Core Clinical Competencies in

Anesthesiology
A case-based approach
The core clinical competencies in anesthesiology can be pretty blurry just how do they apply to
real life?
This book answers this question, incorporating the core clinical competencies into an
engaging format that anesthesiologists like: case studies. So, far from being a dry and dusty
volume 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, the
Board 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 medical
students alike.

Dr. Christopher J. Gallagher is an Associate Professor in the Department of Anesthesiology at Stony

Brook 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 for
Achievement in Education by the International Anesthesia Research Society. Dr. Gallagher is the author of
books on oral boards, anesthesia procedures, transesophageal echocardiography, and simulation. Outside
of medicine, he has written one book on tennis, one on World War I, and another on learning foreign
languages. He is fluent in five languages, conversant in another five, and can ask for the bathroom in an
additional five. He has not yet achieved People magazines 50 Most Beautiful People list, but hope springs
eternal 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 its
director of medical student teaching. At UM, he has also held the position of chief of academic programs
in transplant anesthesia in addition to his capacity as residency program director, chair of the Medical
School Faculty Council, and vice chair of the University Senate. Most recently, he was appointed assistant
dean for international graduate medical education. Dr. Lewis has been awarded a Hartford Award from
the American Society of Geriatrics and was a Fulbright Scholar in 2006. He is active in the Florida Society
of Anesthesiologists, presently serving as its president. He is also the current national president of the
Israel Medical Association, World Fellowship: USA, and is on two committees of the American Society
of Anesthesiologists, while being an active member of the House of Delegates of the American Board of
Anesthesiology. He is married to Judy and has three daughters.

Dr. Deborah A. Schwengel is an Assistant Professor in the Department of Anesthesiology at Johns

Hopkins School of Medicine and a pediatric anesthesiologist at the Johns Hopkins Childrens Center.
She is the anesthesiology residency program director and designer of an innovative education program at
Johns Hopkins. She is founder and director of the International Adoption Clinic of the Kennedy Krieger
Institute and the Johns Hopkins Childrens Center. In addition, she is a critical care consultant at St. Agnes
Hospital and Mt. Washington Pediatric Hospital, both in Baltimore. Dr. Schwengels research is focused
on 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 education
programs. She has three internationally adopted children who, together with 75 anesthesiology residents,
make life a never-ending string of dramatic and humorous tales.
Core Clinical Competencies in
Anesthesiology
A case-based approach
Edited by
Christopher J. Gallagher
Stony Brook University

Michael C. Lewis
University of Miami

Deborah A. Schwengel
Johns Hopkins Medical Institutions
CAMBRID GE UNIVERSIT Y PRESS
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Cambridge University Press

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Information on this title: www.cambridge.org/9780521144131


c Cambridge University Press 2010

This publication is in copyright. Subject to statutory exception

and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.

First published 2010

Printed in the United States of America

A catalog record for this publication is available from the

British Library.

Library of Congress Cataloging in Publication data

Core clinical competencies in anesthesiology : a case-based

approach / 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. Clinical
Competence Case Reports. WO 200 C7965 2010]
RD82.45.C67 2010
617.9 6dc22 2009036865

ISBN 978-0-521-14413-1 Paperback

Cambridge University Press has no responsibility for the

persistence or accuracy of URLs for external or third-party
Internet Web sites referred to in this publication and does
not guarantee that any content on such Web sites is, or will
remain, accurate or appropriate.

Every effort has been made in preparing this book to

provide accurate and up-to-date information that is in accord with
accepted standards and practice at the time of publication.
Although case histories are drawn from actual cases, every effort
has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors, and publishers can make no
warranties that the information contained herein is totally free
from error, not least because clinical standards are constantly
changing through research and regulation. The authors, editors,
and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material
contained in this book. Readers are strongly advised to pay careful
attention to information provided by the manufacturer of any
drugs or equipment that they plan to use.
To that person who coined the phrase that guides residency directors
everywhere: a residency director should beat the love of learning into his
or her residents with a stout stick.
Contents
Rogues Gallery of Contributing Authors xi

Introduction: From the mountain 1 Case 10. Flame on! 56

Christopher J. Gallagher and Matthew Neal
1 An anesthetic view of the Core Clinical
Competencies 3 Case 11. What date would you like
carved in stone? 61
2 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 dont 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 doesnt 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
 Contents

Case 21. Are you sure theres 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
wont 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 236
viii Neera Tewari and Vedan Djesevic Deborah Brauer and Murlikrishna Kannan
 Contents

Case 45. Cut off at the knees 240 Case 58. DIC: Disseminated
Ashish Udeshi intravascular coagulation or
devastating injury to the cervix? 313
Case 46. Neuro 246
Sayeh Hamzehzadeh and Tina Tran
Eric A. Harris and Miguel Santos
Case 59. All I had was a knee
Case 47. Cardiac catheterization bursectomy; now do I have RSD (CRPS)? 318
laboratory to cardiac operating room 252
Adam J. Carinci and Paul J. Christo
Lebron Cooper and Adam Sewell
Case 60. Obstetricians cannot detect
Case 48. Lap choly in someone great FH sounds, and Moms cyanotic: Whats
with child 260 an anesthesiologist to do? 324
Amy Klash Pulido and Shawn Banks Ramola Bhambhani and Lale Odekon
Case 49. Renal transplant 263 Case 61. A case of mistaken identity 334
Carlos M. Mijares and Sana Nini Nishant Gandhi and Bradford D. Winters
Case 50. Surprise! Its a liver and Case 62. To block or not to block, that
kidney transplant 266 is the question: Anticoagulation and
Michael Rossi and Sujatha Pentakota epidural anesthesia 340
Case 51. Left lower extremity pain 269 Brandon M. Togioka and Christopher Wu
Omair H. Toor and David A. Lindley Case 63. Anterior mediastinal mass
Case 52. Trauma 276 with total occlusion of the superior
Edgar Pierre and Patricia Wawroski vena cava and distal tracheal
compression 347
Case 53. Whack-an-eye 281 Andrew Goins and Daniel Nyhan
Steve Gayer and Shafeena Nurani
Case 64. Puff the magic dragon 352
Steven J. Schwartz
Part 5 Contributions from Johns Case 65. You mean the screw isnt
Hopkins Medical Institutions supposed to be in the aorta? Massive
bleeding during spine surgery 360
under Deborah A. Schwengel Melissa Pant and Lauren C. Berkow
Case 54. Singin the OSA blues 289
Case 66. Oh no, someone get the NO! 365
Jennifer K. Lee and Deborah A. Schwengel
Rabi Panigrahi, Brijen L. Joshi, and
Case 55. Oxygen 295 Nanhi Mitter
Justin Lockman and Deborah A. Schwengel Case 67. What to do when HITT hits
Case 56. My patients an airhead! the fan 369
Management of air embolism during Ira Lehrer and Nanhi Mitter
sitting craniotomy 301
Case 68. Just dont stop my achy,
Alexander Papangelou breaky heart. . . 375
Case 57. Fifty-one-year-old female Sapna Kudchadkar and R. Blaine Easley
with abdominal pain, diarrhea,
Case 69. Too bad, so sad. . . its Friday
flushing, and heart murmur for
afternoon with a VAD 382
exploratory laparotomy 307
Jeremy M. Huff and Theresa L. Hartsell
Peter Lin and Ralph J. Fuchs

ix
 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. Hes 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, thats 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 451

x
Rogues Gallery of Contributing Authors

The following people allegedly contributed to this Misako Sakamaki, MD, Resident
book. An insignificant number (p .05) were water- Joy Schabel, MD, Associate Professor
boarded into this admission. Bharathi Scott, MD, Professor
Peggy Seidman, MD, Associate Professor
Stony Brook University Medical Center Shiena Sharma, MD, Resident
Ramon Abola, MD, Chief Resident Vishal Sharma, MD, Resident
Rishimani Adsumelli, MD, Associate Professor Ellen Steinberg, MD, Associate Professor
Syed Azim, MD, Assistant Professor Neera Tewari, DO, Assistant Professor
Tazeen Beg, MD, Assistant Professor Jane Yi, DDS, Resident
Helene Benveniste, MD, Professor Jonida Zeqo, MD, Resident
Louis Chun, MD, Resident
Ramtin Cohanim, MD, Chief Resident University of Medicine and Dentistry of
Dominick Coleman, MD, Resident
Joseph Conrad, MD, Resident New Jersey
Tommy Corrado, MD, Resident Peter Chung, MD, Resident
Jason Daras, DO, Resident John Denny, MD, Associate Professor
Michelle DiGuglielmo, MD, Chief Resident Steven H. Ginsberg, MD, Associate Professor
Vedan Djesevic, MD, Resident Jeremy Grayson, MD, Assistant Professor
Andrew Drollinger, DDS, Resident Jonathan Kraidin, MD, Associate Professor
Kathleen Dubrow, MD, Resident Stephen Lemke, DO, Resident
Brian Durkin, DO, Assistant Professor Tejal Patel, MD, Resident
Ralph Epstein, DDS, Assistant Professor Salvatore Zisa Jr., MD, Fellow
Christopher J. Gallagher, MD, Associate Professor
Xiaojun Guo, MD, Assistant Professor
Sofie Hussain, MD, Resident University of Texas M.D. Anderson
Ron Jasiewicz, DO, Assistant Professor Cancer Center
Anna Kogan, DO, Resident Charles Cowles, MD, Instructor
Ursula Landman, DO, Associate Professor Marc Rozner, MD, PhD, Professor
Rany Makaryus, MD, Resident
Daryn Moller, MD, Assistant Professor
Tate Montgomery, DDS, Resident University of Miami Miller School of
Matthew Neal, MD, Resident
Khoa Nguyen, MD, Resident
Medicine
Marco Palmieri, DO, Resident Shawn Banks, MD, Assistant Professor
Shaji Poovathor, MD, Assistant Professor Deborah Brauer, MD, Assistant Professor
Eric Posner, MD, Resident Lebron Cooper, MD, Assistant Professor
Deborah Richman, MB, ChB, FFA(SA), Assistant V. Samepathi David, MD, Fellow
Professor Steve Gayer, MD, Associate Professor
Andrew Rozbruch, DO, Resident Steven Gil, MD, Resident xi
 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
Core Clinical Competencies in
Anesthesiology
A case-based approach
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.
 You washed up on the shores of a residency. And the teachers of doctors trembled before the
 For three years, you did anesthesia. men and women of education. And these same teach-
 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 education
But, alas, as time passed, the educational process grew that we will live all the years of our lives in fear and
in 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 of
thusly 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! As
For them to teach unto their young charges, they must manna from heaven fed those who wandered through
teach as we, the wise men and women of education, feel the desert, so also this book from three residency
you 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 is
climbed a great mountain, to seek commandments. a boon to medical students, residents, and teachers
They 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 Core
healing 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 screeching
these commandments, which we of needs must now of monkeys. We will go us forth into actual cases, cases
employ 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 those
spend all the hours of the day and all the hours of the who are afflicted by the thousand and one ills that flesh
night 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 the
unto the ground, so that one brick no longer lies upon Four Horsemen of the Residency Review Committee
1
 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
 Chapter

An anesthetic view of the Core

1 Clinical Competencies

Here are the Core Clinical Competencies with an anes- but if the tube doesnt find the trachea, or the spinal
thetic twist. The first two, patient care and medical needle doesnt splash down in cerebrospinal fluid, or
knowledge, are the traditional things weve always the central line knifes through the pleura, then were
taught. 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 lets 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 the
Patient care patient:
Residents must be able to provide patient care that is  Secure that airway.
compassionate, appropriate, and effective for the treat-  Get the line in.
ment of health problems and the promotion of health.
 Keep an eye on those vital signs.
Residents are expected to do the following:
 Provide good analgesia.
 communicate effectively and demonstrate caring  React to changes and problems.
and respectful behaviors when interacting with  Keep those lines open between you and the
patients and their families
 surgeon, the obstetrician, and the consultants so
gather essential and accurate information about you dont miss anything.
their patients
 make informed decisions about diagnostic and That is the anesthetic take on patient care, and theres
therapeutic interventions based on patient not a lot of room for interpretation.
information and preferences, up-to-date scientific
evidence, and clinical judgment
 develop and carry out patient management plans
Medical knowledge
 counsel and educate patients and their families
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.
perform competently all medical and invasive
Residents are expected to do the following:
procedures considered essential for the area of
 demonstrate an investigatory and analytic
practice
 provide health care services aimed at preventing thinking approach to clinical situations
 know and apply the basic and clinically supportive
health problems or maintaining health
 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 little
The anesthetic take on patient care removed from the anesthetic take on patient care. You
This 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  Chest pain, ST segment changes? You have to
3
wax dreamy about all the other educational rigmarole, know the components of ischemia, know the latest
 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
 New device for securing the airway safely? You guide our therapy. Heres one example that affected our
have to know how to use it to care for the patient. recent thinking:
 New block (say, the transverses abdominalus  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.  Hey, lets give everyone beta-blockers, and all our
This is just the knowing behind the doing, so theres not patients will live forever.
 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 theres
and improvement a fly in the soup!
Residents must be able to investigate and evaluate their  Ischemia is, indeed, down.
patient care practices, appraise and assimilate scien-  But death and stroke rates are up.
tific evidence, and improve their patient care practices.  Oh, no! The sacred cow of perioperative
Residents are expected to do the following: beta-blockade is slain.
 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 dont care how fast
 locate, appraise, and assimilate evidence from you turn over a room; youre 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
 obtain and use information about their own Core Clinical Competency.
Whats 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
 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
 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 Perignon from
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 weve all leaned on doesnt hold dents are expected to do the following:
4  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
 Chapter 1 An anesthetic view of the Core Clinical Competencies

 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 steams
 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 need
The anesthetic take on interpersonal the Core Clinical Competencies to tell me that I have to
and communication skills be ethical? We all took the Hippocratic oath; our whole
This competency and the next one (professionalism) life has been geared to taking good care of our fellow
are damned hard to tease apart. I wish they would have human beings. Now some educationo-wonk is telling
checked with me before they split these into two. Here me I have to be sensitive and appropriate around a
goes, but, as you will see, theres a lot of overlap here. person of different background, or a person with a
You cant 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 with
nurses, cardiopulmonary bypass techs, doctors, inten- Systems-based practice
sive care unit staff, respiratory techs, you name it. Any-
Residents must demonstrate an awareness of and
one that crosses paths with you in the clinical orbit, you
responsiveness to the larger context and system of
have to work well with them and make sure you get the
health care and the ability to effectively call on system
information right.
resources to provide care that is of optimal value. Resi-
dents are expected to do the following:
Professionalism  understand how their patient care and other
Residents must demonstrate a commitment to carry- professional practices affect other health care
ing out professional responsibilities, adherence to eth- professionals, the health care organization, and
ical principles, and sensitivity to a diverse patient pop- the larger society and how these elements of the
ulation. Residents are expected to do the following: system affect their own practice
 demonstrate respect, compassion, and integrity; a  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  practice cost-effective health care and resource
professional development allocation that does not compromise quality of
 demonstrate a commitment to ethical principles care
pertaining to provision or withholding of clinical  advocate for quality patient care and assist
care, confidentiality of patient information, patients in dealing with system complexities
informed consent, and business practice  know how to partner with health care managers
 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 performance
The anesthetic take on professionalism
As noted previously, this goes hand in glove with The anesthetic take on systems-based
the competency of interpersonal and communication practice
skills. A professional communicates well with patients,
Money makes the world go round, and medicine is
fellow doctors, and all other medical providers. (Core
no exception. For anesthesiologists, the main idea we
Clinical Competencies force you to use administrato-
glean from systems-based practice is related to money:
speak, with stupid phrases like health care providers 5
and crap like that.) Part of that communication is reg-  practice cost-effective medicine
istering the different backgrounds your patients have  know how you fit into the great big overall picture
 Chapter 1 An anesthetic view of the Core Clinical Competencies

 do QA things (they dont call it that anymore about the Core Clinical Competencies, youll probably
they say continuous quality improvement but we get some variant of my barbed comments.
all know thats just more administratodouble But theyre here to stay, and we have to know how
talk) to teach them, so thats 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, lets do what were best at: clinical anesthe-
laid out, complete with the anesthetic take on them. sia. Well lay out a case, then wrap that case around the
Sound jaded? Core Clinical Competencies. That way, well breathe
Yeah, its 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 lets have at it.

6
 Chapter

Anesthetic cases through the Core Clinical

2 Competencies looking glass

Without 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 Clinical
actually did these cases!). And well look at each Competencies is not the purpose of these cases, nor is
case 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 two
the 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 you
gle competency. As you will see, this leads to interest- how you can take a case, or one horrific moment in
ing verbal gymnastics as I struggle to find a connec- midoperation, and wrap it around the Core Clinical
tion. Competencies.

