately 20 mL. An arte- that the rest of her children needed her and that she rial line and three large-bore IVs are placed. The needed to consent to the treatment plan. After the con- patient is sedated with versed and incremental doses sent was obtained, sedation was given. of ketamine. During the surgery, the obstetricians per- It must be said that this mother of nine children form a cesarean section; after opening the uterus, a has an abundance of progeny, and although the loss of large amount of brownish amniotic fluid is expelled, a child may be devastating, the clear course of action in and it becomes readily apparent that the cause of IUFD this case would be to prevent postpartum hemorrhage. was, in fact, placental abruption. The obstetricians dis- You must put aside any resentment and difficulties you128 continue efforts to remove the placenta after initial might have with providing care for a patient not will- attempts reveal brisk bleeding and then successfully ing to comply with the advice of doctors. The patient
  • 138. Case 25 – Jerry and Terry want one more babyis making the best decision for her, and not for you. ine artery, or the hypogastric artery, to prevent intra-The role that the physician should play in this situa- operative hemorrhage. The option of general anesthe-tion is to inform the patient of the risks, benefits, and sia was offered to the patient in view of her emotionalalternatives of surgery and anesthesia and advise a status and high risk of hemodynamic instability. Hercourse of action that is both safe and effective in treat- airway examination was optimal. However, the patienting this mother. Adapting to the patient is part of being refused general anesthesia, and the procedure was per-a good anesthesiologist. formed with epidural. Obviously, hemodynamic insta- bility in this case would warrant an arterial line and Gather essential and accurate information about several large-bore IVs for the administration of fluid, their patients. blood products, and vasopressors. The patient had many risk factors for postpartum Discussion with interventional radiology abouthemorrhage. This patient had advanced maternal age. the possible need for intervention subsequent to theThe patient had four previous cesarean sections. The surgery was warranted.patient had a previous history of uterine atony. Thepatient had an ultrasound consistent with placenta Counsel and educate patients and their families.previa and accreta. A discussion with your patient is needed to facil- Make informed decisions about diagnostic and itate understanding and trust between doctor and therapeutic interventions based on patient patient. In this difficult situation, you are trying to pro- information and preferences, up-to-date scientific vide anesthesia safely, while trying to appease not only evidence, and clinical judgment. the mother, but also the father. It is important not to neglect the father in this situation because the mother Placenta previa is a condition in which the placen- may have some degree of trust in you, but not nearlytal tissue covers the cervix. There are both partial and the amount of trust that she has in her husband. Medi-complete varieties, which refer to the degree of previa cal decisions are not made by patients; rather, they arecovering the cervical os. The incidence of previa is 1 in made by the patients and their families.200 pregnancies and increases with prior cesarean sec- Here, discussing the options of GA versus regionaltions, advanced maternal age, and multiparity. Ultra- was important. It is also important to discuss possiblesound remains the most useful diagnostic test used to conversion to GA, if need be.detect previa. Placenta accreta is an abnormal adherence of the Use information technology to support patientplacenta to the uterine wall. This degree of invasion care decisions and patient education.of the uterine wall can be graded as accreta when thechorionic villi are in contact with myometrium (80% of The preoperative discussion is when informationcases), placenta increta when the chorionic villi invade from the obstetrician and anesthesiologist can be pre-into myometrium (15% of cases), or the most serious, sented to the patient so that she can have an abundancepercreta, when the chorionic villi invade into serosa of understanding about the risks that she is under-(5% of cases). taking and can make an informed decision about her health care. In this case, the high incidence of bleeding Develop and carry out patient management plans. and the useful role of interventional radiology can be discussed. Since there was no live baby, hysterectomy withoutopening the uterus was an option in this situation. That Perform competently all medical and invasivewill decrease the bleeding. However, the ultrasound procedures considered essential for the area ofdiagnosis of placenta accreta is not specific. Moreover, practice.the patient was adamant that the uterus be preserved.She only consented to hysterectomy as a life-saving It is important to remember that this is not anmeasure. emergency. All proper steps should be undertaken to Our initial plan, which was defeated by the patient, reduce risk to the patient. Having an epidural with anincluded uterine artery embolization. This is a pro- adequate level is key to providing anesthesia and keep- 129cess in which a balloon can be inserted into the uter- ing the patient comfortable throughout the procedure.
  • 139. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 There is a need for large-bore IVs, and an ALine must occult bleeding. No vigorous attempts were made to be in place prior to incision. Ensuring an adequate sup- remove the placenta, the partially abrupted placenta ply of blood and blood products is also critical for this was left relatively intact without significant blood loss procedure. Having additional means of placing access, when the hysterectomy was initiated. However, the that is, an introducer, and devices to give large vol- patient became hypotensive. Remember that with a umes of fluid or blood products, such as a level 1 rapid closed uterus, an obstetrician may not readily identify transfuser, is also important. Adequate sedation is also bleeding from a previa. With all the IV access, this did needed here to keep the patient calm throughout the not become an issue, and the patient was given crystal- procedure – you must remember that this isn’t the loid solutions and blood products to keep her hemody- procedure the patient wanted or expected. Pharma- namically stable. cologic interventions would include oxytocin, methyl- ergonovine, and prostaglandin F2alpha. These drugs Know and apply the basic and clinically are used frequently in the obstetric population to treat supportive sciences that are appropriate to their uterine atony. discipline. Provide health care services aimed at preventing An appreciation of intraoperative obstetrical hem- health problems or maintaining health. orrhage is key to being prepared for this situation. The All the steps mentioned previously are designed to uterine artery at term delivers 700 mL/min of blood prevent hemorrhage in the operating room and after- to the uterus. With unchecked bleeding, it can become ward. very clear that this patient can exsanguinate in merely 4–5 minutes. Work with health care professionals, including those from other disciplines, to provide patient-focused care. Practice-based learning Having good communication with an obstetrician and improvement is critical to get a sense of when critical events will Residents must be able to investigate and evaluate their occur in the operating room and the overall state of patient care practices, appraise and assimilate scientific their concerns with regard to this patient. Being able evidence, and improve their patient care practices. to talk to a surgeon alleviates stress and ensures that things are not omitted. In this situation, the decision to Analyze practice experience and perform perform hysterectomy was made immediately when practice-based improvement activities using a the uterus was opened. Knowing this, we can plan our systematic methodology. anesthesia accordingly. Also, communication with the interventional radi- This is what can never be taught, but rather, must ology in case there is continuing oozing even after hys- be experienced in the operating room from previous terectomy is warranted. cases. The vigilance that must be provided for this patient is heightened not only by knowledge of the lit- Medical knowledge erature, but also by previous cases. Experience teaches us the finer nuances that cannot be learned from a Residents must demonstrate knowledge about estab- book. lished and evolving biomedical, clinical, and cognate For example, in this case, when the patient looks as (e.g., epidemiological and social-behavioral) sciences if she is spacing out, it probably means that she is losing and the application of this knowledge to patient care. blood rapidly and in shock. Bleeding in obstetrics is Demonstrate an investigatory and analytic difficult to assess. Alert the surgeon. thinking approach to clinical situations. Your previous experience tells you that at times, the blood products may not reach you in a timely fashion, The sudden cause of hypotension in this patient so make arrangements so that you have enough sup-130 should alert the anesthesiologist to the possibility of port staff to help you.