7
Part Contributions from Stony Brook

1 University under
Christopher J. Gallagher
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

1 Pop goes the aneurysm

Christopher J. Gallagher and Tommy Corrado

The case Make informed decisions about diagnostic and

A previously healthy 45-year-old man developed therapeutic interventions based on patient
headaches and blurry vision. Workup revealed a large information and preferences, up-to-date scientific
cerebral aneurysm requiring a heroic procedure. In evidence, and clinical judgment.
effect, his face would be taken apart to get at the
aneurysm. The lesion itself was extremely large, and It doesnt take a genius to peg this as Cushings triad
the neurosurgeon was quite concerned about whether stemming from a catastrophic intracerebral bleed.
hed 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 have
section, 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! from
the surgeon. The patients blood pressure rose to 260, Develop and carry out patient management plans.
and his heart rate fell from 90, to 80, to 70, and didnt
stop 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, youd need to jump into a time
Patient 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. Here
compassionate, appropriate, and effective for the treat- is a patient who was healthy up to this point, but there
ment 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 dont have to sweat about car-
ing and respectful behavior in our interaction. We can Use information technology to support patient
show 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 what
didnt fall on the floor. the surgeon will be doing. 11
 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 instapole 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 Cushings 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  the aneurysm popped
the sake of completeness (each case considers all the  blood is pouring into the meat of the brain
Core Clinical Competencies, but different competen-  as the brain expands, it attempts to maintain
cies receive different emphasis).
perfusion by increasing the blood pressure
 the heart (which has no way of knowing whats 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 worlds fastest anal-
thinking approach to clinical situations. ysis of practice experience:
12  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  He knew this was bad going in.
 Case 1 Pop goes the aneurysm

 Hes swearing and the brain is blowing up like a shortest of short terms and need all the help you can
Macys Thanksgiving Day Parade cartoon get, so you abandon considerations of whats 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 own
not lost as far as this Core Clinical Competency is population of patients and the larger population
concerned! 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 you
do just that. Difficult cases, complications, deaths all draw on the larger world of experience, that is, the
these 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 lets not talk about it.
Maybe the case could have been done with coils? Apply knowledge of study designs and statistical
Was this case so horrifically complicated that it should methods to the appraisal of clinical studies and
have been referred to a better-equipped tertiary cen- other information on diagnostic and therapeutic
ter? Should the surgeon have done cardiopulmonary effectiveness.
bypass with circulatory arrest to more safely clamp the
aneurysm? Oh, just kill me now that theyve mentioned statis-
tics! Well, theres no getting around it if youre 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: lets look
based 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 guy
literature and what constitutes dreck. down a little! That will decrease his cerebral metabolic
Ooph! In other words, you cant 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, youd rologic outcome has been examined in the litera-
read a timely, scientific article on the very case youre ture and has been found wanting. Although it makes
doing. What does the literature say about clipping physiologic sense that hypothermia would protect the
aneurysms? Keep control of the pressure; be ready to brain, a study looking at that very issue showed that
drop the pressure drastically if the surgeons having hypothermia does not protect the brain. Not only that,
trouble getting the clip on; and administer adenosine but hypothermia causes its own problems (including
if 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! atmosphere
if we need to hear that), and eucarbia to avoid cerebral of an OR emergency, you still have to be able to draw
ischemia. on the literature to guide individual steps.
What does the literature say about a disaster like
this? It is difficult to do a double-blind, placebo- Use information technology to manage
controlled, 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 youre left with your best phys- 13
iologic guess right now. In the long term, hyperventi- What did we do before PubMed and all the other
lation is not a good idea, but right now, you are in the online wizardry that brings the worlds literature to our
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

fingertips? In this case, you wouldnt be looking things teaching rounds, go to meetings, and get the latest on
up in the OR, but rather, youd 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 (dont talk about the
presentations of their lectures online). Surf the Inter- case where others can overhear, and dont 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 patients 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, were 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,
 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 wouldnt do that.
 Disparaging comments about a patients national
Respect and compassion are demonstrated to the
patient and family in the preop visit and the holding identity? No, an Eagle Scout wouldnt do that.
 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 wouldnt 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 youre 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 youre 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 before
14 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.)
 Case 1 Pop goes the aneurysm

Interpersonal and communication Back to the case, what happened, and what we did.
It became evident, after just a few minutes, that the
skills bleed into the brain was unstoppable and the brain
Residents 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 down
mation exchange and teaming with patients, their the pressure (whole sticks of Pentathol, Nipride wide
patients 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 mornings prein- We all suspected (and we later demonstrated) that the
duction. 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 patients hand. No. Heres how the discussion among the team
Introduce yourself, look professional, and give the went:
patient your undivided attention.  We had to notify the family.
 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,  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 with
mation 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 the
clues as to the mans level of understanding and gear
process.
your interaction appropriately. University professor in
the neurosciences? Your explanation can be technical.
Blue-collar worker who never finished high school? Systems-based practice
Different 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 of
skills. The rule here is simple: if, for some reason, you health care and the ability to effectively call on system
cant 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), then
make sure all the information is there. In this particu- Understand how their patient care and other
lar case, you would want to make sure that your notes professional practices affect other health care
include the surgeons concerns (big aneurysm, possi- professionals, the health care organization, and
bility of rupture is real), the plans for the airway (intu- the larger society and how these elements of the
bation followed by trach because of extensive dissec- system affect their own practice.
tion in the facial area), and the patients understanding This first aspect of systems-based practice segues
of 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 its hard to draw a line where one ends and
group. another begins.)
This neurosurgical patient has suffered a life-
Aha! Now theres some actual relevance, and we ending hemorrhage, but his organs may save the lives
can get away from Eagle Scout discussions! (You will of others in society. Thus your responsibility has, in
see 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 15
petencies merit emphasis in different cases.) ensure that his organs are best preserved. That means
 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.  Get everyone in a private room this is no
hallway conference.
The primary resource of interest here is the healthy  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 hospitals policy on notify-  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.
 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 patients care and, ultimately, his dona-
sive desflurane, can use isoflurane; muscle relaxant tion to other peoples 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. wont be doing that for all the rest of the cases because
different cases will emphasize different competencies.

16
 Case 1 Pop goes the aneurysm

Additional reading 2. Qureshi AI, Suri MF, Khan J, et al. Endovascular

treatment of intracranial aneurysms by using
1. Wijdicks EFM. The diagnosis of brain death.
Guglielmi detachable coils in awake patients: safety
Neurosurgery 2001;344:12151221.
and feasibility. J Neurosurg 2001;94:880885.

17
 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 wont 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 patients early dalliances in the roman- itourinary (GU) consult or not to place the Foley.
tic realm. Could this Foley-not-passing be evidence of Theyll 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
mores the pity.)
patients clients and junk like that.
The surgeon doesnt answer the call. Still, the Foley
The current best (gag) patient management plan in
wont pass, and now theres 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:
 keep the myocardial oxygen supplydemand ratio
Patient care favorable
Residents must be able to provide patient care that is  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
 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
 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 cant be talk- seeding the bloodstream with gram-negative
18 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
 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 scientific
line 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 optimal
 wash hands ahead of time
time to get a committee together to discuss how we can
 gown and glove
improve on the situation and possible future situations
 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 doesnt show up, then you method to drain urine with the help of our urology
have to assume the role of consultant getting a consul- colleagues.
tant and do whats right for the patient. Tell the GU doc
whats going on and get him or her whatever equip- Locate, appraise, and assimilate evidence from
ment is necessary for the funky Foley placement. scientific studies related to their patients health
problems.

Medical knowledge Since you were prepared for anything that might
Residents must demonstrate knowledge about estab- occur with your patient, you did your research into
lished 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 doesnt 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. The
the surgeon is AWOL. Nothing can happen until the moral of story is that you hope the nurse who tried to
urine 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 and
lot of fluid administration, including lots of fluids con- other information on diagnostic and therapeutic
taining mannitol (from the cardiopulmonary bypass effectiveness.
machine). This will fill the bladder with lots of urine, so
proceeding without a Foley invites problematic blad- Again, not many studies have looked at difficult 19
der overdistension, or even rupture. Foley placement as they are usually unanticipated
 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 patients 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 these
20 sibility to the other team members about a plan of activities can affect system performance.
action. One person should be calling for a urology
 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 us
multidisciplinary team of nurses and physicians can sit a refresher on the anatomy and proper technique of
down to determine the best way to prevent trauma dur- placing a Foley catheter to help improve the outcomes
ing difficult Foley placements and what do to in the of future placements and reduce cost from lost OR
event of such an event in the middle of an OR case. time as well as complications.

21
 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;179:22542257; discussion
embolism after traumatic Foley catheter placement.
22572258.
Urology 2009;73(4):748749.

22
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

3 Bad airway in the Andes

Christopher J. Gallagher and Khoa Nguyen

The case made to make sure the patient and her family under-
stand everything that is being discussed. Make sure
They dont have electricity up there, in the moun-
to answer all questions asked by the patient and fam-
tains, the plastic surgeon told me. Its all oil lamps.
ily after listening to all their concerns. Having a local
Kerosene. And then the kids, you know, theyre crawl-
translate may also be helpful in that he or she could
ing around, pulling on things, so they pull on the blan-
give you an idea of what may be considered appro-
ket thats hanging down, and everything comes down
priate and disrespectful behavior in this region of the
on them. The lamp, too. Thats 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 about
ica all the time, but you dont see scarring like this.
their patients.
No, the surgeon said, you dont.
Maria Luisas lip was fused to her chest, her 13- As accurately as possible, get a detailed history
year-old head bent straight down, forcing her to be from the patient and her family regarding the injury
forever 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 of
fused 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 and
pital. They didnt have any fiber-optic equipment here. therapeutic interventions based on patient
How 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 of
Residents must be able to provide patient care that resources in our current location and the severity of
is compassionate, appropriate, and effective for the her injuries, the patient and her family should be given
treatment of health problems and the promotion of a detailed explanation of all the risks, benefits, and
health. 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 the
local language) fluently, then make sure that some- airway, what if we cannot extubate? Can the facility
one who does is in the room to translate. As a part handle such a patient postoperatively? Laryngeal mask 23
of being respectful and caring, every effort should be airways seem to work well in these types of patients,
 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 exotic
24 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
 Case 3 Bad airway in the Andes

arsenal 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 village
learn more about the health care system and the larger knows that Maria is going to surgery, but keeping the
hospitals in the area, if needed, to better acquaint your- details of the operation private may provide some level
self with what youre 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 the
is always helpful to read case studies on how others people of region. You tried your best to make Maria feel
obtained 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 to
write up the case with all the details and cross reference
skills
them with the current case reports. The more infor- Residents must be able to demonstrate interpersonal
mation 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, their
how 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.
Professionalism
Residents 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 family
ical principles, and sensitivity to a diverse patient pop- fully understood everything that was involved in the
ulation. case. Part of sustaining a sound relationship entails
obtaining the patients 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 translator
understand all that was discussed, and provide the best speak, although we can only catch bits and pieces of
care 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
 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 dont 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
 Case 3 Bad airway in the Andes

Additional reading pediatric-burned patient: a new solution to an old

problem. Paediatr Anaesth 2006;16:360361.
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 Anesthesiol
2. Khan RM, Verma V, Bhradwaj A, et al. Difficult
1996;13:527535.
laryngeal mask airway placement in a

27
 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 nobodys 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 familys 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 about
28 their patients. As stated previously, honest and open discus-
sions with the family regarding the patients status are
 Case 4 Wedge is 18; he must be full

important to help minimize stress. They should be Medical knowledge

informed 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 cognate
ity 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 computed
tomography (CT) angiogram to assess the repair. Also, Currently the patient is being treated for low urine
depending 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 coronary
would 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 is
paramount. The patient should be on broad-spectrum Know and apply the basic and clinically
IV antibiotics. It is important to perform frequent supportive sciences that are appropriate to their
suctioning 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. Being
Also, turning the patient at least every 2 hours would
aware of the fluid shifts and hemodynamic changes
help with preventing decubitus ulcers, and placing
and their consequences is important. The low urine
sequential compression devices (SCDs) would ward off
output implies decreased perfusion of the kidneys but
acute 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-side
As in this case, the renal service was consulted due to atrial pressure, normal being approximately 612. Ele-
low urine output and the appropriate management was vation would be due to either a cardiac or pulmonary
implemented. However, consults are not golden, and cause. When interpreting the data, understanding the
so their recommendations should be factored into the Startling curve is helpful. A wedge of 18 may be present
equation. 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 29
answered by the surgeon. result, including fluid overload and/or ARDS.
 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 patients 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 patients prognosis, at some point,
would have been medically optimized and assessed for there may need to be a discussion with the family about
30 appropriateness to undergo an EVAR procedure. do not resuscitate/do not intubate (DNR/DNI) status.
 Case 4 Wedge is 18; he must be full

Integrity would be demonstrated by ensuring that Use effective listening skills and elicit and provide
everything 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 to
discuss the matter with the CT tech to have the scan Allowing the patient to talk and ask questions is the
done 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 or
family of an intubated patient is usually done with a
leader of a health care team or other professional
designated 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 demonstrates
tions, 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 system
to deal with individuals from many different back- resources to provide care that is of optimal value.
grounds with various beliefs and disabilities. Simply
being dedicated to the patient and his or her well- Understand how their patient care and other
being, without bias, fulfills this requirement. professional practices affect other health care
professionals, the health care organization, and
Interpersonal and communication the larger society and how these elements of the
system affect their own practice.
skills
Residents must be able to demonstrate interpersonal The patient was taken to surgery for a minimally
and communication skills that result in effective infor- invasive procedure to repair an AAA and was taken
mation 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 resource
you care, are approachable, and are open in your dis- allocation that does not compromise quality of
cussions with him or her, you will have effectively care.
developed a sound relationship. 31
 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 patients 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
 Case 4 Wedge is 18; he must be full

Additional reading 3. Greenhalgh RM, Brown LC, Epstein D, et al.

Endovascular aneurysm repair versus open repair in
1. 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;365:21792186.
S174S185.
4. Vincent J-L, Pinsky MR, Sprung CL, et al. The
2. 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;36:30933096.
patients with acute lung injury and acute respiratory
distress syndrome. Intensive Care Med 2002;28:
10731077.

33
 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 patients family. If and when the patient becomes more
 Case 5 Calling across specialties

stable, a conversation could be held with the family teamwork between the anesthesia, surgical, and nurs-
regarding the patients status. If the outcome is poor ing personnel. Morbidity and mortality will be reduced
with this patient, the wishes of the patient and the if patient care is a team effort
family regarding end-of-life care, further resuscitation,
and possible organ donation need consideration. Even
if the patient and family were educated regarding all Medical knowledge
possible 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 analytic
of 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 patients 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 Cordis
placement. Conversation between the anesthesiologist Know and apply the basic and clinically
and surgeon will need to take place because this patient supportive sciences that are appropriate to their
is likely in the lateral position, which may make line discipline.
placement extremely difficult. Cross-matched blood
and fluids need to be run wide open in this patient. The This patient is having this procedure likely because
use 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 with
lines, and praying, the anesthesiologist should ask the esophageal cancer include the following:
circulating nurse to page the primary care doctor stat
to find out when this patient last had the flu shot and  chronic alcohol use (increase MAC)
his most recent colonoscopy. (Just kidding!)  liver disease (drug metabolism)
Prior to this catastrophic event, antibiotics should  significant smoking history (ventilatory
be given prior to incision within an hour. Assessment difficulties, COPD)
of need and continuation of beta-blockers should also  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 35
it will be absolutely necessary to have rapid and fluid care.
 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:
 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 patients family. As physi-
 Was there enough surgical exposure? Should cians, we must act with integrity at all times by keeping
cardiopulmonary bypass (CPB) have been more the patients 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).
 Case 5 Calling across specialties

Patients come from all different backgrounds, and When these critical events are happening with this
this 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 females 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 calls
operative team may need to be assembled. for help, make a crash cart available, and be ready to
Showing respect to patients isnt 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 know
Residents must be able to demonstrate interpersonal
about this patient to make sure plenty of vasopressors
and communication skills that result in effective infor-
are made available for inotropic support.
mation exchange and teaming with patients, their
patients 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 system
preoperative 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 other
stand. Let the patient know of possible complica-
professional practices affect other health care
tions and adverse outcomes, and discuss his or her
professionals, the health care organization, and
wishes with the patient should extremely poor out-
the larger society and how these elements of the
comes 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 best
cians 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 hypovolemic
anxiety. 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 as
that they can understand, including about all risks, a wasted resource.
benefits, alternatives to the surgery, and anesthetic
management. This will need to be done with the coop- Practice cost-effective health care and resource
eration of the surgeon. Proper documentation of these allocation that does not compromise quality of
discussions 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 become
documentation 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
 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 wouldnt 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
 Case 5 Calling across specialties

Additional reading
1. Nguyen NT, Hinojosa MW, Smith BR, Chang KJ, Gray
J, Hoyt D. Minimally invasive esophagectomy: lessons
learned from 104 operations. Ann Surg
2008;248:10811091.

39
 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 worlds shortest chin and neck. You are airway.
alone in this setting as its 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
 Case 6 Extubation wrecking a perfectly good Sunday

sciences 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 practice
formulate a plan with the help of others and carry out Residents must demonstrate an awareness of and
that plan as safely as possible. If the patients vital signs responsiveness to the larger context and system of
are stable, I would attempt to reintubate, with the sur- health care and the ability to effectively call on system
geons standing by to perform a surgical airway. resources to provide care that is of optimal value.
Practice cost-effective health care and resource
Practice-based learning allocation that does not compromise quality of
care.
and improvement
Residents must be able to investigate and evaluate their It would be cost-effective to intubate this patient as
patient care practices, appraise and assimilate scientific quickly as possible to prevent any further damage to
evidence, 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
 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):11681171.
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):25412543. endotracheal tubes in the intensive care unit. Nurs Crit
Care 2009;14(2):6874.

42
 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 Posner

The 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 tendon
peels off its attachment to the bone and goes fip-fip-fip After all is said and done, I would counsel the
up 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 about
tion (thick, muscular neck; Mallampati class IV view; this problem.
big teeth), so you do an awake intubation.
The case goes well, and now its time to extubate. Provide health care services aimed at preventing
You do all the cautious stuff sitting him up, making health problems or maintaining health.
sure hes wide awake. You extubate, and within roughly
To prevent future problems, I would counsel this
6 nanoseconds, you see that this was not the bright-
patient to lose weight and also to keep his doctors
est 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 color
looks less than reassuring. He has neither lost weight Work with health care professionals, including
nor improved his airway since last you intubated him, those from other disciplines, to provide
which 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 is
compassionate, 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 no
family around, the best thing would be to reintubate Demonstrate an investigatory and analytic
this patient as quickly and safely as possible. When the thinking approach to clinical situations.
patient is in the recovery room, I would then explain
to 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 improvement
bation.
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.
 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! Weve 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
 Case 7 The sin of pride after an awake intubation

Additional reading 2. de Almeida MC, Pederneiras SG, Chiaroni S, de Souza

L, Locks GF. Evaluation of tracheal intubation
1. 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;56:38.
Anesthesiology 2009;110:891897.

45
 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 Cupids 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 boys 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
mans 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 hes trolled? Do we have good access, or are we working off
going to the operating room (OR) for removal. He cant 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 guys 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 isnt 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
mans strong suit (the overwhelming majority of lovers patient who cannot be moved and maintaining hemo-
quarrels fortunately dont end up in a stabbing), but dynamic stability in a patient with a major vascular
its 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
(hes 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 patients 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,
 Case 8 Brown-Sequard and the orthopedic knife extraction

factor VII, etc.). Ideally, we would like to be able to removed, we have to be ready for the inevitable change
isolate the lungs to aid the surgeons, but all our plans in hemodynamics (huge fluid shifts; the potential need
need 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 in
the 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 us
severity of the situation and should be provided with much now, the possible decrease in spinal cord reflexes
whatever support is available (e.g., a chaplain should and the potential drop in SBP may complicate issues
be 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 play
a role. Many hospitals now have integrated computer Not only should we be aware of the immediate
systems, 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 patients angiogram and any other studies he may ing of antibiotics, steroid administration for spinal
have 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 and
skill. For all intents and purposes, we are living an oral Eventually, this patient is going to have significant
boards 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 psych
the blood in him. While we are going to ensure that and social work, to name a few).
the patient is adequately anesthetized and will have
a fiber optic ready, with support to help us use it, as Medical knowledge
well 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 cognate
weird position in a pinch), we are also going to want
(e.g., epidemiological and social-behavioral) sciences
surgery to have open and ready everything necessary
and the application of this knowledge to patient care.
to do an emergent tracheostomy or cricothyrotomy
should the need arise. Apart from appropriate Amer- Demonstrate an investigatory and analytic
ican Society of Anesthesiologists (ASA) monitors, we thinking approach to clinical situations.
would need invasive monitoring such as ALine (both
right arm and femoral monitoring would be nice to In this very complicated case, it was extremely
monitor perfusion pressures both above and below the important to break things down into recognizable and
aortic lesion) as well as central access for both fluids manageable pieces that the resident had likely seen
and medications. Perfusionists may want to prepare before. Understanding that airway management would 47
for partial CPB, if necessary. When the knife is finally be difficult and being prepared with knowledge of
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

the difficult airway algorithm were key. Recognizing  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 patients 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 Its hard to think of a case for which this com-
include the following: petency is more relevant. While its unlikely that
 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
 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 patient
48 began to decompensate, were OR and anesthesia Obviously, this sort of case doesnt 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
 Case 8 Brown-Sequard and the orthopedic knife extraction

be the only reasonable way to effectively evaluate this type of case, and a whirlwind of people are going
type 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 arent 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 of
any significant clinical investigation. Other resources, Interpersonal and communication
however, can add some depth and perspective to a res-
idents education. Plugging a term into a search engine
skills
like Google is bound to return a host of places to Residents must be able to demonstrate interpersonal
begin to get information, as is doing a wiki search. and communication skills that result in effective infor-
While many of these sources arent peer reviewed and mation exchange and teaming with patients, their
their 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 ethically
sites have message boards or forums, in which people sound relationship with patients.
post information about cases they have done and novel
ways 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 out
Professionalism of your heart establishes a relationship pretty damn
Residents must demonstrate a commitment to carry- fast. In reality, though, its the role of the anesthesiol-
ing out professional responsibilities, adherence to eth- ogist to be a reassuring and calming presence in what
ical 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 checking
to talk about. When everyone has finally scrubbed blood products and medications helps prevent poten-
out, youll want to tell a coresident and the nurses tially devastating errors. While in the heat of a trauma
and maintenance and that nice lady in the cafeteria paper work seems tertiary at best, the OR record is a
and . . . 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, medications
sitivity for the patient and his family and loved ones is and fluids given, and lab results like arterial blood
as 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 have
Miller combined), and identifiers like names or dates huge medical and legal implications.
of birth shouldnt be included when referring to the
Work effectively with others as a member or
case 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 49
but 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.
 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 members 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, its 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 (lets 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
 Case 8 Brown-Sequard and the orthopedic knife extraction

Additional reading neurological syndrome. Spinal Cord 2005;43:

678679.
1. Jonker Frederik HW, Schlosser Felix JV, Moll Frans L,
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;16:7180. (Tokyo) 2004;44:263265.
2. Harris P. Stab wound of the back causing an acute
subdural haematoma and a Brown-Sequard

51
 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 hospitals 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 youre 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 arent 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. Theyre I know takes a surgeon at his word on something as
stented open, after all! The ENT surgeon, who doesnt 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 patients 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 patients 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 doesnt 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; dont open with some- information and preferences, up-to-date scientific
thing like Sir, Ive 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-eluting
52 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
 Case 9 When were those stents placed?

metal stent, the procedure should be postponed for

Know and apply the basic and clinically
a least 6 weeks not 2 days [2]. Even if the surgeon
supportive sciences that are appropriate to their
is willing to operate on a patient who remains on
discipline.
antiplatelet therapy, the perioperative period induces
a hypercoagulable state, which makes the risk of stent The key issue here is the drug-eluting stents. You
thrombosis unacceptable. You should be prepared to need to know that a minimum of 1 year of antiplatelet
integrate 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 risks
case. 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 learning
To properly counsel the patient, you need to know and improvement
this stuff like the back of your hand. Maybe the rea-
Residents must be able to investigate and evaluate their
son the surgeon is so gung ho to go ahead is because
patient care practices, appraise and assimilate scientific
she doesnt really understand the risks either. This
evidence, and improve their patient care practices.
could present a golden opportunity not only to educate
your patient, but also to educate one of your surgical
Locate, appraise, and assimilate evidence from
colleagues.
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 evidence
of going ahead with the surgery beforehand than it is you need. You could also consult a textbook or a more
to discuss what the hell just happened after you had to highly regarded colleague every department has a
shock 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 be
noted that timing is pretty important here. You should
have this conversation in the holding area, not in the Professionalism
operating 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 knowledge
Residents must demonstrate knowledge about estab- Demonstrate respect, compassion, and integrity; a
lished 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 to
and 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. If
cardiologist. After you have gathered some informa- you are having a disagreement with a surgeon, dont
tion, analyze it. What are the benefits of this procedure, take it personally; you should simply think about the
and what are the potential risks? With this informa- implications for the patient. This will help you keep 53
tion, you can decide on the best approach going for- a cool head while dealing with your colleague on the
ward. other side of the ether screen.
 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 patients best interests at heart. Even if you conflict in a professional manner so that nobodys 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 dont 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 patients 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, dont send the patient for an echo. It is
time to listen to the patients 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 elses problem. This will probably add costs,
Systems-based practice and nothing else, to the patients 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. Dont just pass the buck.

54
 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 stent
1. Rabbitts JA, Nuttall G, Brown M, et al. Cardiac risk of
percutaneous coronary intervention. Anesthesiology
noncardiac surgery after percutaneous coronary
2008;109:588595.
intervention with drug-eluting stents. Anesthesiology
2008;109:596604.

55
 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 youre going to intubate or what exactly Gather essential and accurate information about
the plan is. their patients.
Morphine, the resident tells you again. Thats the
plan, you follow me? Hes 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  arterial blood gas, including carbon monoxide
and respectful behaviors when interacting with level
patients and their families.  hematocrit
 electrocardiogram
This is based on a real case, believe it or not. No one
 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 Zoneesque that he
that youre 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 its 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 we
56 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 werent writing someone off who
 Case 10 Flame on!

stood a chance. That was the consensus, and the burn Demonstrate an investigatory and analytic
people came down and gave us their blessing on this, thinking approach to clinical situations.
too.
Shift into high gear and become the worlds 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 doesnt 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  Watch for signs of an upper airway burn (singed
of 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  Volume replacement can be tremendous as the
as professionalism all wrapped into one. Ill get into insulation is lost and the patient loses vast
what I told the guy in the latter section. amounts of fluid.
 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.
its 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 didnt 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 large
cuers 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 Im doing The most practical approach to this Core Clinical
the 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 on
Medical knowledge the latest.
Residents must demonstrate knowledge about estab- Locate, appraise, and assimilate evidence from
lished and evolving biomedical, clinical, and cognate scientific studies related to their patients health
(e.g., epidemiological and social-behavioral) sciences problems. 57
and the application of this knowledge to patient care.
 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 patients 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 dont 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? Heres 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 youre lost This is the most important aspect of this case, so
in statistics. Ill 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 heres what I did. Ill call the patient, for
the Internet was not yet even a glimmer in Bill Gatess the sake of this reconstruction, Jim Smith.
eye. But today, of course, youd Google anything you Jim, Im going to be giving you some morphine to
didnt know. make you a little more comfortable.
Its bad, huh? (As mentioned earlier, he was sur-
prisingly lucid.)
Professionalism Jim, youre burned over all your body, and its all
Residents must demonstrate a commitment to carry- third degree, thats the worst kind.
ing out professional responsibilities, adherence to ethi- Its 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 didnt 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 Im going to make sure youre 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, were mainly going to make sure you
professional development. dont hurt. Do you follow what Im 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.
 Case 10 Flame on!

Yeah, yeah, I know what youre 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, and
finished him. I was hoping that it would go that way the larger society and how these elements of the
and 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 societys resources when the issue has already been
I 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 resource
Residents must demonstrate an awareness of and allocation that does not compromise quality of
responsiveness to the larger context and system of care.
health care and the ability to effectively call on system
resources to provide care that is of optimal value. See the preceding comment.

59
 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;30:190191.
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;96:111117.
2009;122:525529.

60
 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 Kogan

The case emaciation could only confirm the obvious no mat-

ter what they found on this patient, he was not going to
A 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 and
least, getting short of breath if hes anything other than
therapeutic interventions based on patient
bolt 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 the
operating table with the back all the way up, and youre The main point about this case and this write-up is
preoxygenating him. Its all you can do to get the satu- that you have to be a perioperative physician, not just
ration 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, Im 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 date
do you want carved in this guys stone? You might as Counsel and educate patients and their families.
well carve todays 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 spell
Patient care out the entire picture. When I went out and talked
Residents must be able to provide patient care that is with the patients family, I asked what they pictured us
compassionate, appropriate, and effective for the treat- doing, and they all agreed that he was far too sick to
ment 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, youre
Communicate effectively and demonstrate caring going to think Im 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 patient
this for was not, precisely, caring and respectful, but it care decisions and patient education.
sure was effective! The main thing here was to take a
step back and look at the whole picture, not just this A complete review of the computed tomography
one procedure. scans confirmed that this guys 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 of
firmed everything I needed to know about this man. practice. 61
The severe degree of disability and advanced state of
 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 whats 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
Its 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 didnt 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. Theres 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. Dont think do anesthe- that supersedes self-interest; accountability to
sia for this one procedure; rather, think do whats 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 wont 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 skills
62 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
 Case 11 What date would you like carved in stone?

information exchange and teaming with patients, their Systems-based practice

patients 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 other
I dealt with the familys concerns. A major point is to professional practices affect other health care
let them have their say and not try to steer the conver- professionals, the health care organization, and
sation 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 well
group. do with this information. Thats what made me throw
up my hands and say, Enough! So we find out its
Of course, the surgeon got fussy, but what can this or that cancer. Are we going to treat it anyway?
you do? Theyre always mad. Maybe we should sneak If the answer is no, then dont do the case in the first
Prozac into their cornflakes? place.

63
 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;20:13. patients: better words to say. JAMA 2009;301:
12791281.
2. Marik PE, Callahan A, Paganelli G, Reville B, Parks
SM, Delgado EM. Multidisciplinary family meetings in

64
 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 Sharma

The case Gather essential and accurate information about

A 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, and
resection of the right lower lobe. The patient had a his-
address anxiety preoperatively. This is the compassion
tory 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 of
brought back to the operating room, and induced and
the hand can do wonders in alleviating preop jitters
intubated 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 and
case and was completely unaware of our quick and therapeutic interventions based on patient
stoic measures to battle the beast of anesthesia, the information and preferences, up-to-date scientific
spasm, 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 of
are behind the drapes, but this phrase reminded me of the chart and confirmed her history, allergies, and all
People 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 was
Patient 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 the
is compassionate, appropriate, and effective for the Proventil.
treatment of health problems and the promotion of
health. 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 an
was 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 invasive
and make her as comfortable as possible. I maintained procedures considered essential for the area of
good eye contact, answered the patients questions, and practice.
smiled . . . then versed incoming! 65
 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 physicians 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
 investigation wrong way. In this case, I felt compassion that super-
 formulation of a hypothesis seded any legal guidelines involving physical contact
 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
 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. Anesthesias friends were all attending stood by me, one hand in the patients 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, Senor sion, and it was more than any textbook could ever
fiber optic. teach me.
 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. How
radiation, my attending and I were very aware of the can we talk to them theyre asleep!
guarded nature of patients who have been in the health In this case, however, it was demonstrated that
care system. They are often weary of medical profes- effective communication has no time constraint and
sionals 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 clues
medical 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 professional
Interpersonal and communication group.
skills
The cardiothoracic (CT) surgeon approached me
Residents must be able to demonstrate interpersonal
and said, You know, I just wanted to thank you for
and communication skills that result in effective infor-
your care with that patient the other day. I saw her
mation exchange and teaming with patients, their
today, and she mentioned that the anesthesiologist was
patients 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 are
wrong 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
 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;89:307310, 313315, 318320.
Helium-sevoflurane association: a rescue treatment in
case of acute severe asthma (in French). Ann Fr
Anesth Reanim 2009;28:8285.