  • 140. Case 25 – Jerry and Terry want one more baby patients, society, and the profession; and a Locate, appraise, and assimilate evidence from commitment to excellence and ongoing scientific studies related to their patients’ health professional development. problems. In this case, it would have been so much better if This is mostly accumulated knowledge. In our case, the patient had agreed to the management options thatit is also good to know the newer options to treat bleed- were presented to her, instead of refusing medical careing such as recombinant activated factor VII. and wanting to die with her baby. However busy you Obtain and use information about their own might be in labor and delivery during the night, giving population of patients and the larger population her time to come to terms with the situation and let- from which their patients are drawn. ting various health care personnel reach out to her was being respectful of her beliefs. This is the knowledge acquired from departmentalstatistics and also the literature. For example, in this Demonstrate sensitivity and responsiveness tocase, how effective is uterine artery embolization? How patients’ culture, age, gender, and disabilities.effective is recombinant factor VII? Understand possi- In this case, her wish to have more children mightble adverse reactions to the blood products and their sound irrational. However, keep in mind that nobodypresentation. is rational all the time, and engaging in nonjudgmental Apply knowledge of study designs and statistical dialogue is important. methods to the appraisal of clinical studies and other information on diagnostic and therapeutic Interpersonal and communication effectiveness. skills Although randomized controlled studies are the Residents must be able to demonstrate interpersonalgold standard, in cases like this, we have to consider and communication skills that result in effective infor-observational studies and case reports. The knowledge mation exchange and teaming with patients, theirthat somebody had a good result with recombinant patients’ families, and professional associates.factor VII is useful, even though it is not a controlledstudy. Create and sustain a therapeutic and ethically sound relationship with patients. Use information technology to manage In our case, explaining all the patient’s options in information, access online medical information, a nonjudgmental way, while giving her time to absorb and support their own education. the barrage of information, really helped in communi- The ability to perform a literature search and use cating with her. Furthermore, using the help of laboryour hospital’s resources for full text articles and and delivery nurses, who might have different commu-review articles any time of the day is important. nication styles, to help the patient come to terms withMaybe the obstetric anesthesia department has com- the situation before presenting the technical informa-piled important articles and study materials, which are tion was also important.made available via the resident portal. Good communication with obstetrics about all the aspects of planning, including involvement of inter- ventional radiology, is also essential.ProfessionalismResidents must demonstrate a commitment to car- Use effective listening skills and elicit and providerying out professional responsibilities, adherence to information using effective nonverbal,ethical principles, and sensitivity to a diverse patient explanatory, questioning, and writing skills.population. Here, even though the patient expressed that she Demonstrate respect, compassion, and integrity; a wished to die, knowing that she really didn’t want to responsiveness to the needs of patients and society die and making her feel that we empathized with her 131 that supersedes self-interest; accountability to situation was very important. It is also important to
  • 141. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 include in the chart all the important elements of the Practice cost-effective health care and resource conversation, while waiting for the patient to make a allocation that does not compromise quality of decision. care. Work effectively with others as a member or leader of a health care team or other professional Here, the appropriate examples are as follows: r keep a level 1 rapid transfuser available but not set group. up This situation is a true example of a multidisci- r ropivacaine versus bupivacaine plinary approach. It would have been inappropriate to give sedation, even though the patient was demanding Advocate for quality patient care and assist it, before obtaining consent. Planning and coordina- patients in dealing with system complexities. tion of care involves a team approach. The appropriate examples in our case follow: Systems-based practice r help Mom and Dad find the resources to deal Residents must demonstrate an awareness of and with their grief such as bereavement support responsiveness to the larger context and system of groups health care and the ability to effectively call on system r help Mom and Dad understand how to navigate resources to provide care that is of optimal value. the physical facility r help Mom and Dad understand what to do with Understand how their patient care and other professional practices affect other health care the little child who accompanied them to the professionals, the health care organization, and hospital the larger society and how these elements of the system affect their own practice. Know how to partner with health care managers and health care providers to assess, coordinate, In our situation, the following would fall under this and improve health care and know how these category: activities can affect system performance. r ability of the blood bank to provide much needed products in a timely fashion This category includes the following: r availability of interventional services at odd hours r take an appropriate time-out r availability of experts, such as a trauma team or, r administer antibiotics even better, a gynecologist, in case the surgical r fill out a QA form if there are any issues that need bleeding becomes hard to control to be addressed so that care can be improved r availability of any help that may be needed down r fill in log books for data collection and the line, such as a need for intensive care unit care management132
  • 142. Case 25 – Jerry and Terry want one more babyAdditional reading 4. O’Brien D, Babiker E, O’Sullivan O, MCauliffe F, Geary M, Bryne B. Causes of massive obstetric1. Teo TH, Law YM, Tay KH, Tan BS, Cheah FK. Use of haemorrhage and outcomes of medical and surgical magnetic resonance imaging in evaluation of placental management strategies. Am J Obstetr Gynecol invasion. Clin Radiol 2009;64:511–516. 2008;199(Suppl 1):S93.2. Delotte J, Novellas S, Koh C, Bongain A, Chevallier P. 5. Esakoff T, Sparks T, Poder L, et al. How good are Obstetrical prognosis and pregnancy outcome ultrasound and MRI for the diagnosis of placenta following pelvic arterial embolisation for post-partum accreta? Am J Obstetr Gynecol 2008;199(Suppl hemorrhage. Eur J Obstetr Gynecol Reprod Biol 1):S189. 2009;145:129–132. 6. Laird R, Carabine U. Recombinant factor VIIa for3. Breathnach F, Geary M. Uterine atony: definition, major obstetric haemorrhage in a Jehovah’s Witness. prevention, nonsurgical management, and uterine Int J Obstetr Anesth 2008;17:193–194. tamponade. Sem Perinatol 2009;33:82–87. 133
  • 143. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 26 Overhextending yourself Helene Benveniste and Jonida Zeqo The case somebody says. “The only thing she has gotten since induction is a bag of . . . Hextend!” Oh, we better stop A 68-year-old woman goes to the operating room that, just to be sure. (OR) for elective resection of a meningioma. She has Now, back at the farm, the patient is stable; she is hypertension (HTN) (reasonably treated!), a history not yet fully awake but will soon be ready to be extu- of deep venous thrombosis (DVT), and is obese. After bated. The next day, the patient is fine. A later workup a smooth intravenous (IV) induction, relaxation, and clarified an allergic reaction to Hextend. intubation, an arterial line is placed, as are two large- bore IVs. The mean arterial blood pressure (MABP) is approximately 60 mmHg, and a bag of Hextend Patient care is started to counteract mild hypotension during the Residents must be able to provide patient care that is expected long (1-hour) neurosurgical prepping and compassionate, appropriate, and effective for the treat- draping, delaying surgical stimulation. A Foley is also ment of health problems and the promotion of health. placed. The attending leaves to start another case. Twenty minutes later, the attending returns to check on things and finds the resident bending over the arterial Communicate effectively and demonstrate caring line. “It’s not working,” he says. The attending notices and respectful behaviors when interacting with patients and their families. that there is sinus tachycardia and a no/low end-tidal carbon dioxide (ETCO2 ) on the respiratory trace mon- This patient did not have any relatives at the hos- itors and immediately starts resuscitating, while telling pital. The appropriate action is therefore to stay with the resident that there is no problem with the arterial the patient at all costs during the acute and suba- line – something else is going on, but what? At this cute phases and to explain to the slowly awakening point, the patient is oxygenating well, tachycardia is patient what is going on and why she has not yet had present, but there is not yet any profound hypotension. any surgery for her primary condition. It will also be No antibiotics have yet been given. appropriate to contact her relatives by phone and to The neurosurgical prepping is stopped; the pres- communicate the current state of the patient and the sure is maintained now with an epinephrine drip. Flu- plan for workup and rescheduling of surgery. ids and Hextend are continued for maintaining MABP, and anesthesia is discontinued as surgery is canceled; Gather essential and accurate information about a femoral venous catheter is quickly placed for cen- their patients. tral venous access. Given the history of DVT, it is suggested that the patient might have thrown a pul- Continue to astutely follow the vital signs from the monary embolism. We rush to radiology; the com- monitors; alert the surgeon about the situation and puted tomography (CT) scan is negative. The anes- maintain resuscitation procedures until the cause of thesiologist notices a rash on the chest of the patient the situation has been established. Call for help to and decides to give diphenydramine, ranitidine, and get a plan together. Examine the patient: check breath steroids in case of a possible anaphylactic reaction – sounds; get a neurological exam, if possible; and what to what? The MABP stabilizes within 10 minutes, and about temperature? It would also be appropriate to the epinephrine drip is off in no time. “But the patient assess urine output and to get an ABG (arterial blood134 did not get anything that could cause this reaction,” gas).