68
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

13 Why dont you join the HIT parade?

HIT in a cardiac surgery patient
Bharathi Scott and Jason Daras

The case on a clinical basis and is supported with the previously

mentioned tests and therapy.
A 70-year-old male is scheduled for coronary artery
bypass 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 the
disease 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 commonly
as 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 dosage
induced thrombocytopenia]. We stopped heparin yes- is adjusted accordingly. Dosage is reduced in patients
terday 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 care
Residents must be able to provide patient care that is Perform competently all medical and invasive
compassionate, appropriate, and effective for the treat- procedures considered essential for the area of
ment 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 blood
the special issues involved in the anticoagulation man- products should be readily available.
agement with the patient, surgeon, and other members
of the operating room (OR) team, especially the perfu- Work with health care professionals, including
sionists. 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 must
priate steps are taken to provide alternative anticoag- be included.
ulation for surgery. This includes special attention to
platelet count and response to cessation of heparin.
Check the platelet factor 4 antibodies in vitro to Medical knowledge
confirm the diagnosis of HIT (type II). In addition, it is Residents must demonstrate knowledge about estab- 69
important to recognize that diagnosis of HIT is made lished and evolving biomedical, clinical, and cognate
 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? Ill 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 Jehovahs 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.
 Case 13 Why dont 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 the
ogists have more of a problem forming relationships system affect their own practice.
with patients because the majority of our interaction is
under anesthesia. However, through our preoperative We must all understand our role in the health care
visit bedside and postoperative visit, we can communi- system and our limitations. Sometimes we go above
cate all our concerns, and the patients can communi- and beyond what we may have to do to save a patients
cate 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-effective
a unique medical condition. Many people working on
medicine should not compromise patient care. How
the 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 bleed
ing with this patient it happens. Dont be a cowboy;
more intraop, and patients will be receiving vari-
read and communicate. Dont be afraid to talk to the
ous blood products. Keeping a mindful watch on the
surgeons 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 blood
Residents 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 O2
resources to provide care that is of optimal value. flows!

71
 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;126:311S337S.

72
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

14 Bad lungs in the ICU

Shaji Poovathor and Rany Makaryus

The case Gather essential and accurate information about

A full-term, 24-year-old, pregnant African American their patients.
woman was rushed to the operating room (OR) for
emergency 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, frothy
in 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 and
of blood. She received 10 units of packed red blood
therapeutic interventions based on patient
cells, 10 units of fresh frozen plasmas, 2 units of cry-
information and preferences, up-to-date scientific
oprecipitate, and multiple boluses of crystalloids. She
evidence, and clinical judgment.
was left intubated and was admitted to the surgical
intensive 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 acute
tube. respiratory distress syndrome (ARDS)? Can she
develop pulmonary embolism (PE)? Can she develop
sepsis? The answer is yes, she could develop any one
Patient care of these. Again, clinical judgment warrants looking for
Residents 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 for
communicate effectively with the primary service who antibiotics in terms of prophylaxis, unless and until
operated on her. Make sure that the family members there is solid evidence of wrong bugs in the wrong
and 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 so
family members updated. What can we do? What are that she doesnt yank off her tube. Also give vaso-
the unfortunate outcomes? Could there be any other pressors, if needed, to support hemodynamics, and get
alternative? Does the patient have a living will? labs to ensure that she is not bleeding, not going into, 73
 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 dont 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 patients 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 dont 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 provide
74 patient-focused care. 1. massive blood loss
2. massive transfusion
 Case 14 Bad lungs in the ICU

3. hit to the lungs: TRALI

Obtain and use information about their own
4. 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 ventilation
6. 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 the
Practice-based learning prevention of TRALI in multiparous women.
and improvement
Apply knowledge of study designs and statistical
Residents must be able to investigate and evaluate their
methods to the appraisal of clinical studies and
patient care practices, appraise and assimilate scientific
other information on diagnostic and therapeutic
evidence, 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 a
cal Competency is concerned! The hospital, obstetric- high index of suspicion
gynecological (OB-GYN) service, anesthesiology, and 2. the ARDS net trial study with low plateau pressure
the critical care service team should all have contin- and low tidal volume, minimizing lung damage
uous quality improvement committees. As previously 3. literature on deep venous thrombosis prophylaxis:
mentioned, difficult cases, complications, deaths all heparin versus fractionated heparin
these things demand a systematic analysis afterward.
Were there any other alternatives to doing this case Use information technology to manage
in 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 hit
with 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. Entering
hypercapnia 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 with
this reaction. Anesthesia and medicine are ever chang- Professionalism
ing 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 patients care team ulation.
to look up the most recent literature on TRALI and
transfusion-associated circulatory overload (TACO): Demonstrate respect, compassion, and integrity; a
responsiveness to the needs of patients and society
1. Whats better a continuous positive airway
that supersedes self-interest; accountability to
pressure (CPAP) machine, or no CPAP?
patients, society, and the profession; and a
2. Should the patient be placed on an oscillator? commitment to excellence and ongoing
3. What monitoring devices have been proven to be professional development. 75
best in this situation?
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

This is demonstrated by the teams 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
patients 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 patients wishes in mind. Many times, This involves the following:
advanced directives may restrict care that we may be  Notify the family of the seriousness of the issue.
able to give as anesthesiologists. We may sometimes  Notify risk management.
want to do more for the patient, but such directives  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  Involve the organ donation task force.
consistent with what the patients wishes are or would  Notify the pastor.
have been. Saying that is the easy part, but figuring it  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 patients family your Maintain hemodynamics and avoid barotrauma/
dynamic attention. (Dont be texting while youre 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 of
76 explanatory, questioning, and writing skills. care.
 Case 14 Bad lungs in the ICU

The primary concern here is to avoid further dam- wrestling with the consequences of the operation. Your
age to the other organs as the lungs are already bad and advocacy for quality patient care will manifest as you
crunched. Be aware of the hospitals policy on notify- continue to take good care of all physiologic variables
ing the organ procurement team, how much lead time (which can be tough, as the brain-dead patient can
they 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; this
ful 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 their
could 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 very
expensive); avoid frequent and unnecessary labs; and Know how to partner with health care managers
to 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 these
physiologic environment for the patients 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 patients
complexities at this point are the family members, care.

77
 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:R601R605.
Care Med 2007;175:160166.
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;75:339348.
of inflammation in patients with acute lung injury.
Crit Care Med 2005;33:16. 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;55:204205.
acute respiratory distress syndrome. N Engl J Med
2000;342:13011308.

78
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

15 A simple breast biopsy

Neera Tewari and Ramtin Cohanim

The case The patient refused to take PO Bicitra. After 2

mg of IV midazolam, the patient is calm, and you
A 61-year-old woman is scheduled for a breast biopsy.
think, This wasnt that bad. In the OR, the rapid
Her 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/vomiting
nonverbal. Her sister understands her nonverbal cues
prophylaxis and a propofol infusion was maintained
and 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 its nice to be back
agents used. The patient is extubated, comfortable, and
at work after a relaxing weekend. Youve had your first
taken to recovery. Her sister soon joins her to keep her
cup of coffee, the drugs are drawn up, the machine is
calm as the anesthetic wears off.
checked, the operating room (OR) is almost ready to
go and the nurses tell you that they need 15 more
minutes to set up and see the patient. You go out to Patient care
holding to meet your first patient. As you draw the cur- Residents must be able to provide patient care that is
tain, 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 wearing
a hospital gown, a hair cap, and thick mismatching Communicate effectively and demonstrate caring
socks. She sees you and shrieks (loudly!). The woman and respectful behaviors when interacting with
in 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 the
is again in a calm trance. details of the anesthetic with the patients sister. You
The patient has no known allergies, has a history must also understand how the patient and her sister
of nausea and vomiting from prior general anesthet- communicate with each other and how you can make
ics, weighs about 68 kg, and has poor dentition and it as comfortable of an experience for both the patient
a MP class I airway (you couldnt help but notice as and the family as possible. Including the family in the
she 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 while
to 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. The
lar) darts, EMLA (eutectic mixture of local anesthetic), patient refused PO Bicitra, so attempting PO sedation
mask induction, and IV induction, the sister explains [2] would have been difficult. A mask induction or an
that the patient will allow you to start an IV if you IM injection are possible but would be hard to do in a
do it in the holding area, while she is present and noncompliant, anxious, combative patient. Remember
the 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 with
ing your rather loud welcome, you quickly locate your the patient and is able to manage her well. It is to our
resident, present the patient, and observe while she advantage and the patients benefit to incorporate the 79
smoothly obtains IV access. Excellent! family in her care.
 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 patients 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 their
80 care decisions and patient education. discipline.
 Case 15 A simple breast biopsy

The past medical history includes GERD you This patient is a 61-year-old woman with a history
must 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 in
a patient with GERD [1]? Interpersonal and communication
skills
Professionalism Residents must be able to demonstrate interpersonal
Residents 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, their
ical 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 (dont ignore her). If her sister is able to communicate
up 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 and
family, even if she did greet you with a deafening shriek Use effective listening skills and elicit and provide
when 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. Make
you 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 dont 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 or
review the consent with the sister, confirm the site of leader of a health care team or other professional
surgery, 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 is
details of the case while riding the elevator! delayed, discuss this with the holding area. Postoper-
atively, discuss the patients 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
 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;91:837855.
of gastric contents in anesthetic practice. Anesth Analg
2001;93:494513.
2. Petros AJ. Oral ketamine: its use for mentally retarded
adults requiring day care dental treatment.
Anesthesiology 1991;46:646647.

82
 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 Hussain
The case thoroughly addressed. In so doing, patients and their
families are integral members of the decision-making
Your 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 will
increasingly innovative ways to take things out of peo-
be conveyed to the patients by a representative from
ple 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 the
measured 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 hospitals acute pain ser- Medical knowledge
vice 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 patient
He says that where hes from in Europe, there is this guy care.
named Dr. Kehlet, and hes always talking about multi-
modal analgesia and fast-track protocols. You see, the Know and apply the basic and clinically
longer you stay in the hospital, the more bad things supportive sciences that are appropriate to their
can 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, specific
Patient care to this case, the resident should be able to discuss
Residents must be able to provide patient care that is the pathophysiology of the postoperative patient. For
compassionate, appropriate, and effective for the treat- example, to support the use of neuraxial blockade in
ment 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 postoperative
and benefits of epidural anesthesia, particularly as it morbidity must be identified and addressed.
pertains to colorectal surgery. One could explain, for
example, that although there is a risk of a postdu- Practice-based learning
ral puncture headache, it is far less than the chance
for postoperative incisional pain, which would com- and improvement
promise early ambulation, which has its own conse- Residents must be able to investigate and evaluate their
quences. If patients are taking blood thinners, the risks patient care practices, appraise and assimilate scientific
and benefits of stopping these medications need to be evidence, and improve their patient care practices. 83
 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
 Case 16 Fast-track perioperative management of patients having a laparoscopic colectomy for colon cancer

Additional 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;109:6166.
discharge: does it work in gynecologic surgery. Am J
Ob Gyn 2008;199:541.

85
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

17 Treatment of complex regional pain

syndrome when the payer doesnt know
anything about what you are treating
Marco Palmieri and Brian Durkin
The case growing inpatient with her, so its 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 clients
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 patients 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, workers 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 doesnt 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 doesnt even touch the pain. and nerve blocks, and (3) psychological counseling.
Shes 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 theyll 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 weeks 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.
 Case 17 Treatment of complex regional pain syndrome

Finally, you start her on lidocaine 5% patches and tell Your office staff lets you know a couple days after
her to place three over her right lower leg and foot. your initial consultation that workers compensation
You give her some hydrocodone/APAP so she doesnt wants an independent medical examiner (IME) to
go into withdrawal and tell her to limit her acetami- evaluate the patient. The following week, you find out
nophen to less than 34 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 cant
know that you are trying to find a psychologist who believe what you see. Did this doctor see the same
specializes in pain control, but the closest one avail- patient? Did I miss something? Wasnt this an ankle
able is about an hour away. The pain psychiatrist at injury? You call the workers compensation office, and
your institution is too busy and is not taking any new they tell you that they have to stand by what the IME
patients, and the institution is not hiring anyone, ever says, and maybe you should call him yourself.
(I know it doesnt make sense). So you must now Having been a big fan of the Hardy Boys when you
wear the hat of a psychologist and counsel her appro- were a kid, you decide to do some investigating. Lets
priately. You may even try to find some cognitive- get him on the phone and work this out. You Google
behavioral exercises or desensitization techniques that him and find several phone numbers scattered around
may be helpful. different locations. You also find a Web page that gives
Thats 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 in
up. 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 give
her 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 it
is 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 IMEs 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. Well for-
for you and your patient, that the block can be both ward this to our doctor. Yall from New York, huh?
diagnostic and therapeutic, and whamo, you can nail
your diagnosis. There is little evidence-based informa-
tion regarding the proper timing, number, or appro-
Medical knowledge
priateness 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 cognate
and to enable patients to resume functional rehabilita- (e.g., epidemiological and social-behavioral) sciences
tion, 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
 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 dont 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 patients personal information to yourself,
and lymphedema. in keeping with HIPAA policy.

88
 Case 17 Treatment of complex regional pain syndrome

Additional reading 2. Cepeda M, Lau J, Carr DB. Defining the therapeutic

role of local anesthetic sympathetic blockade in
1. 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;18:216233.
regional pain syndromes: a double blind
placebo-controlled crossover trial. Anesthesiology
2009;111:372380.

89
 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-
patients 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 dont, 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 dont, 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 patients 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 hasnt done any research about us, she
ally inserted central (PIC) line with ultrasound guid- hasnt 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. Thats 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
 Case 18 OB case with cancer and hypercoagulable state

patient before you meet her. Pick up her chart, review concerned about the clots because the catheter would
her medical history, speak to other physicians caring be placed proximal to her SVC clots, and explained
for 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 patients
her room and start speaking at her. Which brings me respect and trust and used good clinical judgment in
to my next point: dont speak at your patients; rather, knowing my limitation of knowledge with respect to
speak to them. Most of our patients have not gone PIC lines, and I went to the appropriate resources to get
through medical school like we have. Dumb it down a the patient sound, truthful information. Part of good
little. Introduce yourself, extend your hand, get down patient care is knowing your limitations and when to
to the patients eye level, sit down next to her if you ask for help.
can. We are not in a hurry, right? We have nothing else
to do, right? Wrong, but the patient does not need to Provide health care services aimed at preventing
know 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 shouldnt be a prob-
Know as much about your patient as you can before lem, well deal with it when the time comes. Dont
you meet her. Your history and physical should be think so! Part of good patient care is always staying one
an opportunity to confirm what you already know step ahead. Making sure that general surgery would be
about the patient and clarify some loose ends. This available for backup prior to induction of this patient
will instantly set the patient at ease and win you many was mandatory, not optional. Remember, lets not get
brownie points. If the patient senses that you are learn- caught with our pants down.
ing about her for the first time, as you are speaking
to 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. Dont 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 good
thing, you wont get caught in a compromising situ-
deal about what will happen to them, oftentimes,
ation.
they are misunderstood or misinformed. Dont 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 for
them will be. Wrong. While we are highly educated, Medical knowledge
trained professionals, we dont know everything. If you
Residents must demonstrate knowledge about estab-
dont already know that, you need help. Listen to your
lished and evolving biomedical, clinical, and cog-
patients 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 patient
utmost importance. We suggested to the patient the
care.
placement of a PIC line. The patient was concerned
because of the clots she had in her superior vena cava. Demonstrate an investigatory and analytic
Good point; did I think of that? Well, sort of, but Ill thinking approach to clinical situations.
just let the interventional radiology people deal with
it, right? No, I listened to the patient, acknowledged Come to your cases with a plan in mind. Dont
her concerns, and consulted with the interventional leave it to your attending to dictate what you are going
radiologists. I then shared the facts of my conversa- to do with your patient. Youll never learn anything 91
tion with the patient, explained that she need not be that way. Use your cases as a vehicle to draw out
 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; its 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 youre 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. Thats 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 dont know, ask; better yet, look it up. As anesthesiologists, we deal with life-and-death
Evidence-based medicine, kids its 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 to
92 to conferences; see whats out there. Suck it all up and patients culture, age, gender, and disabilities.
incorporate it into your practice as you see fit.
 Case 18 OB case with cancer and hypercoagulable state

Though it is difficult to understand and support the Understand how their patient care and other
incomprehensible decision to impregnate this patient professional practices affect other health care
via IVF, what was done was done. We could only be professionals, the health care organization, and
respectful to the patient and her decision making as the larger society and how these elements of the
we 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 been
did so with compassion and sensitivity to her many available to observe the extensive medical and surgical
needs. planning necessary to keep this patient out of harms
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 with
and communication skills that result in effective infor- surgery, obstetrics, anesthesiology, radiology, main OR
mation exchange and teaming with patients, their and L&D staff, and the acute pain team were essential
patients 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 to
tory was crucial in this case to understand all the com- advocate for the best quality care for this patient and
plicated 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 patient
of 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 managers
alarming 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 these
honestly with patients and other health care teams to activities can affect system performance.
maximize patient safety.
The coordination of this patients care maximized
patient safety for this patient and her unborn child.
Systems-based practice What is missing in the coordination of health care in
Residents must demonstrate an awareness of and this case is the involvement of the IVF specialist once
responsiveness to the larger context and system of fertilization had taken place. One would wonder if the
health care and the ability to effectively call on sys- IVF specialist would have changed his or her future
tem resources to provide care that is of optimal practice after being part of the delivery end of this
value. patients care scenario!