  • 144. Case 26 – Overhextending yourself Make informed decisions about diagnostic and seek information on the possibility of Hextend causing therapeutic interventions based on patient an anaphylactic reaction. information and preferences, up-to-date scientific Perform competently all medical and invasive evidence, and clinical judgment. procedures considered essential for the area of practice. The patient is suddenly hypotensive without appar-ent reason; go through the list of possibilities: air- An arterial line was placed immediately afterway, ventilation/oxygenation, circulation, cardiac his- induction, which was appropriate for a case involv-tory (electrocardiogram shows normal sinus, although ing resection of a large meningioma. Two large-borethere is tachycardia). Given the history of DVT, rule IVs were also placed. Resuscitation was continuedout a pulmonary embolism. through a femoral venous catheter – was that really necessary? Probably, given the need to infuse pres- Develop and carry out patient management plans. sor drugs. Can epinephrine safely be given through a peripheral venous catheter? Yes, you can, and people Make preparations to transport the patient from do give epinephrine through peripheral intravenousthe OR to the radiology suite, while maintaining lines, however in a code situation you would prefer topatient stability. Call for help transporting and for use a central line. And of course a concern arises thatmonitors, and alert radiology that there is an acute sit- if the peripheral line would infiltrate, you can get skinuation. Coordinate and communicate. necrosis at the site. Counsel and educate patients and their families. Provide health care services aimed at preventing health problems or maintaining health. It is essential to stay with the patient through thisepisode; she has no relatives nearby, and you are her Aseptic technique when placing all invasive lines isclosest “relative” at this time as well as her patient advo- paramount; the femoral line is probably in the worstcate. In parallel, her family should be informed contin- place, given infection, and should not stay in. Con-uously about her status. sider antibiotic coverage – given the anaphylactic reac- tion, can an antibiotic be given safely? During the acute Use information technology to support patient phase, the patient was intubated because she was anes- care decisions and patient education. thetized, but the plan after she was stabilized was to extubate as soon as possible. She was admitted to the As all most likely possibilities were ruled out surgical intensive care unit and placed under a stan-(pulmonary embolism, intracerebral hematoma), it is dard of care that included suctioning of the endotra-appropriate to go to scientific and clinical databases to cheal tube and turning, including DVT prophylaxis. 135
  • 145. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading anaphylaxis: summary report. J Allergy Clin Immunol 2005;115:584–591. 1. Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reactions occurring during anesthesia 3. Smith PL, Kagey-Sobotka A, Bleecker ER, et al. in France in 1999–2000. Anesthesiology Physiologic manifestations of human anaphylaxis. J 2003;99:536–545. Clin Invest 1980;66:1072–1080. 2. Sampson HA, Munoz-Furlong A, Bock SA, et al. Symposium on the definition and management of136
  • 146. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 27 Broken catheter after Whipple Xiaojun Guo and Khoa NguyenThe case deficit, considering that there is now a small plastic for- eign body floating around the patient’s epidural space.Bruce was about to undergo a major operation with Having that exam gives a baseline level of function toremoval of several internal organs – the “Whipple.” He compare to, should there be a change later on. Measurereceived the standard spiel about the anesthesia and the broken catheter to determine how much of the tipreceived the pain-destroying epidural catheter prior to may have broken off. Also, examine the insertion siteentering the operating room (OR). The case went as to make sure that no further trauma has been missedsmoothly as it could have, considering it was a Whip- on movement.ple. As he was being moved over to the stretcher fortransport to the recovery room, he hit a snag, or at Make informed decisions about diagnostic andleast, his catheter did. The tip of the catheter became therapeutic interventions based on patientcaught up on a rail on the bed and the tension was too information and preferences, up-to-date scientificmuch for the small catheter. It gave way after stretching evidence, and clinical judgment.to its fullest. No problem, thought the anesthesiologist,who assumed that the catheter was just pulled out of its Based on the textbooks that you have read regard-snug position in the thoracic spine. On closer inspec- ing epidural catheters, you decide to leave the brokention, the catheter was missing something peculiar – catheter piece in place, assuming the patient remainsthe tip! asymptomatic. The literature on broken catheters recommends watchful vigilance with asymptomatic patients, imaging to determine exact location of thePatient care fragmented catheter, and a possible neurosurgical con-Residents must be able to provide patient care that sult should you need their expertise to remove it.is compassionate, appropriate, and effective for thetreatment of health problems and the promotion of Develop and carry out patient management plans.health. As the patient becomes more awake, you make him Communicate effectively and demonstrate caring aware of the event that has transpired regarding the and respectful behaviors when interacting with catheter. You explain to him the risks of having a for- patients and their families. eign body in the epidural space (i.e., infection, migra- tion leading to nerve irritation or compression) and The patient is just waking up after general anesthe- the red flags to watch out for symptomatically. Yousia and no family is present now, so the most caring then send him for the appropriate imaging studies toand respectful interaction we can have is making sure get an exact idea of the catheter’s current location,that the patient arrives to the recovery room in stable while sending out a consult to your neurosurgicalcondition and that no other lines or catheters become friends so they can get to know the patient should theydislodged or removed. take him to the OR in the future. Gather essential and accurate information about Counsel and educate patients and their families. their patients. The patient and his family should be counseled As the patient is waking up, make sure a quick neu- about the fact that most of the cases like this have no 137rological exam is done to determine if there is any further sequelae related to the broken catheter. Answer
  • 147. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 all questions regarding the situation as honestly as pos- (e.g., epidemiological and social-behavioral) sciences sible. Make sure the patient understands that he should and the application of this knowledge to patient care. be aware of red flags such as pain, weakness, or fever in the affected areas. He must be advised to call his sur- Demonstrate an investigatory and analytic geon or the anesthesiologists if complications do arise thinking approach to clinical situations. and be ready to return to the emergency room if things worsen quickly. During his recovery at home, his fam- Removing an epidural catheter is usually unevent- ily should also be made aware to watch for the same ful, but not in this case. Your first investigative thought symptoms and act accordingly. is where exactly the tip is located. To answer that ques- tion, you send the patient for a computed tomography Use information technology to support patient or magnetic resonance scan. Your analytical thought care decisions and patient education. leads you to possible outcomes of the broken catheter, including neurological deficits or dysfunction and pos- We have done that by looking up the latest recom- sible infection. You start antibiotics and do routine mendations regarding the handling of such situations. neurological exams. We reviewed the case reports and are acting on the cur- rent knowledge base to support our decisions about the patient’s care. Practice-based learning Perform competently all medical and invasive and improvement procedures considered essential for the area of Residents must be able to investigate and evaluate their practice. patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. All imaging and physical exams should be per- formed competently so that we have a baseline should Analyze practice experience and perform anything change with the catheter position or the practice-based improvement activities using a patient’s status. systematic methodology. Provide health care services aimed at preventing Using the case reports and review articles you health problems or maintaining health. found, you act according to what the experts recom- mend. After following this patient, writing up your Giving the patient a course of antibiotics may not own case reports to add to the information that already be a bad idea considering that he does have a foreign exists for situations like this may allow for improve- body in a usually sterile place that may be a nidus for ments in catheter manufacturing or appropriate man- infection. Also, give the patient the appropriate con- agement when catheters are sheared in patients. Also, tact information for the anesthesia department and reeducate all operating personnel about proper patient arrange a follow-up appointment in the near future to movement and the dangers that lie within. assess for any changes in the catheter position and any possible related symptoms. Locate, appraise, and assimilate evidence from Work with health care professionals, including scientific studies related to their patients’ health those from other disciplines, to provide problems. patient-focused care. It is known that this situation does not happen very We have already contacted our colleagues in the often, and thus there are not many studies regarding neurosurgery department, but it is hoped that we will its management. What does exist is advice from text- not need their services. books, the experience of others in case reports, and a few reviews of the current literature. Currently most literature recommends leaving the catheter in place, Medical knowledge assuming that the patient is asymptomatic, and imme-138 Residents must demonstrate knowledge about estab- diate removal should the catheter lead to problems. lished and evolving biomedical, clinical, and cognate Sounds simple enough.
  • 148. Case 27 – Broken catheter after Whipple Develop a rapport with the patient and his fam- Use information technology to manage ily. Arrange a follow-up appointment for the patient information, access online medical information, with a neurologist or neurosurgeon and make sure and support their own education. that you are at that follow-up appointment to demon- We know you feel badly enough about the situa- strate to the patient that you are committed to his care,tion, but reliving it through literature searches about which should contribute to a sound relationship withthe subject is necessary to learn from the mistake and him.see how others managed the situation. Use effective listening skills and elicit and provide information using effective nonverbal,Professionalism explanatory, questioning, and writing skills.Residents must demonstrate a commitment to car-rying out professional responsibilities, adherence to During the preop visit, a focused history and phys-ethical principles, and sensitivity to a diverse patient ical was obtained. You listened to the patient’s ques-population. tions and concerns and addressed them all appropri- ately using language he could understand. You then Demonstrate respect, compassion, and integrity; a documented the history and physical and conversa- responsiveness to the needs of patients and society tion in the chart and have now become a consultant that supersedes self-interest; accountability to in interpersonal and communication skills. patients, society, and the profession; and a commitment to excellence and ongoing Work effectively with others as a member or professional development. leader of a health care team or other professional You apologize to the patient and his family, explain group.exactly what occurred, and offer any resource that Since you were the one ultimately responsible forthe hospital has should they need it to demonstrate the epidural catheter, you arrange the appropriaterespect, compassion, and integrity. imaging modalities needed as well as any consults and Demonstrate a commitment to ethical principles follow-up appointments. Make sure that all involved pertaining to provision or withholding of clinical are on the same page regarding the management of the care, confidentiality of patient information, situation. informed consent, and business practice. Observe all HIPAA regulations and keep the Systems-based practicepatient’s information confidential when you present Residents must demonstrate an awareness of andthis case at the next quality assurance meeting. responsiveness to the larger context and system of health care and the ability to effectively call on system Demonstrate sensitivity and responsiveness to pa- resources to provide care that is of optimal value. tients’ culture, age, gender, and disabilities. Understand how their patient care and other Follow the golden rule. Enough said. professional practices affect other health care professionals, the health care organization, andInterpersonal and communication the larger society and how these elements of theskills system affect their own practice.Residents must be able to demonstrate interpersonal The patient had an unfortunate event occur withand communication skills that result in effective infor- the breakage of the catheter. It is now your respon-mation exchange and teaming with patients, their sibility to make sure that the patient has appropri-patients’ families, and professional associates. ate follow-up for the possible complications that may Create and sustain a therapeutic and ethically occur. That means further studies and visits to other sound relationship with patients. health professionals to ensure the best outcome of this 139 situation.
  • 149. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Make sure to remind the patient that you are avail- Practice cost-effective health care and resource able to assist the patient with further follow-up should allocation that does not compromise quality of he run into difficulty with scheduling office visits or care. other appointments. Cost-effective health care at this point probably Know how to partner with health care managers involves not ordering every imaging modality known and health care providers to assess, coordinate, to medicine to find the catheter, but rather, ordering and improve health care and know how these one that will provide adequate visualization so that you activities can affect system performance. only need one test, and also one with the least radiation to the patient to maintain quality of care. Writing up this case as a report can aid in the improvement of handling these types of situations. Advocate for quality patient care and assist With enough reports and expert opinions, a consen- patients in dealing with system complexities. sus may be reached about how to systematically deal with such situations.140
  • 150. Case 27 – Broken catheter after WhippleAdditional reading 2. Fragneto RY. The broken epidural catheter: an anesthesiologist’s dilemma. J Clin Anesth1. Mitra R, Fleischmann K. Management of the sheared 2007;19:243–244. epidural catheter: is surgical extraction really necessary? J Clin Anesth 2007;19:310–314. 141
  • 151. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 28 Pierre who? Ron Jasiewicz and Khoa Nguyen The case Gather essential and accurate information about We were having an enjoyable morning in the their patients. endoscopy suite, and then we were told that we would have an add-on endoscopy from the neonatal intensive Getting a detailed history of the pregnancy and care unit (NICU) by our pediatric gastroenterology birth as well as the patient’s short medical history is colleague. The patient was a 1-month-old with fre- vital in anesthetizing such a unique patient. In addition quent emesis after feeding. And yes, he was premature, to speaking with the parents, it is necessary to speak but without “apneas and bradycardias” while in the to our NICU colleagues about the patient’s medical NICU. He had been diagnosed with Pierre Robin course so far. Important issues to consider are cardiac malformation. Our friend was 2.5 kg and quite active. and respiratory status as many of these patients often Although he could not roll yet, we were convinced have cardiac abnormalities. Nutritional status is also a that he wanted to run out of the room! He must have concern as children with Pierre Robin syndrome have suspected what was going to happen to him and didn’t cleft palates, which can cause respiratory and feed- want any part of it. ing difficulties. Malnourishment may lead to anemia, He was brought into our world as an elective causing decreased oxygen delivery for the infant, so cesarean section because his mother’s preeclampsia the patient’s hematocrit may be useful to obtain. Be was worsening. Born with Apgar scores of 7 and 8, aware of current medications the infant may be taking he appeared to have a murmur on oscillation. He pre- which may interact with the anesthetic medications. sented to our suite with no other medical history. At Naught per oris (NPO) status must be determined as the time of delivery, he was 35 weeks postconception. this patient is about to undergo a procedure in which Currently he was a “feed and grow” in the NICU near- aspiration is a concern. ing discharge, but had trouble keeping it down. Make informed decisions about diagnostic and Patient care therapeutic interventions based on patient information and preferences, up-to-date scientific Residents must be able to provide patient care that is evidence, and clinical judgment. compassionate, appropriate, and effective for the treat- ment of health problems and the promotion of health. This patient is considered to have a difficult air- Communicate effectively and demonstrate caring way, so a plan must be made regarding securing and respectful behaviors when interacting with the airway for the procedure. Numerous case reports patients and their families. have led to several review articles with recommen- dations for securing the airway in Pierre Robin syn- Considering that our patient is a neonate, most of drome patients. Infants may be intubated awake and our interaction will be with the parents. Speak with the unanesthetized as they usually tolerate the stress well. parents about the procedure in a compassionate way, Maintaining spontaneous respiration is recommended as this must be a difficult time for them. Respect them as there is a high risk of airway collapse with induc- by making sure that you use language they under- tion or muscle relaxation. Intubation may be car- stand. For truly effective communication, give them ried out via fiber-optic scope or with direct visualiza-142 a chance to ask questions, while you listen attentively, tion with laryngoscopy. Inhalational inductions may and answer them as best you can. be done with an emphasis on keeping the patient
  • 152. Case 28 – Pierre who?spontaneously breathing due to a risk of loss of theairway. Provide health care services aimed at preventing health problems or maintaining health. Develop and carry out patient management plans. This is the whole reason for the case. We were After appropriate monitors are placed, the patient attempting to provide a service to the patient (theis allowed to spontaneously breathe, while an intra- endoscopy) with the aim of preventing any furthervenous (IV) is placed. Once the IV is functional, an deterioration and maintaining his health!awake intubation is attempted but is unsuccessful dueto the patient’s vigorous activity. Inhalational agents Work with health care professionals, includingare then used to help with sedation for another attempt those from other disciplines, to provideat intubation, but due to the severity of the patient’s patient-focused care.airway issues, the intubation attempt is aborted as the With the help of our NICU and gastrointestinalpatient begins to obstruct. The patient is then emerged. (GI) colleagues, in this case, we were able to provideOral midazolam is agreed on by the team to help with a high level of patient-focused care.sedation with causing airway obstruction. The mida-zolam works well, and the airway is obtained, thoughit did require some serious external airway mani- Medical knowledgepulation. Residents must demonstrate knowledge about estab- lished and evolving biomedical, clinical, and cognate Counsel and educate patients and their families. (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Again, this is mainly directed to the patient’s fam-ily. Every effort should be made to explain to the par- Demonstrate an investigatory and analyticents the severity of the situation. The patient needs an thinking approach to clinical situations.urgent procedure to help with a diagnosis, but thereare always risks involved. Airway collapse is the major Hearing the words Pierre Robin should automat-concern. Counseling the parents must include the pos- ically generate the three common entities associatedsibility that the endotracheal tube may remain in place with the syndrome. The three include micrognathia,after the procedure, until it is determined to be abso- glossoptosis, and cleft palate. Also, we must also belutely safe to remove it. ready for other congenital anomalies the patient may have other than the three just mentioned, especially Use information technology to support patient the cardiac anomalies. Difficult airway is synonymous care decisions and patient education. with Pierre Robin patients, and thus we develop an analytical approach to obtaining the airway, with a The parents may not fully understand the scope backup plan and a backup plan for the backup plan,of Pierre Robin syndrome and can be directed to the which was put into action in this case.many Web sites and support groups for parents of chil-dren with similar issues. Practice-based learning Perform competently all medical and invasive and improvement procedures considered essential for the area of Residents must be able to investigate and evaluate their practice. patient care practices, appraise and assimilate scientific IV placement should be done quickly and com- evidence, and improve their patient care practices.petently to minimize stress to the patient as well as Analyze practice experience and performto confirm that a patent IV is available should the practice-based improvement activities using apatient require rescue medications. The most impor- systematic methodology.tant procedure in this case was obtaining the airway,which was successful, but only after several attempts At the conclusion of the procedure, it would makedue to the abnormal anatomy related to the patient’s sense to sit down with our NICU and GI colleagues 143disease. to analyze what we did correctly and what we could
  • 153. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 improve. Attention to what worked well in this patient care, confidentiality of patient information, may serve us well in the future with patients like him informed consent, and business practice. or others with difficult airways. When referencing this case in the future, during Locate, appraise, and assimilate evidence from presentations or case reports, be sure to respect HIPAA scientific studies related to their patients’ health policies and do not divulge any confidential patient problems. information. This is exactly what was done prior to taking this Demonstrate sensitivity and responsiveness to case on. We made sure that we had an idea of what to patients’ culture, age, gender, and disabilities. expect when we looked into the patient’s airway. We You did your best to demonstrate your sensitivity to also tried to read and learn about what worked for our the patient’s disabilities by speaking in depth with the colleagues around the world when dealing with Pierre parents and showing compassion when discussing the Robin syndrome patients. Thus we had all our airway specifics about the case. Answering all their questions equipment ready as well as medications to help allow appropriately shows your responsiveness. us to obtain the airway. Obtain and use information about their own Interpersonal and communication population of patients and the larger population skills from which their patients are drawn. Residents must be able to demonstrate interpersonal and communication skills that result in effective infor- We will be sure to record the experience with this mation exchange and teaming with patients, their case for future reference, and in time, we should have patients’ families, and professional associates. a sizable database from which to learn. Create and sustain a therapeutic and ethically sound relationship with patients. Professionalism Residents must demonstrate a commitment to car- This seems so obvious and redundant, but the rap- rying out professional responsibilities, adherence to port that you develop with the parents will help create ethical principles, and sensitivity to a diverse patient a level of trust that contributes to a sound relationship population. with the patient and his family. Demonstrate respect, compassion, and integrity; a Use effective listening skills and elicit and provide responsiveness to the needs of patients and society information using effective nonverbal, that supersedes self-interest; accountability to explanatory, questioning, and writing skills. patients, society, and the profession; and a Summoning all that you learned in grade school, commitment to excellence and ongoing you use your ears and eyes as much as your hands and professional development. mouth to practice effective listening and explanatory It is very easy to act responsively to the needs skills. of such a young and unique patient in a way that Work effectively with others as a member or supersedes our own self-interest. Your commitment leader of a health care team or other professional to excellence is shown by the extensive preparation group. done to make sure this case goes off without any com- plications. Your commitment to ongoing professional Before and after the procedure, you work as a mem- development is evidenced by your writing a case report ber of the health care team to ensure that the patient of this case to add to your repertoire of anesthesia and his family are on the same page as the health care experience. team. During the procedure, you become the team leader and manage the patient and team to ensure that144 Demonstrate a commitment to ethical principles the procedure is completed safely so that the appropri- pertaining to provision or withholding of clinical ate treatment can be determined.