93
 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;109:131139.

94
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

19 Extubated and jaws wired shut

Peggy Seidman and Ramon Abola

The case treatment of health problems and the promotion of

health.
A 16-year-old male patient is under the care of the
pediatric intensive care unit (PICU). He was a pedes-
trian struck by a motor vehicle and has suffered a Communicate effectively and demonstrate caring
traumatic brain injury (TBI) and mandible fracture. and respectful behaviors when interacting with
He 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 ask
and 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 the
of the mandible with the oral-maxillary facial surgery room?
(OMFS) service. Preoperative, his oral-tracheal tube is Family members have reported various satisfaction
exchanged to a nasal-tracheal tube. The operation pro- levels when they have been allowed to be present for
ceeds uneventfully. His jaws are wired at the end of the their loved ones in an emergency resuscitation setting
procedure. He returns to the PICU nasally intubated. [1]. However this scenario is quite different from an
Overnight, the patients pulmonary status is favorable. emergency resuscitation in an emergency room. In this
He has maintained normal oxygen saturation with a situation, the patient would not benefit from family
fractional inspired oxygen (FiO2) of 35% and is sponta- being present, and it is not clear if the family would
neously 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 both
mands. He is evaluated by the PICU staff and the deci- the parent and the child. However, the data do not
sion is made to extubate. After extubation, he quickly clearly support the benefit to the child of having a
becomes hypoxic, with a SpO2 in the 80s. Chest aus- parent in the operating room. Apparently, around the
cultation 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 recent
the 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 parental
in respiratory distress. presence does not appear to alleviate parents or chil-
As the anesthesia resident on call, you look at drens anxiety. In the rare instances when it does seem
the PICU staff, who are searching for answers. The to diminish parents or childrens anxiety, premedicat-
patients jaws are wired shut, and hes not doing well. ing children with midazolam has shown to be a viable
You wonder what to do with this handy MAC 3 laryn- alternative. Other anxiety-reducing solutions, such as
goscope that youre holding in your left hand. distracting children with video games, should also be
considered [4, p. 57].

Patient care Gather essential and accurate information about

Residents must be able to provide patient care that
their patients. 95
is compassionate, appropriate, and effective for the
 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 patients
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 patients 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.

Lets 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 Seidmans 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. Well 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 patients bed, as is standard for care for this type of to evaluate for placement of a tracheostomy may be
patient for exactly this reason. Its 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 analytic
96 No time to educate the patient and his family dur- thinking approach to clinical situations.
ing this emergency. However, you hope that the PICU
 Case 19 Extubated and jaws wired shut

Respiratory distress after extubation occurs. You 4. management of ICPs in the head trauma patient
need to quickly consider a differential diagnosis as to 5. ventilator management for the ICU patient
the current situation. Postoperatively, failed extuba-
tion could be related to several factors:
Practice-based learning
1. 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 their
2. pulmonary: pulmonary edema, pneumothorax patient care practices, appraise and assimilate scientific
(hey, we werent 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, or
edgeable about determining the appropriateness of
even a discussion between physicians and nursing
extubation. Extubation criteria in the operating room
staff. There are a variety of different perspectives about
may have some difference to criteria in the ICU setting.
the events, the critical decisions, the implications of
However, 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 health
2. 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 the
4. 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 patients
6. 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 midline
adequate care for this patient is extensive: 3. manage patients temperature aggressively to
1. ICU care avoid hyperthermia and increased cerebral
2. approach to the trauma patient metabolic rate 97
3. approach to the patient with TBI 4. provide seizure prophylaxis
 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.
3035 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 whos 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 youve 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 612 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 phrase
98 1. Does the study group adequately represent the recited time and time again by our pediatric col-
characteristics of my current patient? leagues.
 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 be
mized, 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 patients family that (1) he
that 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 patients 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 a
mechanical ventilation. This allows for a decrease in relationship with the family, the ICU team will need
sedation and mobilization of the patient out of bed, if to do this, and they are the most appropriate medical
possible. The question is, why not place a tracheostomy service to inform the family. Often, it is best for the
in our 16-year-old PICU patient during this first week, physician who has developed a relationship with the
when he has demonstrated that he will likely require family to meet with the family to discuss bad news. As
prolonged ICU care? an anesthesiologist, meeting with a family postopera-
Although practices differ between hospitals, our tively is enhanced by the presence and support of the
PICU 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 working
deal with. This has been the observation of our PICU relationship between the medical staff, the patient, and
staff, and it represents an example of how the prac- the family. Discussion with patients and families ahead
tice of medicine requires the clinician to be sensitive of time about what to expect, plus the possible com-
to the patients age and also the family members, who plications, is essential to help guide patients through
become 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 skills
Residents must be able to demonstrate interpersonal Work effectively with others as a member or
and communication skills that result in effective infor- leader of a health care team or other professional
mation 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 about
practice is providing patients and families with bad the situation. Team building is essential for a group of
news. 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 and
extubation. 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 allowing
were not accounted for during the airway emergency teams to work together in the safety of simulation.
after extubation. The patient needed to be brought
back to the operating room and placed under general Systems-based practice
anesthesia for endoscopy and direct laryngoscopy to Residents must demonstrate an awareness of and
extract these jaw wires and remove them as an infec- responsiveness to the larger context and system of
tion risk and to prevent them from getting buried into health care and the ability to effectively call on system 99
mucosa or other tissues. resources to provide care that is of optimal value.
 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 patients need for continued ICU, which gers and trying to find who is to blame are typically not
may significantly impact the cost of the patients 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
 Case 19 Extubated and jaws wired shut

References anesthesia induction and parent/child anxiety. Can J

Anaesth 2009;56:5770.
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;26:6173. anesthetic management of maxillofacial trauma
including ophthalmic injuries. Anesth Clin North Am
2. Vagnoli L, Caprilli S, Robiglio A, et al. Clown doctors 1999;17:141153.
as a treatment for preoperative anxiety in children: a
randomized, prospective study. Pediatrics 6. Carney NA, Chestnut R, Kochanek PM. Guidelines for
2005;116:e563e567. 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 Im sorry before see you in
2009;19:262266. 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
 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-
patients 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 shes 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 couldnt get IV, even though the patient was not obese).
which coordinates anesthesia, obstetrics, and the
102 blood bank. Medical therapy is attempted to slow the Make informed decisions about diagnostic and
hemorrhage, with minimal improvement. therapeutic interventions based on patient
 Case 20 Code Noelle

information and preferences, up-to-date scientific  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-  competency in obtaining IV access, both
ological procedures such as uterine artery emboliza- peripheral and central
tion [3] and cell saver use. (The worry that a cell  competency in placing an arterial line
saver might produce amniotic fluid embolism has been  competency in using the pharmacotherapy
unfounded. Moreover, if you salvage the blood after
the 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 preventing
that GA can be done safely, you could even choose gen- health problems or maintaining health.
eral anesthesia instead of regional. It all depends on
your judgment after careful consideration of risks and Pertinent points include the following:
benefits.  preparation for counteracting massive blood loss
and maintaining hemodynamic stability
Develop and carry out patient management plans.  measures to prevent aspiration such as naught per
A regional anesthesia with GA backup is planned. oris status, use of H2 blockers and Bicitra, and
Prepare for major blood loss with good IV access, rapid sequence induction
 timely antibiotic administration
blood products, a cell saver, an arterial line, and central
venous 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.
 discussion regarding the possible need for blood
This case is a true reflection of a multidisciplinary
transfusion and hysterectomy
 honest discussion about the possible need for approach:
 dialogue with obstetrics
interventional radiology help and even intensive
 discussion with the blood bank, labor and delivery
care unit (ICU) admission
 discussion of the possible need for postop nurses, and other support staff
 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-
 the advantages of regional versus GA nate (e.g., epidemiological and social-behavioral) sci-
 the useful role of interventional radiology ences and the application of this knowledge to patient
procedures care.
 recent pharmacological modalities for uterine
atony Demonstrate an investigatory and analytic
 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  Is a well-conducted GA really so harmful? What is
procedures considered essential for the area of
practice. the current thinking?
 Is it better to do preemptive radiological
The following should be considered: procedures?
 competency in performing and conducting  Am I really prepared for possible blood loss of
103
regional anesthesia 700 cc/min?
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

 in general, having good exposure to blood

Know and apply the basic and clinically product therapy
supportive sciences that are appropriate to their  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
 thorough knowledge of blood therapy and down to obstetric anesthesia)
 additionally, debriefing and discussion between
complications such as transfusion-related acute
anesthesia residents and attendings about case
lung injury
 appropriate use of products management, critical events, and lessons from the
 knowledge of pharmacotherapy of uterotonics case aid in generating new information
 resident self-reflection on the role of their
 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:  knowledge of the statistics needed to evaluate the
 your own experience of exposure to such cases in power of the studies
the past  ability to analyze statistical significance
 your own reflection of how to improve care
 departmental quality control reviews of these
Use information technology to manage
cases and debriefings that follow
 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  ability to use search engines to get information
scientific studies related to their patients health  knowledge of departmental online resources
problems.
This is based on the following: Professionalism
 lectures on this topic that you attended Residents must demonstrate a commitment to carry-
 literature searches ing out professional responsibilities, adherence to ethi-
 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
 having knowledge of newer modalities of airway commitment to excellence and ongoing
104 professional development.
management in case of difficult intubation
 Case 20 Code Noelle

This involves the following:  overcoming language barriers

 respectful communication regarding the pros and  effective communication with Dad when he needs
cons of GA to leave the room and continuing the
 respectful communication about the need for an communication about patient status and new
arterial line and large-bore IV when still awake developments
 overcoming language barriers to connect with the
patient Use effective listening skills and elicit and provide
 preparing with necessary skills such as advanced information using effective nonverbal,
cardiac life support and neonatal advanced life explanatory, questioning, and writing skills.
support
 attending departmental grand rounds and This involves the following:
continuing use of medical education resources  judging that there is a severe uterine atony and
massive hemorrhage by the expression on the
Demonstrate a commitment to ethical principles obstetricians face
pertaining to provision or withholding of clinical  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 or
 ethicality of refusing the care [6] if the patient is leader of a health care team or other professional
adamant about GA group.
 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  effective communication about the patients
status, need for GA and blood products, and need
Demonstrate sensitivity and responsiveness to for more personnel
 calling code Noelle when extra help is needed
patients culture, age, gender, and disabilities.
This involves the following:
 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 of
 might be more comfortable with women
health care and the ability to effectively call on system
 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 other
Interpersonal and communication professional practices affect other health care
professionals, the health care organization, and
skills 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 This involves the following:
patients families, and professional associates.  understanding of the hospital rules and
Create and sustain a therapeutic and ethically regulations for narcotic use
 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]
 honest informed consent and explanation of the  availability of help from other physicians such as
105
rationale behind the use of invasive monitoring interventional radiologists and gynecologists
 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,
 having a rapid infuser available but not ready and improve health care and know how these
 cost differences between bupivacaine and activities can affect system performance.

ropivacaine The pertinent issue in our case is that in our hos-

 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
 Case 20 Code Noelle

References combined with leucocyte depletion filtration to

remove amniotic fluid from operative blood loss at
1. 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;20:249263. 5. King M, Wrench I, Galimberti A, et al. Introduction of
cell salvage to a large obstetric unit: the first six
2. Afolabi BB, Lesi F, Merah N. Regional versus general
months. Int J Obstet Anesth 2009;18:111117.
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;96:14801485.
embolization: an effective treatment for intractable
obstetric haemorrhage. Clin Radiol 2004;59:96101. 7. Bendavid E, Kaganova Y, Needleman J, et al.
Complication rates on weekends and weekdays in US
4. Catling S, William S, Fielding A. Cell salvage in
hospitals. Am J Med 2007;120:422428.
obstetrics: an evaluation of the ability of cell salvage

107
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

21 Are you sure theres 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.
patients 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 patients body habitus, in our case, complicates
1. Nursing staff is unable to obtain intravenous (IV) medical care:
access.  difficult IV access
2. Anesthesia requires IV access prior to epidural  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.  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  difficulty in accurate monitoring both fetal and
108 approach will be to perform a cesarean section in maternal
 Case 21 Are you sure theres a baby there?

 increased comorbid conditions during pregnancy internal jugular triple lumen catheter was placed
(hypertension, diabetes [1]). under ultrasound guidance. There is current
 potentially difficult cesarean section debate about increased safety, success rate, and
 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 technique
obese 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 to
there have been no significant problems during this induction of labor should be completed. Should
pregnancy. The patient has had no previous surgeries. the patient develop the need for a stat cesarean
Medications 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 allow
P 76, SpO2 96% on room air. The patient appears to be for rapid administration of surgical-level
in no acute distress. Her airway exam reveals a good anesthesia, without instrumentation of the
mouth opening and a Mallampati class II airway, with patients airway.
good neck extension. Thyromental distance appears 4. Then, induction of labor for a
to be greater than three finger breadths; however, the large-for-gestational-age fetus should be
patients 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 different
and heart are difficult secondary to the patients body laryngoscope blades, a laryngeal mask airway, an
habitus. You note the multiple attempts that the nurses intubating laryngeal mask airway, gum elastic
have 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 invasive
priate 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 of
patient. 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 obese
plan 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
 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 days 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.
 Case 21 Are you sure theres 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 it
case about the obstetric management of the morbidly should not be done in a matter that may jeopardize the
obese patient allows one to ensure that one is perform- life of the mother.
ing evidenced-based medicine and adhering to good
practice principles. Reviewing literature may also pro- Interpersonal and communication
vide ways to improve patient care, for example, would
the use of ultrasound guidance improve success in skills
epidural 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 dealing
well as performing a critical review of this information with this difficult patient. The medical staff needed
for its validity will allow the medical team to prepare to develop a trusting relationship with this patient
patients for what they should expect in their care. The in a very short amount of time. Trust is important
care 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 access
fetus. and epidural placement.

Work effectively with others as a member or

Professionalism leader of a health care team or other professional
Residents must demonstrate a commitment to car- group.
rying out professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient One practice that we have implemented on labor
population. 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 care
is that we are caring for two patients: both the mom Systems-based practice
and the fetus. A principle to review is that fetal well-
Residents must demonstrate an awareness of and
being is dependent on maternal well-being. If maternal
responsiveness to the larger context and system of
health is jeopardized, then the outcome of the fetus is
health care and the ability to effectively call on system
jeopardized. 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 other
obese patient is on labor and delivery with continu- professional practices affect other health care
ous fetal monitoring. The fetus demonstrates nonre- professionals, the health care organization, and
assuring fetal heart tracing, and the decision is made the larger society and how these elements of the
to perform a stat cesarean section. Performing an ill- system affect their own practice. 111
prepared general anesthetic in this patient may result
 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
 Case 21 Are you sure theres a baby there?

Additional reading 4. Birnbach D, Browne I. Anesthesia for obstetrics. In:

Miller R, editor. Millers anesthesia. 6th ed.
1. Castro LC, Avina R. Maternal obesity and pregnancy
Philadelphia: Elsevier Churchill Livingston; 2005:
outcomes. Curr Opin Obstetr Gynecol
23072344.
2002;14:601666.
5. Popescu WM, Schwartz JJ. Perioperative
2. Schneid-Kofman N, Sheiner E, Levy A, Holcberg
considerations for the morbidly obese patient. Adv
G. Risk factors for wound infection following
Anesth 2007;25:5977.
cesarean deliveries. Int J Obstetr Gynecol 2005;90:
1015. 6. Weiss JL. Obesity, obstetric complications and
cesarean delivery rate a population-based screening
3. Espinet A, Dunning J. Does ultrasound-guided central
study. Am J Obstetr Gynecol 2004;190:10911097.
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;3:523527. 2005;17:235236.

113
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

22 Smoking, still smoking, and wont 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 hes 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 doesnt take any pulmonary mation from this patient to establish a working diag-
medications because he doesnt 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 cant, however, afford a sleep study because his monary disease (COPD) are mainly done on history
darned health insurance, which, again, doesnt exist, and physical exam.
cant 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 cant work because hes in too much pain, information and preferences, up-to-date scientific
and he cant 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-  see a pulmonologist for optimization
way that improve with coughing and in an open-  be encouraged to quit smoking and have his
114
mouth sniffing position, but not completely. The rest surgery scheduled for 8 weeks after he quits
of the physical exam was noncontributory.  have his sleep apnea evaluated and treated
 Case 22 Smoking, still smoking, and wont quit

However, 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 wont lation.
quit smoking and that he has severe sleep apnea, and
to provide anesthesia with these facts and assumptions Perform competently all medical and invasive
in 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 patients plan includes smoking cessation, come in these patients and are not indicated.
incentive spirometry education preoperatively, and Provide health care services aimed at preventing
beta 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 the
prophylaxis. incentive spirometer and send him home with one.
The physician should keep careful documentation Offer a prescription for nicotine patches. If sputum
of these plans and the reasoning behind them. Com- is infected (green or yellow), have the patient take an
munication with the anesthesia and surgical teams antibiotic for at least 48 hours prior to surgery, with
who 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 postanesthesia
on the negative effects of smoking, especially in such care unit team, pulmonary experts, and the patient to
little 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 knowledge
fact 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 cognate
opioid toxicity, but also because of the adverse hepatic (e.g., epidemiological and social-behavioral) sciences
effects 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 being
canceled on the day of surgery by the anesthesiologist Know and apply the basic and clinically
due 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 patients probable diagnosis of obstructive inhaler technique be adequate enough to get the drug
sleep 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 115
which, in the literature, has been proven to be effec- preoperative steroids.
 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 its all about the riskbenefit 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 patients 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 result
116 effectiveness. of being sensitive to the patients disabilities, lack of
insurance, and need for employment.
 Case 22 Smoking, still smoking, and wont quit

Interpersonal and communication Understand how their patient care and other
skills professional practices affect other health care
professionals, the health care organization, and
Residents must be able to demonstrate interpersonal the larger society and how these elements of the
and communication skills that result in effective infor- system affect their own practice.
mation exchange and teaming with patients, their
patients families, and professional associates. Deciding that this guy is OK to do might fit your
clinical judgment and moral values youve 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, and
subject 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 cut
he lacks insurance, yet needs this surgery. Using inex- our budget again.
pensive tests and interventions, for example, the STOP
screen and incentive spirometry, to assess and manage Practice cost-effective health care and resource
this patient provided necessary medical information allocation that does not compromise quality of
and 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 assist
anesthesiologist providing the patients care is huge patients in dealing with system complexities.
the anesthesiologist of the day would not be wrong
to 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 heads up, and let him without giving him undue financial stress, is important
or her think it over, bounce it off the boss/spouse/dog, here.
and make an informed decision to anesthetize this
patient because of the unique circumstances of Know how to partner with health care managers
2009. and health care providers to assess, coordinate,
and improve health care and know how these
activities can affect system performance.
Systems-based practice
Residents must demonstrate an awareness of and The patients surgery and recovery period were
responsiveness to the larger context and system of uneventful. He was discharged home on postop day
health 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
 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
581595.
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;104:356367.
2006;144:575580. 6. Egan TD, Wong KC. Perioperative smoking cessation
2. Pasquina P, Tramer MR, Granier J, Walder B. and anesthesia: a review. J Clin Anesth 1992;4:
Respiratory physiotherapy to prevent pulmonary 6372.
complications after abdominal surgery: a systematic 7. Practice guidelines for the perioperative management
review. Chest 2006;130:18871899. 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;104:10811093.
1995;80:276284. 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;108:812821.

118
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

23 Pseudoseizures following office extubation

Ralph Epstein and Andrew Drollinger

The 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 via
sive 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 over
lems 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 no
depression, lorazepam for anxiety, and amoxicillin for changes noted. Her BIS was noted to be in the 70s, as
dental infection. expected after the administration of benzodiazepines.
At a recent dental appointment under general anes- It was noted that this seizurelike behavior would
thesia 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 mothers involvement. About
platelets and differential and a thyroid panel. All results 20 minutes into this event, when she was called by the
were found to be within normal limits. Evaluation of wrong name, she opened her eyes slightly and jokingly
her airway classified her as Mallampati class I, with full became upset that such a mistake was made, and then
range 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 patients 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 was
tracheal tube was inserted atraumatically through the transported to the emergency department via ambu-
patients left naris. Monitoring included electrocardio- lance. All the involved dentists went to the emergency
gram, blood pressure, heart rate, pulse oximetry, pre- department to provide necessary information to the
tracheal 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 patients 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 the
awake, responsive, and resting comfortably. At 7:20 room, the patient opened her eyes, woke up, and the
p.m., the patients behavior began to change. She started seizurelike behavior stopped. A brain MRI was taken
shaking and shuttering and was no longer respon- and the patient was admitted overnight. The brain MRI
sive. 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 in
placed, and a reading of greater than 90 was noted. the private office was removed the next morning, the
At this point in time, the mother reported that her patient exhibited 5 minutes of the seizurelike activity. 119
 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:
 four nonepileptic events Work with health care professionals, including
 EEG normal those from other disciplines, to provide
 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.
patients mother. The patients 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 to
120 The patients mother was included in the decision- ethical principles, and sensitivity to a diverse patient
making process. population.
 Case 23 Pseudoseizures following office extubation

excellence and ongoing professional

Demonstrate respect, compassion, and
development.
integrity; a responsiveness to the needs of
patients and society that supersedes self- Everyone involved in the patients care went to the
interest; accountability to patients, society, emergency department and stayed until her care was
and the profession; and a commitment to complete.

121
 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;91:598600. pseudoseeing is pseudobelieving. Epilepsy Behav
2001;2:7884.
2. Allen G, Farling P, Ng L, Chambers N. Anaesthesia
and pseudoseizures. Br J Anaesth 2004;92:451452.

122
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

24 What happened to the ETT tip?

Ralph Epstein and Tate Montgomery

The case 2 hours and 30 minutes. All vital signs, respiratory

A 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 throat
were noncontributory. On examination, it was deter- pack and allowed the anesthesiologist to extubate the
mined that he would require a more extensive exam- patient. It was done atraumatically, although some
ination, radiographs, multiple restorations, cleaning, secretion or something came out with the tube. The
and 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 recovering
under 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 and
the patient and determined that he was a good candi- that part of it was missing. A direct laryngoscopy was
date 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 then
cations to general anesthesia. Prior to the start of anes- transferred to another room to continue recovery and
thesia, the patient was evaluated by the anesthesiolo- monitoring. The operatory was thoroughly inspected
gist and found to be in good condition for office-based and cleaned in an attempt to find the missing tip from
general 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 at
and 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, without
with a 22-gauge Jelco catheter in the right anticubital discontinuing his IV. A pediatric radiologist reviewed
fossa. Standard ASA monitors were placed as well a BIS the patients chest PA and a lateral and found an area
monitor 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 no
drops, and nasal airways 2026, which were lubricated opaque foreign body. A pediatric mag study was also
with 2% lidocaine jelly, were successively placed in done, and there was atelectasis or infiltrate in the right
the right naris. To decrease the trauma to the naris, upper lung field; no radiopaque foreign body and no
an 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 patient
diately 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 laryngoscopy
tube was secured, eyes were taped, and the head was with phenylephrine. There was no evidence of a foreign
wrapped in the usual manner for a dental procedure. body, abrasion, or any airway compromise. The patient
The dentist placed one throat pack. Maintenance anes- was then sent home, and instructions were given to
thesia was sevoflurane and nitrous oxide/oxygen for the parents that if anything abnormal occurred with 123
 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 34 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 patients 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
 Case 24 What happened to the ETT tip?

manufacturer was contacted to further explain what Throughout this entire case, the parents were fully
happened. informed and involved to make sure they knew that the
best health care available was provided to their child.
Practice-based learning
and improvement Interpersonal and communication
Residents must be able to investigate and evaluate their skills
patient care practices, appraise and assimilate scientific Residents must be able to demonstrate interpersonal
evidence, 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 if
this has been a problem and to see what would be done The family was kept informed of the status of
to 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 professional
to this patients 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 cause
Professionalism for the issue. Multiple other health care providers
Residents must demonstrate a commitment to car- were consulted, but the anesthesiologist took the
rying 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 the
population. 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 other
tional care, other patients had to be rescheduled to professional practices affect other health care
another day. Total productivity for the day was de- professionals, the health care organization, and
creased, which resulted in a decrease of income for the the larger society and how these elements of the
operating 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.
 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
patients 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
 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 a
1. 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;71:365367.
2003;56:791794.
4. Krzanowski TJ, Mazur W. A complication associated
2. Lampl L. Tracheobronchial injuries: conservative
with the Murphy eye of an endotracheal tube. Anesth
treatment. Interact Cardiovasc Thorac Surg
Analg 2005;100:18541855.
2004;3:401405.

127
 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. wasnt 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 couldnt 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 you
128 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
 Case 25 Jerry and Terry want one more baby

is 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 emotional
alternatives of surgery and anesthesia and advise a status and high risk of hemodynamic instability. Her
course of action that is both safe and effective in treat- airway examination was optimal. However, the patient
ing 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 about
hemorrhage. This patient had advanced maternal age. the possible need for intervention subsequent to the
The patient had four previous cesarean sections. The surgery was warranted.
patient had a previous history of uterine atony. The
patient 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 nearly
tal 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 are
covering 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 regional
tions, advanced maternal age, and multiparity. Ultra- was important. It is also important to discuss possible
sound 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 patient
placenta to the uterine wall. This degree of invasion care decisions and patient education.
of the uterine wall can be graded as accreta when the
chorionic villi are in contact with myometrium (80% of The preoperative discussion is when information
cases), 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 abundance
percreta, 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 without
opening the uterus was an option in this situation. That Perform competently all medical and invasive
will decrease the bleeding. However, the ultrasound procedures considered essential for the area of
diagnosis 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 an
measure. 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 an
included uterine artery embolization. This is a pro- adequate level is key to providing anesthesia and keep- 129
cess in which a balloon can be inserted into the uter- ing the patient comfortable throughout the procedure.
 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 isnt 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
45 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.
 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 that
it is also good to know the newer options to treat bleed- were presented to her, instead of refusing medical care
ing 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 departmental
statistics and also the literature. For example, in this Demonstrate sensitivity and responsiveness to
case, 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 might
ble adverse reactions to the blood products and their sound irrational. However, keep in mind that nobody
presentation. 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 interpersonal
gold 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, their
that somebody had a good result with recombinant patients families, and professional associates.
factor VII is useful, even though it is not a controlled
study. Create and sustain a therapeutic and ethically
sound relationship with patients.
Use information technology to manage
In our case, explaining all the patients 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 labor
your hospitals 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 with
Maybe 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.
Professionalism
Residents must demonstrate a commitment to car- Use effective listening skills and elicit and provide
rying 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 didnt 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
 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:
 keep a level 1 rapid transfuser available but not set
group.
up
This situation is a true example of a multidisci-  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  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  help Mom and Dad understand how to navigate
resources to provide care that is of optimal value. the physical facility
 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.
 ability of the blood bank to provide much needed
products in a timely fashion This category includes the following:
 availability of interventional services at odd hours  take an appropriate time-out
 availability of experts, such as a trauma team or,  administer antibiotics
even better, a gynecologist, in case the surgical  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
 availability of any help that may be needed down  fill in log books for data collection and
the line, such as a need for intensive care unit care management

132
 Case 25 Jerry and Terry want one more baby

Additional reading 4. OBrien D, Babiker E, OSullivan O, MCauliffe F,

Geary M, Bryne B. Causes of massive obstetric
1. 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;64:511516.
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;145:129132.
6. Laird R, Carabine U. Recombinant factor VIIa for
3. Breathnach F, Geary M. Uterine atony: definition,
major obstetric haemorrhage in a Jehovahs Witness.
prevention, nonsurgical management, and uterine
Int J Obstetr Anesth 2008;17:193194.
tamponade. Sem Perinatol 2009;33:8287.

133
 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. Its 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 blood
134 did not get anything that could cause this reaction, gas).
 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 after
way, 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-bore
there is tachycardia). Given the history of DVT, rule IVs were also placed. Resuscitation was continued
out 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 intravenous
the OR to the radiology suite, while maintaining lines, however in a code situation you would prefer to
patient stability. Call for help transporting and for use a central line. And of course a concern arises that
monitors, and alert radiology that there is an acute sit- if the peripheral line would infiltrate, you can get skin
uation. 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 this
episode; she has no relatives nearby, and you are her Aseptic technique when placing all invasive lines is
closest relative at this time as well as her patient advo- paramount; the femoral line is probably in the worst
cate. 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
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Additional reading anaphylaxis: summary report. J Allergy Clin Immunol

2005;115:584591.
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 19992000. Anesthesiology Physiologic manifestations of human anaphylaxis. J
2003;99:536545. Clin Invest 1980;66:10721080.
2. Sampson HA, Munoz-Furlong A, Bock SA, et al.
Symposium on the definition and management of

136
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

27 Broken catheter after Whipple

Xiaojun Guo and Khoa Nguyen

The case deficit, considering that there is now a small plastic for-
eign body floating around the patients epidural space.
Bruce was about to undergo a major operation with
Having that exam gives a baseline level of function to
removal of several internal organs the Whipple. He
compare to, should there be a change later on. Measure
received the standard spiel about the anesthesia and
the broken catheter to determine how much of the tip
received the pain-destroying epidural catheter prior to
may have broken off. Also, examine the insertion site
entering the operating room (OR). The case went as
to make sure that no further trauma has been missed
smoothly as it could have, considering it was a Whip-
on movement.
ple. As he was being moved over to the stretcher for
transport to the recovery room, he hit a snag, or at Make informed decisions about diagnostic and
least, his catheter did. The tip of the catheter became therapeutic interventions based on patient
caught up on a rail on the bed and the tension was too information and preferences, up-to-date scientific
much 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 broken
tion, the catheter was missing something peculiar catheter piece in place, assuming the patient remains
the tip! asymptomatic. The literature on broken catheters
recommends watchful vigilance with asymptomatic
patients, imaging to determine exact location of the
Patient 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 the
treatment 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. You
sia and no family is present now, so the most caring then send him for the appropriate imaging studies to
and respectful interaction we can have is making sure get an exact idea of the catheters current location,
that the patient arrives to the recovery room in stable while sending out a consult to your neurosurgical
condition and that no other lines or catheters become friends so they can get to know the patient should they
dislodged 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 137
rological exam is done to determine if there is any further sequelae related to the broken catheter. Answer
 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
patients 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
patients 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.
 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 with
the 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 patients 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 for
the hospital has should they need it to demonstrate
the epidural catheter, you arrange the appropriate
respect, 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 practice
patients information confidential when you present Residents must demonstrate an awareness of and
this 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, and
Interpersonal and communication the larger society and how these elements of the
skills system affect their own practice.
Residents must be able to demonstrate interpersonal The patient had an unfortunate event occur with
and 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.
 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
 Case 27 Broken catheter after Whipple

Additional reading 2. Fragneto RY. The broken epidural catheter: an

anesthesiologists dilemma. J Clin Anesth
1. Mitra R, Fleischmann K. Management of the sheared
2007;19:243244.
epidural catheter: is surgical extraction really
necessary? J Clin Anesth 2007;19:310314.

141
 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 patients 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 patients 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 didnt 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 mothers preeclampsia the patients 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
 Case 28 Pierre who?

spontaneously breathing due to a risk of loss of the

airway. 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 (the
is allowed to spontaneously breathe, while an intra- endoscopy) with the aim of preventing any further
venous (IV) is placed. Once the IV is functional, an deterioration and maintaining his health!
awake intubation is attempted but is unsuccessful due
to the patients vigorous activity. Inhalational agents Work with health care professionals, including
are then used to help with sedation for another attempt those from other disciplines, to provide
at intubation, but due to the severity of the patients patient-focused care.
airway issues, the intubation attempt is aborted as the With the help of our NICU and gastrointestinal
patient begins to obstruct. The patient is then emerged. (GI) colleagues, in this case, we were able to provide
Oral 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, though
it did require some serious external airway mani- Medical knowledge
pulation. 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 patients fam-
ily. Every effort should be made to explain to the par- Demonstrate an investigatory and analytic
ents the severity of the situation. The patient needs an thinking approach to clinical situations.
urgent procedure to help with a diagnosis, but there
are 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 associated
sibility 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 be
lutely 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 perform
to confirm that a patent IV is available should the practice-based improvement activities using a
patient 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 make
due to the abnormal anatomy related to the patients sense to sit down with our NICU and GI colleagues 143
disease. to analyze what we did correctly and what we could
 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 patients airway. We You did your best to demonstrate your sensitivity to
also tried to read and learn about what worked for our the patients 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 that
144 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.
 Case 28 Pierre who?