  • 154. Case 28 – Pierre who?Systems-based practice Practice cost-effective health care and resourceResidents must demonstrate an awareness of and allocation that does not compromise quality ofresponsiveness to the larger context and system of care.health care and the ability to effectively call on systemresources to provide care that is of optimal value. You do your best to be cost-effective by not open- ing instruments or drugs that you may not need so Understand how their patient care and other that their integrity is intact for the next patient, but professional practices affect other health care by no means do you compromise the quality of care professionals, the health care organization, and for any patient, especially this one, with such unique the larger society and how these elements of the needs. system affect their own practice. This patient has a constellation of issues that may Advocate for quality patient care and assistrequire further medical intervention in the future. patients in dealing with system complexities.Making sure that this patient gets appropriate diagno-sis and treatment early on for his medical issues may Provide the parents with documentation of thehelp reduce his chances of having more serious med- management of the patient’s airway for future refer-ical issues in the future. That alone affects everyone ence, if necessary. Make sure that the parents under-involved in his care, from his parents to his physicians stand that you are always available for consultationand, finally, the big health care organizations. from an anesthesia perspective for their child. 145
  • 155. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Additional reading 3. Meyer AC, Lidsky ME, Sampson DE, Lander TA, Liu M, Sidman JD. Airway interventions in children with 1. Shprintzen RJ, Singer L. Upper airway obstruction and Pierre Robin sequence. Otolaryngol Head Neck Surg the Robin sequence. Int Anesthesiol Clin 1992;30: 2008;138:782–787. 109–114. 2. Olasoji HO, Ambe PJ, Adesina OA. Pierre Robin syndrome: an update. Niger Postgrad Med J 2007;14:140–145.146
  • 156. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 29 Submandibular abscess Syed Azim and Jane YiThe case important; and sometimes they lie. I once had a patient deny having had any medical conditions, but when IA 44-year-old male presented for an incision and asked her if she had high blood pressure, she said yes.drainage of a left submandibular abscess. The patient As I continued with the interview and asked abouthad presented to the emergency department with a her past surgical history, she revealed that she hadchief complaint of pain and swelling for 15 days, lim- coronary artery disease, with a history of myocardialited mouth opening, and difficulty swallowing. Com- infarction (MI), and was status post (s/p) coronaryputed tomography (CT) scan of the head and neck artery bypass graft (CABG) × 4!revealed moderate displacement of the trachea to the This is why we should ask pointed questions. Forright. Physical exam by oral maxillo-facial surgery example, one could ask, “Do you have any allergies to(OMFS) revealed trismus and a carious mandibular any medications, latex, or foods?” rather than asking,left third molar, with periapical pathology. “Do you have any allergies?” Speaking of allergies, it is also important to confirm whether a documentedPatient care allergy is an actual allergy. Once I read in a patient’sResidents must be able to provide patient care that is chart that she had an “allergy to general anesthesia.”compassionate, appropriate, and effective for the treat- What does that even mean? Did she have a history ofment of health problems and the promotion of health. malignant hyperthermia? It turned out that she had a history of postoperative nausea and vomiting. Communicate effectively and demonstrate caring and respectful behaviors when interacting with Develop and carry out patient management plans. patients and their families. Abscesses that invade the fascial spaces can become Always introduce yourself to the patient and family airway nightmares, especially if it is bilateral-Ludwig’smembers. Keep in mind that most people are afraid of angina. Furthermore, if imaging studies show tra-the unknown. You may have been involved in dozens cheal deviation, the abscess should be properly drainedof surgical procedures, but this might be the patient’s urgently. So, needless to say, the most important partfirst surgery. of this anesthetic plan lay in successfully securing the airway. Gather essential and accurate information about The anesthesia plan was general anesthesia (GA) their patients. with awake, fiber-optic, nasal intubation. Equipment included a fiber-optic scope; nasal endotracheal tubes, Before administering anesthesia, you want to know preferably soaked in warm water to soften; and nasalthe patient’s past medical history (PMH), past sur- airways, with lubrication. Drugs used included gly-gical history (PSH), current medications, allergies, copyrrolate (antisialogogue), dexmedetomidine (seda-naught per oris (NPO) status, and Mallampati air- tive), 4% lidocaine nebulizer and 5% lidocaine jellyway assessment. It is also important to get a his- (topical anesthetic), and oxymetazoline spray (topicaltory of present illness, family history (especially of decongestant).anesthesia), and social history. Many patients are notcompletely forthcoming with information. Sometimes Counsel and educate patients and their families.they don’t remember; sometimes they don’t think it’s 147
  • 157. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 Explain the following: tell the patient to think of it as a lollipop or popsicle, 1. nasal versus oral intubation: nasal intubation is advancing it further, as tolerated. preferred because the approach for the I&D was going to be both extraoral and intraoral Provide health care services aimed at preventing 2. awake versus asleep intubation: awake is preferred health problems or maintaining health. because of the risk of losing the airway Make sure antibiotics ordered by surgery are ad- The idea of being awake for the intubation might be ministered appropriately. Ideally, antibiotics should be frightening to some patients. I explained it as such: delivered within 1 hour of surgical incision. Know “Because of the changes in your airway brought on your patient’s allergies and know the antibiotics. Some by the abscess, we need to use a camera to place the antibiotics, such as vancomycin, should be adminis- breathing tube for you. You will be awake because it tered over a longer period of time, whereas others, is safer if you are breathing on your own, but you will such as aminoglycosides, will potentiate the effects of be sedated and your throat will be numb.” Remember, neuromuscular blocking drugs. Usually, the pre- the patient is probably already feeling quite anxious – ferred antibiotic for dental infections is penicillin, imagine being unable to open your mouth and unable but because of the patient’s allergy to penicillin, clin- to swallow, and having difficulty breathing. damycin was ordered. Once you start the antibiotics, watch for signs of an allergic reaction. Use information technology to support patient care decisions and patient education. Work with health care professionals, including those from other disciplines, to provide Use the CT of the head and neck as an illustration patient-focused care. for the patient. For the most part, patients like to be informed and appreciate having an active role in their It is really important to communicate with the sur- health care. Showing this patient the deviation of his gical team. OMFS explained that they will take an trachea emphasized the importance of an awake, fiber- extraoral and intraoral approach as well as extracting optic intubation. the carious tooth. Therefore nasal intubation was pre- ferred so that the tube would not be in the way of the Perform competently all medical and invasive surgical site. It is also a good idea to know that the procedures considered essential for the area of surgeon is planning on using local anesthesia. In this practice. case, the surgeon used 2% lidocaine with 1:100,000 epinephrine. We should know that the maximum dose Make sure you have adequate peripheral access, is 7 mg/kg and make sure surgeons and nurses are especially when the patient arrives with an IV already aware. in place. If the IV is running poorly but is not infil- trated, do yourself and the patient a favor and use it to induce but start a new one, once the patient is asleep. Medical knowledge Also, try to avoid the ante-cubital fossa (ACF) so you Residents must demonstrate knowledge about estab- don’t have to concern yourself with making sure the lished and evolving biomedical, clinical, and cognate patient’s elbow isn’t bent. Most likely, the patient will (e.g., epidemiological and social-behavioral) sciences be continued on IV antibiotics postoperatively, so he and the application of this knowledge to patient care. will appreciate having an IV elsewhere. Once the IV is placed, you can start the steps Demonstrate an investigatory and analytic toward a successful awake, fiber-optic, nasal intuba- thinking approach to clinical situations. tion. A little bit of glycopyrrolate goes a long way. It’s amazing how much easier it is to make out anatomy Infection of the submandibular space causes when you don’t have salivary juices getting in your swelling that begins at the inferior border of the way. Start the dexmedetomidine 0.5–1 ␮g/kg since this mandible and extends medially to the digastric muscle loading dose should be infused over a period of 10– and posteriorly to the hyoid bone. Some clinical signs148 15 minutes. During this time, have the patient start can include the following: trismus, drooling, dyspha- puffing on the nebulizer containing 4% lidocaine. Then gia, and dyspnea. Progression of this swelling can lead squeeze some 5% lidocaine on a tongue depressor and to upper airway obstruction. The most common cause
  • 158. Case 29 – Submandibular abscessof this abscess is a dental infection, usually involving Once it is determined that an awake, nasal, fiber-the mandibular third molars. optic intubation is the plan of choice, one has to decide Knowing this, we should expect that we won’t be the appropriate steps to follow through with this plan.able to properly assess the airway due to trismus and The literature supports the use of different drugs toswelling. We also know that it would be even more ben- provide adequate sedation and analgesia for the patienteficial to administer an antisialogogue, to counteract during what can be a frightening experience (and I’mthe drooling due to dysphagia. Let’s not forget the obvi- not just talking about the patient here). The mostous; this can become a true airway emergency. important thing we need for successful awake fiber- optic intubation is spontaneous respiration. In addi- tion to that, it would be nice to have analgesia, amne-Practice-based learning sia, and sedation.and improvement Reusche and Egan [2] reported the use of remifen-Residents must be able to investigate and evaluate their tanil as a sedative-analgesic for an awake intubation inpatient care practices, appraise and assimilate scientific a patient with Ludwig’s angina. The patient was pre-evidence, and improve their patient care practices. medicated with glycopyrrolate 0.2 mg IV, droperidol 0.625 mg IV, and midazolam 2 mg IV over 10 min- Analyze practice experience and perform utes. The airway was topicalized with 4 mL of 4% lido- practice-based improvement activities using a caine through the use of a nebulizer, and the right systematic methodology. naris was swabbed with 4% cocaine. Then a remifen- tanil infusion at 0.05 ␮g/kg/min was started before As you proceed in a case like this, you realize how nasal fiber-optic intubation. Spontaneous ventilationoverwhelming things can get, especially when it comes was maintained and the vocal cords were sprayed withto the airway. It is therefore important to develop a 2 mL of 4% lidocaine via the suction port located onsystematic approach to the