Systems-based practice Practice cost-effective health care and resource

Residents must demonstrate an awareness of and allocation that does not compromise quality of
responsiveness to the larger context and system of care.
health care and the ability to effectively call on system
resources 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 assist
require 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 the
help reduce his chances of having more serious med- management of the patients 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 consultation
and, finally, the big health care organizations. from an anesthesia perspective for their child.

145
 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;138:782787.
109114.
2. Olasoji HO, Ambe PJ, Adesina OA. Pierre Robin
syndrome: an update. Niger Postgrad Med J
2007;14:140145.

146
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

29 Submandibular abscess
Syed Azim and Jane Yi

The case important; and sometimes they lie. I once had a patient
deny having had any medical conditions, but when I
A 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 about
had presented to the emergency department with a
her past surgical history, she revealed that she had
chief complaint of pain and swelling for 15 days, lim-
coronary artery disease, with a history of myocardial
ited mouth opening, and difficulty swallowing. Com-
infarction (MI), and was status post (s/p) coronary
puted 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. For
right. 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 documented
Patient care allergy is an actual allergy. Once I read in a patients
Residents 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 of
ment 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-Ludwigs
members. 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 drained
of surgical procedures, but this might be the patients urgently. So, needless to say, the most important part
first 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 nasal
the patients 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 jelly
way assessment. It is also important to get a his- (topical anesthetic), and oxymetazoline spray (topical
tory of present illness, family history (especially of decongestant).
anesthesia), and social history. Many patients are not
completely forthcoming with information. Sometimes Counsel and educate patients and their families.
they dont remember; sometimes they dont think its 147
 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 patients 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 patients 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-
dont have to concern yourself with making sure the lished and evolving biomedical, clinical, and cognate
patients elbow isnt 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. Its
amazing how much easier it is to make out anatomy Infection of the submandibular space causes
when you dont have salivary juices getting in your swelling that begins at the inferior border of the
way. Start the dexmedetomidine 0.51 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 signs
148 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
 Case 29 Submandibular abscess

of 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 wont 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 to
swelling. We also know that it would be even more ben- provide adequate sedation and analgesia for the patient
eficial to administer an antisialogogue, to counteract during what can be a frightening experience (and Im
the drooling due to dysphagia. Lets not forget the obvi- not just talking about the patient here). The most
ous; 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 in
patient care practices, appraise and assimilate scientific a patient with Ludwigs 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 ventilation
overwhelming things can get, especially when it comes was maintained and the vocal cords were sprayed with
to the airway. It is therefore important to develop a 2 mL of 4% lidocaine via the suction port located on
systematic approach to the steps taken, from the the fiber-optic scope. Moreover, this article reports
moment 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 laryngeal
of antibiotics to be administered, requiring use of reflexes. The disadvantage of using remifentanil is that
multiple lines. Have the difficult airway cart ready it is an opioid and has all the side effects that come with
and 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 case
invades fascial spaces, always keep in mind the pos- of a patient with a submandibular abscess presenting
sibility of an airway complication. Larawin et al. [1] with progressive respiratory difficulty. A loading dose
reported 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
 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
Chassaignacs 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 patients
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 the
150 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
 Case 29 Submandibular abscess

to the likelihood of success by being vigilant in the OR Understand the immediate postoperative concerns
and 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 managers
want 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 these
decrease 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 important
is 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
 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;19:370373.
2006;135:889893.
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;66:26422645.
1999;11:6468.

152
 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 DiGuglielmo

The 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 the
ished a case and the anesthesia coordinator asks you
stimulation will make her breathe again. His scope is
to 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 have
pancreatography). ERCP? You remember learning
you in my field or the patient moving! As you point
about it in medical school but never got a chance to
to the monitors, a look of fear comes over his face and
observe one being done. While wolfing down a greasy
he quiets down, whispering, Do whatever you need
cheeseburger 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 up
tion. Easy MAC, let me grab a bunch of propofol, you
with some positive pressure ventilation. Uh-oh, theres
think 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 ask
few times on the way there and introduce yourself to
the nurse to bring in the stretcher and put the patient
the gastroenterologist. He explains that the patient is
back in the supine position quickly, as the endoscope
in-house and not that sick and that the gastroenterol-
is removed by the gastroenterologist. You realize that
ogist 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 direct
endoscopy suite as a new attending, you reassure him
laryngoscopy. Luckily, you have a grade 1 view of the
that youll get things moving along its just a MAC
vocal cords, so you throw in an entotracheal tube, hook
case 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 reappearance
a history of hypertension (HTN), 65 kg, and recently
soon!
diagnosed with gallstone pancreatitis. She looks as if
shes in pain. You approach the patient and introduce
yourself. The patient looks around and asks, Are there Patient care
any real doctors here? You look like my granddaugh- Residents must be able to provide patient care that is
ter! You reassure her that youve 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 upper
dentures) and physical exam, you explain the risks Communicate effectively and demonstrate caring
and benefits of anesthesia and the prone position. The and respectful behaviors when interacting with
patient is then moved over to the procedure table and patients and their families.
makes herself as comfortable as possible in the prone
position. You place the monitors and make sure the IV Preoperatively, the patient seemed concerned
is secured and flushing well. You put a nasal cannula about how young you look! Reassurance is crucial; the
on her at 2 L/min, see that youre getting adequate end- patient needs to know that you are a trained medical 153
tidal CO2 , and proceed by pushing 50 mcg of fentanyl doctor and that you have had years of experience
 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 patients 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.

Lets 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) III patients; her HTN was pre- any procedure, its not about doing it fast, but rather,
sumed to be under control, she was thin, and she had a its 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 patient
154 and postoperative vision loss. This is particularly care.
 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 13. When administering monitored anesthe-
fentanyl and what can be considered an induction sia care, one must realize that just as with a general
dose of propofol. Although approximately 2 mg/kg of anesthetic, each patient is individualized, and extra
propofol 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, the
gists should not treat all cases like a chocolate chip airway in the prone position is not readily available
cookie 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 the
algorithm for yourself in this situation. You need to airway was difficult from the beginning or the patient
maintain 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 dont do something soon,
youll lose your C as well: Professionalism
1. 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.
wont 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, theres 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 dont 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 patients
5. 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 youre 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 should
and improvement not matter to the patient. The patient will see that at
Residents must be able to investigate and evaluate their the core, you are clinically competent (hows that for
patient 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 of
ogist utilized time well by doing an online search of the procedure by the gastroenterologist as well as the 155
the procedure and the usual anesthetic management risks for anesthesia. Particularly crucial to this case was
 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, dont supersize that Big MAC!

156
 Case 30 ERCP with sedation

Additional reading and use as an intravenous anesthetic. Drugs

1988;35:334372.
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;88:14591466. 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;49:677683.
pharmacodynamic and pharmacokinetic properties

157
 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 patients 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 doesnt 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 patients 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
 Case 31 On call in labor and delivery

aware but stated that he was unable to help if there was debrief about the patient was done so that we could all
a 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 throw
plus patient could be up to this point, but there is a our hands up and hope for the best if she were to be
genuine 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 obstetricians best interests to
the risks are x, y, and z, and this could very well hap- have an appropriate anesthetic on board it will make
pen 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. She
appeared to understand this and became more willing Medical knowledge
to 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 babys size and Demonstrate an investigatory and analytic
how 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 Tuohy
low lying. This patient did not have a low-lying pla-
needle for the additional attempt at an epidural. We
centa. 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 necessary
adequate 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 in
there is lack of an adequate cuff size). comparison to just attempting without the tape. Dont
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 this
size of a patient is application of compression stock- Know and apply the basic and clinically
ings to avoid deep venous thrombosis (DVT) later on. supportive sciences that are appropriate to their
Also, 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 was
phylactic 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, a
incision. 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 13 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 159
develop a plan for this type of patient. A huddle to baseline variability (fluctuations in the baseline FHR of
 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
140150. 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 patients 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 anesthesiologists facial expressions and body
all looking to have the best outcome a healthy baby language, so its best to be nonjudgmental and not to
and mother. approach the patient with hands on your hips many
times, the patient will not open up to you about the
Obtain and use information about their own situation.
population of patients and the larger population Professionalism encompasses a commitment to
from which their patients are drawn. excellence and your own development. If you have
been attending hospital and teaching rounds and going
It is important to revisit this literature in case new
to meetings, this will help you keep up to date in the
developments occur regarding morbidly obese preg-
field. There is always new information in medicine,
nant patients.
and we cannot ignore that you have to be a lifelong
learner as a physician.
Use information technology to manage
information, access online medical information;
160 and support their own education. Demonstrate a commitment to ethical principles
pertaining to provision or withholding of clinical
 Case 31 On call in labor and delivery

care, confidentiality of patient information, sies, such as listening to all in the room and answering
informed consent, and business practice. questions, puts the patient at ease.
It is unprofessional to talk about other patients in Use effective listening skills and elicit and provide
front of your patient. Many times, we have multiple information using effective nonverbal,
laboring patients, and it is best to take the discussion explanatory, questioning, and writing skills.
outside of labor and delivery so that it can be dis-
cussed in privacy. Patient privacy should be respected. We have to ask directed questions. Many times,
I always make it a practice to knock on the door before we have emergent situations in which we get only the
I enter the labor and delivery room and to wash my most basic of information: last ate, allergies, and so
hands in front of the patient before and after seeing on. If we ask these questions and look the patient in
her. It also seems silly, but a time-out should be held the eye then it could mean a world of difference to
with the patient, nurse, and physician to ensure that the patient. Of course, we are doing a hundred other
the patient is receiving the correct procedure. Many things: putting monitors on, starting a line, and so on.
times, patients will comment, Of course I am having
a c-section dont we all know that? Just look at my Work effectively with others as a member or
belly! leader of a health care team or other professional
group.
Demonstrate sensitivity and responsiveness to On labor and delivery, we work very closely with
patients culture, age, gender, and disabilities. the obstetricians, and we become aware of many
idiosyncrasies, for better or worse. The case began
Many of the female laboring patients come to us with the slowest truly slowest obstetrician in the
from different backgrounds, and although they have to hospital. At the 1.5-hour mark, I suggested that we
bare their bottom to deliver, they still want to pre- get another obstetrician to help, or else my anesthetic
serve modesty. I always tell my residents to place a would run out (remember that I had done an inten-
drape up while the patient is being prepped in the oper- tional spinal, so I did not have an epidural to redo)
ating room. This is then switched out with the ster- a big worry because the patient had a class 34 airway.
ile drape afterward. Patients who have modesty and/or The patient was operated on in a regular bed that did
cultural issues will then be more at ease. They will only not go up and down and managed to have an anesthetic
see the anesthesiologists, and although they know very that did last. The anesthesiologist has to have a good
well that they are naked for all in the room, it will now rapport with the obstetrics team here a second obste-
not be so disturbing to them. trician was clearly needed, and my suggestion worked
well enough to have the obstetrician say, Yes, please
call her in.
Interpersonal and communication
skills Systems-based practice
Residents must be able to demonstrate interpersonal
Residents must demonstrate an awareness of and
and communication skills that result in effective infor-
responsiveness to the larger context and system of
mation exchange and teaming with patients, their
health care and the ability to effectively call on system
patients families, and professional associates.
resources to provide care that is of optimal value.

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
Everyone with whom I work needs to introduce the larger society and how these elements of the
himself or herself by name and position. We have a system affect their own practice.
short period of time in which we must gain the trust
and respect of the patient. If we just barge into the The patient was operated on in a regular bed that
patients room with no regard, the patient will not did not go up and down, and this complaint of mine to 161
have a good first impression of us. Common courte- the RNs and director of obstetric anesthesia enabled
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

the unit to change the type of operating room tables patients and their families make informed decisions
available so that no other team would have to endure regarding their care. This patient allowed me to reat-
what I had endured. It was an impossible situation in tempt an epidural once everything was explained to
which to operate, but we made do at the time. Even her. The day crew had tried to explain everything ear-
placement of the spinal was challenging because I am lier, just before the change of shift, but was it done well?
tall and had to bend down; normally, I would bring the Maybe the team was looking just to go home. We owe it
bed up, but this one only went so high. to our patients, though, to explain all, even at the end of
the day. We have to repeat information as necessary
Know how types of medical practice and delivery this is difficult material to process.
systems differ from one another, including
methods of controlling health care costs and Know how to partner with health care managers
allocating resources. and health care providers to assess, coordinate,
and improve health care and know how these
Review of the literature showed us that there are activities can affect system performance.
more and more morbidly obese pregnant patients
around the country, and it was good to see how each This baby was not in distress and did not have any
institution deals with this patient population, thus apnea. I still like to know how these babies are doing
the idea to see patients in a clinic beforehand, for and will follow up with the neonatal intensive care unit
evaluation. team afterward, just so I know how all is going for the
baby and family. The baby girl had a 9, 9 Apgar, which
Practice cost-effective health care and resource is a scale signifying heart rate, respiratory effort, mus-
allocation that does not compromise quality of cle tone, reflex, irritability, and color. It is measured
care. at 1 and 5 minutes (less than 7, then continued every
5 minutes up to 20 minutes). There are limitations
Standard cost-effectiveness should be used. This
Apgar is useful in predicting short-term mortality for
would mean not opening up additional epidural kits if
groups of infants with low birth weight. It has a low
this can be avoided. The best action would be to open
value in predicting the survival of an individual. Pri-
an additional larger epidural needle as it is needed.
mary apnea occurs after the initial attempts to breathe
Thus we use only what we need and will have the others
(stimulation or tapping feet can cause resumption of
for a rainy day or another day with a similar potential
breathing). Secondary apnea occurs with continued
disaster case.
oxygen deprivation the baby gasps several times and
Advocate for quality patient care and assist then enters secondary apnea (stimulation does not
patients in dealing with system complexities. restart breathing). I also followed up with postpartum
on the patient. She did not even get a postdural punc-
Sometimes we can be the only voice of reason ture headache. As one of the senior anesthesiologists
for the patient. A calm voice that is reassuring and who trained me stated, Its better to be lucky than
can state the facts in a nonjudgmental tone will help good.

162
 Case 31 On call in labor and delivery

Additional reading 2. Mhyre J. Anesthetic management for the morbidly

obese pregnant woman. Int Anesth Clin
1. Hawkins J. Labor and delivery management of the
2007;45:5170.
morbidly obese patient. IARS 2008;57:6.