steps taken, from the the fiber-optic scope. Moreover, this article reportsmoment the patient enters the OR to the point at which the advantages of using remifentanil as the following:he settles down in the recovery room. Institution- short context-sensitive half-time, analgesia, synergis-specific protocols call for certain types and dosages tic with sedatives, and the ability to suppress laryngealof antibiotics to be administered, requiring use of reflexes. The disadvantage of using remifentanil is thatmultiple lines. Have the difficult airway cart ready it is an opioid and has all the side effects that come withand checked. With proper preparation and practice, that classification of drug. Remifentanil can cause res-experience, and practice-based improvement activi- piratory depression, bradycardia, hypotension, nau-ties, there should be little variation in the way this sea, vomiting, muscle rigidity, and pruritis [2].surgery is handled, even among different clinicians. Abdelmalak et al. [3] described the use of dex- medetomidine as a sedative for awake intubation in Locate, appraise, and assimilate evidence from the management of a critical airway. Dexmedetomi- scientific studies related to their patients’ health dine is an ␣2-agonist that has the desirable proper- problems. ties of analgesia and amnesia and that acts as an anti- When a patient presents with an abscess that sialogogue. Abdelmalak et al. further describe a caseinvades fascial spaces, always keep in mind the pos- of a patient with a submandibular abscess presentingsibility of an airway complication. Larawin et al. [1] with progressive respiratory difficulty. A loading dosereported upper airway obstruction that required tra- of dexmedetomidine 1 ␮g/kg was initiated for 10 min-cheotomies in 8.3% of patients. Other complications utes, followed by a maintenance dose of 0.6 ␮g/kg/included septic shock, asphyxiation and descending hour. Additionally, 4% lidocaine via nebulizer and 2%mediastinitis, and respiratory failure. Moreover, death lidocaine gel were used to topicalize the oropharynx.was reported in 8.7% of patients. Four percent lidocaine was also administered dur- ing bronchoscopy in what the author described as a Apply knowledge of study designs and statistical “spray-as-you-go-technique.” Once general anesthesia methods to the appraisal of clinical studies and was induced, the dexmedetomidine infusion was dis- other information on diagnostic and therapeutic continued. The advantage of using dexmedetomidine 149 effectiveness. is that you have the desired effect of sedation with min- imal risk of respiratory depression. The disadvantages
  • 159. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 of dexmedetomidine include possible bradycardia and Interpersonal and communication hypotension [3]. Is there an alternative to an awake fiber-optic intu- skills bation? Shteif et al. [4] describe the use of the super- Residents must be able to demonstrate interpersonal ficial cervical plexus block to drain a submandibu- and communication skills that result in effective infor- lar and submental abscess as an alternative to general mation exchange and teaming with patients, their anesthesia. The patient is placed in the supine posi- patients’ families, and professional associates. tion and draped in a sterile fashion. The landmarks identified are the following: the mastoid process and Create and sustain a therapeutic and ethically Chassaignac’s tubercle of C6 transverse process. Using sound relationship with patients. a 25-gauge needle, local anesthetic is delivered with Hand washing is an important habit to develop, the fan technique. The goal is to block all four major especially when seeing patients with infectious pro- branches of the superficial cervical plexus. Supplemen- cesses going on in the system, like this particular tal anesthesia may be required in the form of the long patient had. buccal for a submandibular abscess and an inferior alveolar block for a submental abscess. Shteif et al. Use effective listening skills and elicit and provide describe advantages of using a block as opposed to information using effective nonverbal, general anesthesia as the following: lowered patient explanatory, questioning, and writing skills. cost, decreased recovery time, and decreased surgi- The patient will likely have many questions, some cal time. However, the disadvantages would include of which you may not be able to answer in detail. complications such as hematoma, local anesthetic tox- You may even be asked a question more appropriately icity, nerve injury, phrenic nerve block, and possible answered by the surgeons, in which case, you should spinal anesthesia. Furthermore, a contraindication for respectfully defer to your colleagues. the use of a superficial cervical plexus block would be patients with significant respiratory disease and highly Work effectively with others as a member or stressed or anxious patients [4]. leader of a health care team or other professional group. Professionalism The significance of working effectively with other Residents must demonstrate a commitment to car- members of the OR staff should be reiterated. In addi- rying out professional responsibilities, adherence to tion, as you transition to the recovery room, your ethical principles, and sensitivity to a diverse patient input may be requested not only by the recovery room population. staff, but also by ENT and OFMS and intensive care unit personnel. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, Systems-based practice informed consent, and business practice. Residents must demonstrate an awareness of and responsiveness to the larger context and system of Review informed consent, double-check on health care and the ability to effectively call on system surgery site, and be cognizant that there are others resources to provide care that is of optimal value. around you as you discuss details of your patient’s medical record in the holding area. Also, make sure Understand how their patient care and other the surgeon has seen the patient prior to taking him professional practices affect other health care to the OR. professionals, the health care organization, and the larger society and how these elements of the Demonstrate sensitivity and responsiveness to pa- system affect their own practice. tients’ culture, age, gender, and disabilities. Many levels of coordination are involved in airway What may transcend all cultures, ages, gender, and cases. It is important to understand the urgency of the150 disabilities is the notion of treating your patients as you case and scarce resources that should be handled with would wish to be treated. utmost diligence. You have a challenge to contribute
  • 160. Case 29 – Submandibular abscessto the likelihood of success by being vigilant in the OR Understand the immediate postoperative concernsand by effectively handling the situation in a controlled for this patient and be prepared to react appropri-fashion. ately in certain situations. For example, what do you do if the patient develops stridors or becomes short Practice cost-effective health care and resource of breath? What if he develops high-grade fever and allocation that does not compromise quality of is not responding to antipyretics? Knowing what to do care. beforehand allows for a smoother postoperative course For this case, we discontinued the dexmedetomi- and a potentially better surgical outcome.dine after induction of anesthesia. However, you might Know how to partner with health care managerswant to consider continuing the infusion. This would and health care providers to assess, coordinate,decrease the amount of anesthetic needed and also and improve health care and know how thesedecrease the amount of waste. Just know the surgery activities can affect system performance.and know when to discontinue the dexmedetomidine.There are some reports of delayed awakening when it The immediate postoperative period is importantis not discontinued at the appropriate time [1]. in terms of laying out the goals, standards, and pro- tocols for the care of the patient. Usually, medication Advocate for quality patient care and assist orders will be clearly preprinted. Communication with patients in dealing with system complexities. the ENT and OFMS teams is imperative. 151
  • 161. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 References 3. Abdelmalak B, Makary L, Hoban J, Doyle DJ. Dexmedetomidine as sole sedative for awake 1. Larawin V, Naipao J, Dubey SP. Head and neck space intubation in management of the critical airway. J Clin infections. Otolaryngol Head Neck Surg Anesth 2007;19:370–373. 2006;135:889–893. 4. Shteif M, Lesmes D, Hartman G, Ruffino S, Laster Z. 2. Reusche MD, Egan TD. Remifentanil for conscious The use of the superficial cervical plexus block in the sedation and analgesia during awake fiberoptic drainage of submandibular and submental abscesses – tracheal intubation: a case report with an alternative for general anesthesia. J Oral Maxillofac pharmacokinetic simulations. J Clin Anesth Surg 2008;66:2642–2645. 1999;11:64–68.152
  • 162. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 30 ERCP with sedation A Big MAC (monitored anesthesia care), supersized! Tazeen Beg and Michelle DiGuglielmoThe case (“for the pain”) with a 150-mg chaser of propofol. The patient becomes apneic, so you tell the gastrointesti-A brand-new anesthesia attending, you have just fin- nal (GI) doctor to place his endoscope, thinking theished a case and the anesthesia coordinator asks you stimulation will make her breathe again. His scope isto go get some lunch and then go to the endoscopy in but the oxygen saturation monitor is reading 80%;unit for an ERCP (endoscopic retrograde cholangio- you attempt jaw thrust, and he yells, “I cannot havepancreatography). ERCP? You remember learning you in my field or the patient moving!” As you pointabout it in medical school but never got a chance to to the monitors, a look of fear comes over his face andobserve one being done. While wolfing down a greasy he quiets down, whispering, “Do whatever you needcheeseburger deluxe from the cafeteria, you Google it to do.” The saturation monitor continues to go down,and find that it is usually done prone and under seda- so you grab for your circuit to bag the patient back uption. “Easy MAC, let me grab a bunch of propofol,” you with some positive pressure ventilation. Uh-oh, there’sthink to yourself. no mask on the end of the circuit – in your new sur- You reach the endoscopy unit after getting lost a roundings, you forgot to do a machine check! You askfew times on the way there and introduce yourself to the nurse to bring in the stretcher and put the patientthe gastroenterologist. He explains that the patient is back in the supine position quickly, as the endoscopein-house and “not that sick” and that the gastroenterol- is removed by the gastroenterologist. You realize thatogist needs to get to office hours, “so can we do this you never looked at her preoperative potassium lev-quickly?” Wanting to develop a good rapport in the els, so you forget the succinylcholine and just do directendoscopy suite as a new attending, you reassure him laryngoscopy. Luckily, you have a grade 1 view of thethat you’ll get things moving along – it’s just a MAC vocal cords, so you throw in an entotracheal tube, hookcase after all! You then go to the room, draw up your up the circuit, and bag her back to a saturation of 98%.propofol syringes, and, as a final thought, crack open You tape your tube in and calmly say to the GI attend-the succinylcholine vial. ing, “Proceed with your ERCP.” That cheeseburger you The patient arrives. She is a 52-year-old female with scarfed down at lunch might be making a reappearancea history of hypertension (HTN), 65 kg, and recently soon!diagnosed with gallstone pancreatitis. She looks as ifshe’s in pain. You approach the patient and introduceyourself. The patient looks around and asks, “Are there Patient careany real doctors here? You look like my granddaugh- Residents must be able to provide patient care that ister!” You reassure her that you’ve been practicing anes- compassionate, appropriate, and effective for the treat-thesia “for years,” and she relents by shrugging her ment of health problems and the promotion of health.shoulders. After a quick airway (class II with upperdentures) and physical exam, you explain the risks Communicate effectively and demonstrate caringand benefits of anesthesia and the prone position. The and respectful behaviors when interacting withpatient is then moved over to the procedure table and patients and their families.makes herself as comfortable as possible in the proneposition. You place the monitors and make sure the IV Preoperatively, the patient seemed concernedis secured and flushing well. You put a nasal cannula about how young you look! Reassurance is crucial; theon her at 2 L/min, see that you’re getting adequate end- patient needs to know that you are a trained medical 153tidal CO2 , and proceed by pushing 50 mcg of fentanyl doctor and that you have had years of experience
  • 163. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 specifically in the field of anesthesia. In addition, it true for cases under general anesthesia greater than was noted that the patient appeared to be in pain. 6 hours. Emphasize to your patient that pain control is a vital part of anesthesia and that you will do all you can to Perform competently all medical and invasive provide pain relief in a safe manner. procedures considered essential for the area of practice. Gather essential and accurate information about their patients. Remember to always do a machine check! You would have picked up on the fact that there was The patient’s history can come from a variety of no mask attached to the circuit had you adequately sources. In this particular instance, we learn from the checked your ventilator. Off-site anesthesia is quickly attending doing the procedure that she was “not that becoming the norm in many hospitals, and your anes- sick.” Recognize that other physicians may simplify thesia equipment is not always ready and available to medical conditions that to an anesthesiologist are crit- you as in your comfort zone of the main operating ical. Did she vomit prior to reaching the endoscopy rooms. suite? Is she a full stomach, or will she aspirate? Are her electrolytes out of whack, and is succinylcholine a Use information technology to support patient possibility if an emergency situation surfaces? A his- care decisions and patient education. tory and physical exam (H&P) with the patient are also crucial – after all, a good H&P is the very heart of Preoperatively, the anesthesiologist can review medicine! Realize that some patients do not know the diagnostic studies to determine the number and size extent of their medical conditions, so a chart review of the gallstones for removal – this may give an indi- is important, particularly for inpatients who may have cation as to the length of time the procedure will take seen several physicians in consultation and/or have and whether or not the patient will be able to tolerate had many diagnostic exams. This patient was known ERCP under MAC. to have HTN – what medications is she on? Was there an electrocardiogram (EKG) done? Work with health care professionals, including those from other disciplines, to provide Develop and carry out patient management plans. patient-focused care. Let’s look at this case retrospectively. You did the Preprocedure, the GI and anesthesiology attend- Google search over lunch – most review articles report ings discussed carrying out this case quickly under that ERCP is done under MAC in American Society of MAC in an otherwise healthy lady. Remember, with Anesthesiology (ASA) I–II patients; her HTN was pre- any procedure, it’s not about doing it fast, but rather, sumed to be under control, she was thin, and she had a it’s about doing it right! Intraoperatively, as critical good airway with upper dentures. You were pretty cer- events develop, the anesthesiologist must adapt calmly tain you could intubate her if you needed to, and sure to changes and direct those in the room on what they enough, you ultimately had to! But remember that the can do to help in stabilizing the patient. Postopera- ABCs are not always as easy as 1-2-3; perhaps general tively, a debriefing of critical events is beneficial to see anesthesia with an endotracheal tube should have been what went wrong and how to avoid such situations in instituted from the start, especially given the prone the future. positioning. Counsel and educate patients and their families. Medical knowledge Residents must demonstrate knowledge about estab- You informed the patient of the risks and benefits lished and evolving biomedical, clinical, and cog- of anesthesia as well as the risks of the prone position – nate (e.g., epidemiological and social-behavioral) sci- corneal abrasions, facial and upper airway edema, ences and the application of this knowledge to patient154 and postoperative vision loss. This is particularly care.
  • 164. Case 30 – ERCP with sedation of this case during a lunch break! As stated earlier, Know and apply the basic and clinically multiple review articles revealed that ERCP is an off- supportive sciences that are appropriate to their site procedure performed under MAC in the prone discipline. position in most patients with average ASA classifica- Our patient became apneic after a small dose of tions of 1–3. When administering monitored anesthe-fentanyl and what can be considered an induction sia care, one must realize that just as with a generaldose of propofol. Although approximately 2 mg/kg of anesthetic, each patient is individualized, and extrapropofol are necessary for tolerating the placement of care must be taken not to be heavy-handed with medi-an upper endoscope in most patients, anesthesiolo- cations – your airway is not secured. In addition, thegists should not treat all cases like a chocolate chip airway in the prone position is not readily availablecookie recipe (milk of anesthesia and cookies – yum!). to you, and it is being shared with the gastroenterol-Use your knowledge of anesthesia to figure out a quick ogist! Have a backup plan if apnea ensues, and if thealgorithm for yourself in this situation. You need to airway was difficult from the beginning or the patientmaintain the ABCs airway, breathing, circulation; you was vomiting perioperatively, then have a low thresh-just took away your A and B with the drugs you pushed, old for endotracheal intubation.and you know that if you don’t do something soon,you’ll lose your C as well: Professionalism1. You tell the GI doc to place his scope, hoping that Residents must demonstrate a commitment to carry- that will stimulate ventilation, but alas, it does not, ing out professional responsibilities, adherence to eth- and saturations are dropping. ical principles, and sensitivity to a diverse patient pop-2. Hmmm, the fentanyl dose was small, Narcan ulation. won’t help the situation, and why has no one designed an antidote to propofol? Demonstrate sensitivity and responsiveness to pa-3. Jaw thrust next to open the airway and, it is hoped, tients’ culture, age, gender, and disabilities. provide a painful stimulation to breathe. Negative.4. On to positive-pressure ventilation – ugh, there’s This patient was middle-aged and concerned that no mask! Hypoxia continues as you hear your you, as a junior attending, looked like her granddaugh- saturation alarm drop – don’t let it follow with ter. Regardless of your specialty in medicine, introduc- bradycardia and cardiopulmonary resuscitation tions and first impressions are key. Dress profession- (CPR). ally, whether in a shirt and tie or scrubs. Keep your scrubs clean; if you dirty them, then change – patients5. OK, think of the Nike ads – “Just tube it!” Intubate do not want to see blood running down your scrub the patient, confirm tube placement, secure the pants or vomit on your scrub top! Wear your white coat airway, and proceed with ERCP under general when not in a sterile location, and have your ID badge anesthesia. visible at all times in the hospital. If you’re fatigued from too many hours on call and it shows on your face, take 5 minutes to wash up and reapply that makeup!Practice-based learning In sum, look the part of a doctor, and your age shouldand improvement not matter to the patient. The patient will see that atResidents must be able to investigate and evaluate their the core, you are clinically competent (how’s that forpatient care practices, appraise and assimilate scientific alliteration?).evidence, and improve their patient care practices. Demonstrate a commitment to ethical principles Locate, appraise, and assimilate evidence from pertaining to provision or withholding of clinical scientific studies related to their patients’ health care, confidentiality of patient information, problems. informed consent, and business practice. Unsure of what an ERCP entailed, the anesthesiol- The patient was adequately informed of the risks ofogist utilized time well by doing an online search of the procedure by the gastroenterologist as well as the 155the procedure and the usual anesthetic management risks for anesthesia. Particularly crucial to this case was
  • 165. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 explaining to the patient that she would be sedated in things are spiraling downward in a crucial situation, the prone position, which can be uncomfortable and it is important to firmly delegate tasks so that all hands intimidating to a patient. are helping. Remember that people panic and freeze in emergencies, and you as an anesthesiologist have only Interpersonal and communication two hands to do many, many tasks. If an anesthesia tech had been in the room, he or she could have been skills a valuable source for finding a mask to ventilate the Residents must be able to demonstrate interpersonal patient. You told the GI doctor to remove the endo- and communication skills that result in effective infor- scope; you told the nurse to get the stretcher; collec- mation exchange and teaming with patients, their tively, you turned the patient from prone to supine and patients’ families, and professional associates. were able to secure the airway. At the end, you said with calm composure to the gastroenterologist to continue, Work effectively with others as a member or even though, on the inside, you were dying! leader of a health care team or other professional group. This case is chock full of communication and inter- Systems-based practice personal skills! As a new attending, it is important Residents must demonstrate an awareness of and to be cordial to your colleagues, especially in this era responsiveness to the larger context and system of of off-site anesthesia. You never know to which cor- health care and the ability to effectively call on system ner or crevice of the hospital you will be asked to resources to provide care that is of optimal value. go to provide your services! The preoperative con- Understand how their patient care and other versation between the anesthesiologist and the gas- professional practices affect other health care troenterologist was necessary to determine how stable professionals, the health care organization, and the patient was and to agree on monitored anesthe- the larger society and how these elements of the sia care in the prone position. The GI doc had office system affect their own practice. hours to follow, and of course, you want to keep him happy by having things go efficiently and smoothly, but When critical events arise, do not underestimate remember that patient safety does not always follow a the power of a debriefing session with all those time line. involved – sometimes even the patients themselves – When gallstones hit the fan and the patient quickly so that a thorough review of the situation can occur. became hypoxic from sustained apnea, the anesthesi- Attempt to answer the question of how this situation ologist in the case maintained composure; the GI doc- can be avoided in the future. Perhaps an ERCP pro- tor began yelling about patient movement, but instead tocol can be developed; perhaps all ERCPs should be of raising a voice in retaliation, a quick point to the done under general anesthesia with endotracheal tube monitors can get your intentions across. In fact, the (ETT) from the very beginning. gastroenterologist quickly humbled after this. When In sum, don’t supersize that Big MAC!156
  • 166. Case 30 – ERCP with sedationAdditional reading and use as an intravenous anesthetic. Drugs 1988;35:334–372.1. Tagaito Y, Isono S, Nishino T. Upper airway reflexes during a combination of propofol and fentanyl 3. Wehrmann T, Kokabpick S, Lembcke B, et al. Efficacy anesthesia. Anesthesiology 1998;88:1459–1466. and safety of intravenous propofol sedation during routine ERCP: a prospective controlled study.2. Langley MS, Heel RC. Propofol: a review of its Gastrointest Endosc 1999;49:677–683. pharmacodynamic and pharmacokinetic properties 157
  • 167. Part 1 Contributions from Stony Brook University under Case Christopher J. Gallagher 31 On call in labor and delivery The morbidly obese nightmare Ursula Landman and Kathleen Dubrow The case Gather essential and accurate information about There is a 30-year-old, 450-pound plus, as stated in their patients. the chart, gravida 1 para 0 (G1P0) in labor and deliv- ery room 4 who is being induced with no epidural, The patient was actually much larger than 450 and there is still no IV. The patient’s blood pressure is pounds – that was an understatement. One area of the 120/70, pulse 70, respirations 15, fetal heart rate (FHR) chart stated that her weight was 600 pounds plus. On 140s. Past medical history/past surgical history none. repeat interview of the patient, she admitted to 600. I Her meds included perinatal vitamins, and she had no always like to recheck history and physical exam for known drug allergies. There were multiple IV attempts myself. Many times, I will gain additional important during the afternoon, without success. The obstetric information, just by asking the question again. anesthesiologist states that “the patient wants general anesthesia if she is to have a c-section.” The obstetri- Make informed decisions about diagnostic and cian states that he does not need anesthesia now. The therapeutic interventions based on patient obstetric anesthesiologist has left. What do you do? information and preferences, up-to-date scientific evidence, and clinical judgment. Patient care Residents must be able to provide patient care that is It doesn’t take a genius to see that this is a disaster compassionate, appropriate, and effective for the treat- about to happen. The patient has no IV and no epidural ment of health problems and the promotion of health. and wants general anesthesia for cesarean section if she needs one. Patient preference here is not an option. The Communicate effectively and demonstrate caring risks had to be clearly spelled out to this patient and and respectful behaviors when interacting with her husband. She was also being induced after normal patients and their families. hours. A mutually agreed on plan is of the utmost impor- Develop and carry out patient management plans. tance. The patient needed to gain the trust of the new team so that a further attempt at an epidural and IV It was necessary to try to get an epidural in this could be done. It was also important to note that the morbidly obese patient, in addition to large-bore IV day team had tried multiple times to get an epidu- access. This was discussed with the obstetric attend- ral and an IV. The first concern would be to check ing. Of course, this obstetric attending then left, and the patient’s airway – just in case she does have a a new obstetrician attending took over. The plan for cesarean section. Next, the patient would have to be an epidural was discussed again. Communication is asked directly about retrying for an epidural, given all very important between the team, especially so that the risks that would go along with a general anesthetic. they understand the possibility of a difficult airway and Although multiple attempts for an epidural were made, difficult IV access. Attempts were made again, with- I felt it necessary to try to get an epidural in this mor- out success. The difficult airway box was checked, as bidly obese patient, in addition to large-bore IV access. was availability of the fiber optic and other necessary The patient actually agreed to another attempt and, if equipment. You should use what you are most com-158 an epidural was obtained, realized it would be used for fortable with and have that available in the operating cesarean section. room. The other attending in-house was also made
  • 168. Case 31 – On call in labor and deliveryaware but stated that he was unable to help if there was debrief about the patient was done so that we could alla need for cesarean section. be on the same page regarding her care. The problem was the change of shift, so this had to be done multi- Counsel and educate patients and their families. ple times, and each time, we had to convince the new Here is a patient who was as healthy as a 600-pound obstetrician taking over that we could not just throwplus patient could be up to this point, but there is a our hands up and hope for the best if she were to begenuine worry that things may end up very badly. It is sectioned. We needed to attempt an IV and an epidu-best not to sugarcoat the risks, but just tell it like it is: ral again. It is also in the obstetrician’s best interests tothe risks are x, y, and z, and this could very well hap- have an appropriate anesthetic on board – it will makepen because you are at increased risk. I explained to the his or her job easier and be the safest for the patient.patient the possibility of having a difficult airway. Sheappeared to understand this and became more willing Medical knowledgeto have an epidural attempted again. Residents must demonstrate knowledge about estab- Use information technology to support patient lished and evolving biomedical, clinical, and cognate care decisions and patient education. (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. If the obstetricians have done a bedside ultrasound,it is great to hear their estimate of the baby’s size and Demonstrate an investigatory and analytichow the placenta is lying. This can alert you to further thinking approach to clinical situations.needs, for example, blood availability if the placenta is It was also necessary to have the longer Tuohylow lying. This patient did not have a low-lying pla- needle for the additional attempt at an epidural. Wecenta. Also, the baby was predicted to be of average had various sizes available, and the one that was suc-weight. cessful was almost “harpoonlike,” in the words of the Perform competently all medical and invasive nurse who was assisting me. Persistence truly paid off procedures considered essential for the area of after about 2.5 hours of attempts for an epidural. A practice. pearl for these obese patients: the excess soft tissue was taped up to help visualize the back better. This was a A competent anesthesiologist would skillfully place much needed intervention. Sometimes it is necessaryadequate venous access and an arterial line (to moni- to think outside the box and use other means to maxi-tor blood pressure on a beat-to-beat basis, especially if mize the best attempt. It made a world of difference inthere is lack of an adequate cuff size). comparison to just attempting without the tape. Don’t underestimate the importance of this taping. A criss- Provide health care services aimed at preventing cross V was made with tape, and the area was prepped health problems or maintaining health. with povidone-iodine. One preventive measure that we can take in thissize of a patient is application of compression stock- Know and apply the basic and clinicallyings to avoid deep venous thrombosis (DVT) later on. supportive sciences that are appropriate to theirAlso, if this patient were to have a cesarean section, discipline.then during such a case, timing the delivery of pro- The FHR was checked multiple times, and it wasphylactic antibiotics is important. Current standards fine. A Doppler transducer was used at first, and then,are for antibiotics to be delivered within an hour of because it was taking a while to obtain an anesthetic, aincision. fetal scalp electrode was placed. The fetal scalp elec- Work with health care professionals, including trode is most accurate. The cervix does need to be those from other disciplines, to provide 1–3 cm dilated for use, and membranes must be rup- patient-focused care. tured. A cardiotachometer uses the peak or thresh- old voltage of the fetal r-wave to measure the interval We must work with the obstetricians closely and between each fetal cardiac cycle. There was good FHR 159develop a plan for this type of patient. A huddle to baseline variability (fluctuations in the baseline FHR of
  • 169. Contributions from Stony Brook University under Christopher J. Gallagher – Part 1 2 cycles per minute). Normal baseline FHR remained The Internet can be a great place to keep up to date 140–150. This gave me the leisure to continue epidural on the latest knowledge in the field. Also, the American attempts. In actuality, a spinal was purposefully done College of Obstetricians and Gynecologists and Soci- with the epidural needle because the epidural space ety for Obstetric Anesthesia and Perinatology publica- could not be located. tions can be great to review for information in the field. Practice-based learning Professionalism and improvement Residents must demonstrate a commitment to car- Residents must be able to investigate and evaluate their rying out professional responsibilities, adherence to patient care practices, appraise and assimilate scientific ethical principles, and sensitivity to a diverse patient evidence, and improve their patient care practices. population. Analyze practice experience and perform Demonstrate respect, compassion, and integrity; a practice-based improvement activities using a responsiveness to the needs of patients and society systematic methodology. that supersedes self-interest; accountability to patients, society, and the profession; and a It took some time, but after more and more of these commitment to excellence and ongoing morbidly obese patients began to come to deliver, a professional development. task force was formed to develop practice guidelines for these patients, who are now frequent in labor and It is always important to treat the patient and fam- delivery. There was a systematic analysis done with the ily with respect and compassion, even if they seem to obstetricians and the anesthesiologists, and now anes- have crazy ideas. This patient wanted general anesthe- thesia is consulted in advance on these patients. They sia, but once her concerns were addressed and all was are seen in clinic, and they may now have lines placed explained, then she was amenable to another attempt preemptively if they are such a difficult stick. at epidural. As always, even for a regional anesthetic, it is important to set up for a general anesthetic, just in Locate, appraise, and assimilate evidence from case – this means that you should always check your scientific studies related to their patients’ health machine and have medications prepared and ready. problems. The best way to be responsive to patient needs is to listen – it sounds simple, but many physicians do not, The literature was reviewed and recommendations and they can miss information or miss cues regarding were made based on it. Early preoperative evaluation the patient’s needs. Facial expressions and body lan- by the obstetric anesthesia team is a necessity. The ulti- guage are very important, and this can help the patient mate disaster can be averted here. It was helpful to have if you can pick up on them. Also, patients can pick up the obstetricians hear our needs and us theirs. We are on the anesthesiologist’s facial expressions and body all looking to have the best outcome – a healthy baby language, so it’s best to be nonjudgmental and not to and mother. approach the patient with hands on your hips – many