163
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

32 Kidney transplant
Syed Azim and Louis Chun

The case information and preferences, up-to-date scientific

evidence, and clinical judgment.
A 61-year-old male with a history of end-stage
renal disease secondary to long-standing diabetes and A patient with end-stage renal disease (ESRD)
hypertension, on hemodialysis for 5 years, presents for on hemodialysis presents many challenges, which
deceased-donor renal transplantation. include if and when to transfuse blood, how to cor-
rect metabolic acidosis if you decide to, and what to
Patient care do with hyponatremia/hypernatremia. Remember, the
deceased-donor kidney is on the watch. You may just
Residents must be able to provide patient care that is
have to work with whatever numbers you have in front
compassionate, appropriate, and effective for the treat-
of you as you prepare to wheel the patient to the OR.
ment of health problems and the promotion of health.
Develop and carry out patient management plans.
Communicate effectively and demonstrate caring
and respectful behaviors when interacting with Have drips ready to go, (e.g., antibiotics, gan-
patients and their families. cyclovir, methylprednisolone, and alemtuzumab). At
some point, you will need heparin. You may also use
No doubt this is a big day for the patient, as he is
Benadryl to prevent allergic reactions; albumin, man-
about to not only go under anesthesia, but also receive
nitol, and furosemide to flush the new kidney; and
an organ that could potentially alter the rest of his life,
sodium bicarbonate and calcium chloride to counter-
for better or worse. Building rapport and showing con-
act the effects of hyperkalemia after restoring blood
fidence in your ability to take care of the patient in the
flow to the new kidney. Usually, these patients are
operating room (OR) cannot be overemphasized. Let
chronically anemic. It is imperative to have blood
him know that you will need to place multiple intra-
ready to be transfused.
venous (IV) lines, a central venous catheter, an arterial
catheter, and a Foley catheter. By the time he wakes up, Counsel and educate patients and their families.
he should feel like a Christmas tree.
Organ transplant surgeries seem always to occur
Gather essential and accurate information about at the most unexpected (and inconvenient) of times
their patients. (e.g., when the schedule for the day is packed to the
point where the laparoscopic appendectomy is to fol-
When was his last dialysis? This gives an indication low three emergency laparotomies and an intubation
of whether he might be dry as a prune (immediately of a patient with epiglottis, or when you are cozying
postdialysis) or plump as a tomato (just before dialy- up on that favorite couch in the call room at 1:00 a.m.
sis). Where is his fistula (if any)? You would never want waiting for the organ and patient to arrive). It
to place monitors or establish access on that extremity. is therefore easy to lose sight of the importance of
What is his exercise tolerance or cardiac status? This informing the patient and family just what to expect
will help guide our anesthetic induction and mainte- during and after surgery.
nance.
Use information technology to support patient
164 Make informed decisions about diagnostic and care decisions and patient education.
therapeutic interventions based on patient
 Case 32 Kidney transplant

Review all available laboratory values, including with bleeding diathesis. Compounding it to chronic
Chem8, complete blood count (CBC), chest X-ray, and anemia, and you could have a recipe for disaster. Every
electrocardiogram results. Check a finger-stick glucose now and then, check how much blood was lost in the
prior to starting. suction canisters and lap pads, and make sure you have
blood ready to go.
Perform competently all medical and invasive Metabolic acidosis can be a chronic problem in
procedures considered essential for the area of these patients. With metabolic acidosis comes hyper-
practice. kalemia, which, by the way, could be exacerbated by
Perform induction and intubation, followed by a number of things, including hemorrhage, massive
establishment of an arterial line (on the extremity blood transfusion, and the establishment of perfusion
without the arterial-venous fistula) to monitor beat-to- to the new kidney (acidosis). So how do you recognize
beat variations in blood pressure and a central line to hyperkalemia? You may want to occasionally check
monitor fluid status. the electrocardiogram (EKG) monitor for the earliest
signs, that is, peaked T-waves, flattened P-waves, pro-
Provide health care services aimed at preventing longed PR, and a widened QRS complex.
health problems or maintaining health.
Know and apply the basic and clinically
The survival of the graft kidney depends, in part, supportive sciences that are appropriate to their
on the timely administration of antibacterial, antiviral, discipline.
and immunosuppressive agents. We can do our part by
getting those drugs in the patient intraoperatively. The kidney is a vital part of homeostasis, affecting
multiple organ systems. Knowing the altered physiol-
Work with health care professionals, including ogy of a patient with ESRD helps prepare for the crit-
those from other disciplines, to provide ical stages of surgery. Common problems associated
patient-focused care. with ESRD include electrolyte imbalance and cardio-
vascular and hematologic dysfunction.
Your transplant surgeons need your help as much
as they need the help of their scrub and circulating
nurses. The surgeon may let you know when to give Practice-based learning
the heparin and when to get the blood pressure up and improvement
to ensure perfusion to the new kidney. Also, you may Residents must be able to investigate and evaluate their
need to ask the circulating nurse to send off multiple patient care practices, appraise and assimilate scientific
ABGs, and when you notice that the H&H confirms evidence, and improve their patient care practices.
that the pallor of the patients fingers is not the lat-
est fashion statement on nail polish, you may ask the Analyze practice experience and perform
nurse to fetch blood in the refrigerator. Can you spell practice-based improvement activities using a
t-e-a-m-w-o-r-k? systematic methodology.
As you work through a case like this, you realize
Medical knowledge how overwhelming things can get, especially if there
Residents must demonstrate knowledge about estab- is an unanticipated glitch along the way. It is there-
lished and evolving biomedical, clinical, and cognate fore important to develop a systematic approach to
(e.g., epidemiological and social-behavioral) sciences the steps taken from the moment the patient enters
and the application of this knowledge to patient care. the OR to the point at which he settles down in the
Demonstrate an investigatory and analytic recovery room. Institution-specific protocols call for
thinking approach to clinical situations. certain types and dosages of antibiotics, antivirals,
and immunosuppressants to be administered, requir-
Always expect the worst and hope for the best. As ing the use of multiple lines. Developing a way to avoid
you begin this case, think about what could go wrong tangling the spaghetti is helpful, to say the least. As
in the operating room. The patient will likely have the surgery progresses, having an idea of the timing 165
abnormalities in platelet function and may present of giving certain medications is crucial. With proper
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

preparation and practice, experience, and practice- Professionalism

based improvement activities, there should be little
Residents must demonstrate a commitment to carry-
variation in the way this surgery is handled, even
ing out professional responsibilities, adherence to eth-
among different clinicians.
ical principles, and sensitivity to a diverse patient pop-
ulation.
Locate, appraise, and assimilate evidence from
scientific studies related to their patients health Demonstrate respect, compassion, and integrity; a
problems. responsiveness to the needs of patients and society
that supersedes self-interest; accountability to
Know what is recommended. For example, how patients, society, and the profession; and a
would you carry out your maintenance anesthetic? commitment to excellence and ongoing
A number of different combinations of inhaled and professional development.
intravenous medications have been used with reason-
able safety margins. General anesthesia is preferred. Again, although this may seem like another 4-hour
Desflurane, isoflurane, and sevoflurane can all be used, haul for you in the middle of the night, when you wish
although there may be some concern with renal toxic- you were snoozing away, try to think about it from
ity from the use of sevoflurane due to production of the patients perspective. As you would on a typical
fluoride and compound A. Opioids other than mor- midmorning routine, you should be prepared to han-
phine and meperidine, which have metabolites depen- dle a bag of emotions at the bedside and demonstrate
dent on renal clearance, should be safe. Ideally, a mus- the appropriate respect, compassion, and responsibil-
cle relaxant not dependent on renal clearance, such as ity that your patient demands.
atracurium or cisatricurium, should be used.
Demonstrate a commitment to ethical principles
Obtain and use information about their own pertaining to provision or withholding of clinical
population of patients and the larger population care, confidentiality of patient information,
from which their patients are drawn. informed consent, and business practice.

Review the latest on anesthetic management of Review informed consent, double-check on sur-
renal transplantation. gery site, and be cognizant that there are others around
you as you discuss details of your patients medical
record in the holding area. Also, make sure the surgeon
Apply knowledge of study designs and statistical has seen the patient prior to taking him to the OR.
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.
Is there any evidence to what is being done? For What may transcend all cultures, ages, gender, and
example, is an arterial line absolutely necessary for a disabilities is the notion of treating your patients as you
kidney transplant procedure? The answer is no there would wish to be treated.
is no proof that arterial line placement improves graft
outcome. However, it seems beneficial to have con-
tinuous blood pressure monitoring, particularly after Interpersonal and communication
revascularization of the transplanted kidney, because skills
hypotension can lead to delayed graft function and/or Residents must be able to demonstrate interpersonal
renal vein thrombosis. and communication skills that result in effective infor-
mation exchange and teaming with patients, their
Use information technology to manage patients families, and professional associates.
information, access online medical information,
and support their own education. Create and sustain a therapeutic and ethically
166 sound relationship with patients.
Again, review the latest literature.
 Case 32 Kidney transplant

Hand washing is an important habit to develop, utmost diligence. From a societal perspective, many
especially when seeing patients who are potentially individuals are on a waiting list to receive a kidney,
immunocompromised, as in this case in the postop- and the ultimate measure of success may mean an
erative period. improved quality of life for a prolonged period of time.
You have a chance to contribute to the likelihood of
Use effective listening skills and elicit and provide success by being vigilant in the OR and by follow-
information using effective nonverbal, ing necessary infection precautions when seeing your
explanatory, questioning, and writing skills. patient.
The patient will likely have many questions, some
Practice cost-effective health care and resource
of which you may not be able to answer in detail.
allocation that does not compromise quality of
Although the patient may be emotionally prepared to
care.
undergo surgery (as he may have had a few years to
ponder on this while being on dialysis), many patients Intraoperatively, one may consider using isoflu-
may still have a zillion thoughts going through their rane as this is relatively inexpensive and provides ade-
heads. You may even be asked a question more appro- quate anesthesia for a lengthy case such as this one.
priately answered by the surgeons, in which case, you From a long-term perspective, length of graft survival
should respectfully defer to your colleagues. is important to overall health care cost. Thus improv-
ing overall outcome means maintaining a blood pres-
Work effectively with others as a member or
sure that will optimize perfusion to the graft without
leader of a health care team or other professional
compromising the anastomoses.
group.
The significance of working effectively with other Advocate for quality patient care and assist
members of the OR staff should be reiterated. In addi- patients in dealing with system complexities.
tion, as you transition to the recovery room, your input Understand the immediate postoperative concerns
may be requested not only by the recovery room staff, for this patient and be prepared to react appropriately
but also by urology, nephrology, and intensive care unit in certain situations. For example, how do you deal
personnel. with steroid-induced psychosis? What is the optimal
blood pressure for this patient? What do you do when
Systems-based practice urine output is not responding to fluid challenges?
Residents must demonstrate an awareness of and Knowing what to do beforehand allows for a smoother
responsiveness to the larger context and system of postoperative course and a potentially better surgical
health care and the ability to effectively call on system outcome.
resources to provide care that is of optimal value.
Know how to partner with health care managers
Understand how their patient care and other and health care providers to assess, coordinate,
professional practices affect other health care and improve health care and know how these
professionals, the health care organization, and activities can affect system performance.
the larger society and how these elements of the
system affect their own practice. The immediate postoperative period is important
in terms of laying out goals, standards, and protocols
There are many levels of coordination involved in for the care of the patient. Usually, medication orders
transplanting a deceased-donor kidney into a recipi- will be clearly preprinted, and fluid management is
ent. It is important to understand that viable organs focused on urine output assessment. Communication
are scarce resources that should be handled with the with the urology and nephrology teams is imperative.

167
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Additional reading 2. SarinKapoor H, Kaur R, Kaur H. Anaesthesia for renal

transplant surgery. Acta Anaesthesiol Scand
1. Lemmens HJ. Kidney transplantation: recent
2007;51:13541367.
developments and recommendations for anesthetic
management. Anesthesiol Clin North Am 3. Halloran PF. Immunosuppressive drugs for kidney
2004;22:651662. transplantation. N Engl J Med 2004;351:27152729.
Erratum, N Engl J Med 2005;352:1056.

168
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

33 Electrical glitch
Daryn Moller and Joseph Conrad

The case the nature of the electrical failure. If the problem is lim-
ited to the machine, these monitors should continue
A previously healthy 58-year-old female with a family
to function; a problem with the electrical supply could
history of breast cancer noted a lump in her left breast
affect these monitors. Your Foley catheter should func-
on self-examination. Following a positive biopsy and
tion appropriately.
an in-depth discussion with her surgeon, the decision
was made to proceed with bilateral total mastectomy
with left sentinel lymph node biopsy. Make informed decisions about diagnostic and
After a smooth induction, easy intubation, and 90 therapeutic interventions based on patient
minutes of general anesthesia with oxygen, desflurane, information and preferences, up-to-date scientific
and fentanyl, the surgeon has nearly completed dissec- evidence, and clinical judgment.
tion of the first breast. In your vigilance, you glance at
your anesthesia machine and notice the digital display As it stands, the patient remains anesthetized and
has gone dark, the bellows are not moving, and there intubated, but without any fresh gas flow, ventilation,
is no evidence of fresh gas flow. or volatile anesthetic. On top of that, patient monitor-
ing has been compromised. Intervention will concen-
trate on these areas.
Patient care
Residents must be able to provide patient care that is Develop and carry out patient management plans.
compassionate, appropriate, and effective for the treat-
ment of health problems and the promotion of health. With an airway already established, breathing
is top priority. For ventilation without a ventilator,
Communicate effectively and demonstrate caring Ambu-bag is the answer. If possible, a portable venti-
and respectful behaviors when interacting with lator will solve this problem as well, but will obviously
patients and their families. take time.
The patient is asleep, and you have your hands full, As the patient is still in the middle of an opera-
so your caring behavior will be exactly that caring tion, she will need anesthesia. The options are limited
for the patient. There will be plenty of time after the to intravenous (IV) anesthetics, so an infusion should
operation for respectful discussion of the days events be started as soon as possible. If the electrical supply
with the patient and her family. to the room is intact, your infusion pumps will work
without a problem. Even in a temporary blackout, their
Gather essential and accurate information about battery backup should still do the job. In case of apoca-
their patients. lypse, total intravenous anesthesia (TIVA) can be done
the low-tech way, with a bag of propofol on a microdrip
With your preoperative assessment complete and IV set.
the patient under general anesthesia, information Monitoring will be a problem. Electrocardiogram
gathering is limited to physical exam and available and pulse ox are easily replaced by battery-powered
monitors. In this case, the oxygen sensor, gas analyzer, units, and blood pressure can be done manually. How-
and end-tidal capnography are lost with the machine. ever, an end-tidal CO2 monitor may be hard to come
The pulse oximeter, blood pressure cuff, electrocardio- by; you may have to make do with auscultation and 169
gram, and temperature probe function will depend on observation of chest wall motion for the short term.
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

The oxygen sensor and gas analyzer may simply be

unavailable. Work with health care professionals, including
With basic life support reestablished and all avail- those from other disciplines, to provide
able monitors in place given the circumstances, the patient-focused care.
next step is to determine whether to abort the opera-
Patient safety and care in the OR depends on
tion. In an elective case such as this, the safest situation
teamwork and communication among the anesthesi-
might be to have the surgeon close at the next possible
ologist, surgeon, and OR staff, even under optimal
opportunity.
conditions. When adverse circumstances do arise, the
Counsel and educate patients and their families. anesthesiologist should communicate clearly with the
rest of the team what needs to be done to alleviate
Clearly the anesthesiologists opportunities to the problem.
counsel and educate patients undergoing general
anesthesia are limited to the preoperative and post-
operative periods. Preoperative counseling should
Medical knowledge
include discussions of reasonably foreseeable risks Residents must demonstrate knowledge about estab-
and their management. Unforeseeable events, such lished and evolving biomedical, clinical, and cognate
as total malfunction of the anesthesia machine, are (e.g., epidemiological and social-behavioral) sciences
better left to the postoperative period. and the application of this knowledge to patient care.

Use information technology to support patient Demonstrate an investigatory and analytic

care decisions and patient education. thinking approach to clinical situations.

While the loss of machine function represents an Once the patient is stable, an attempt should be
acute problem and intervening to stabilize the patient made to determine the underlying nature of the prob-
leaves little time for immediate information gather- lem and its implications for the rest of the case.
ing, the anesthesiologists thorough knowledge of the Where was the malfunction that caused the anesthesia
machine and operating room (OR) environment will machine to stop working? If the digital display fails and
allow effective decision making. the machine continues to work, that is likely a problem
limited to the display itself. That the whole machine
Perform competently all medical and invasive shut down indicates either a problem in the machines
procedures considered essential for the area of power supply or a problem with the electrical supply
practice. to the OR. Multiple circuits in the OR help to localize
the problem. If the anesthesia machine, electrocautery,
Competent performance in this case requires the surgeons stereo, and everything else in the room
quick, rational judgment. As in any case, you must craps out simultaneously, the problem is likely outside
realize that there is indeed a problem, identify and the OR and nothing you can fix. If your machine is
prioritize the relevant issues, and then address those the only piece of equipment in the room to fail, you
issues. This means skillful use of hand ventilation and should check that it is plugged into an uninterruptible
proper preparation of necessary infusions and moni- power supply, that is, a power supply with a backup.
tors to expedite patient care. An interruptible power supply, one that can go off and
stay off, may be identical to the uninterruptible socket,
Provide health care services aimed at preventing and machines have been plugged into the wrong sup-
health problems or maintaining health. ply. You should never assume that somebody probably
checked it; you may be the first to diagnose this prob-
Once a situation such as this arises, the anesthe-
lem in your own OR.
siologist maintains the patients health by reestablish-
ing adequate resuscitation and monitoring. Again, in
an elective case such as this, preventing health prob- Know and apply the basic and clinically
lems and maintaining health may best be carried out supportive sciences that are appropriate to their
170 discipline.
by aborting the procedure.
 Case 33 Electrical glitch

You dont need a biomedical engineering degree Again, the anesthesiologists knowledge base de-
to be a competent anesthesiologist, but you should rives from attentive assessment of each patient, com-
know enough about your anesthesia machine to per- bined with a knowledge of the current literature per-
form basic troubleshooting. The high-yield solution is taining to the patients primary disease process and
to perform a complete machine check every day, ask- comorbidities.
ing yourself at each step, What might go wrong, and
how will I fix it? Apply knowledge of study designs and statistical
methods to the appraisal of clinical studies and
Practice-based learning and other information on diagnostic and therapeutic
effectiveness.
improvement
Residents must be able to investigate and evaluate their Once again, in the face of equipment failure, there
patient care practices, appraise and assimilate scientific is not much time for a perusal of the literature, and it
evidence, and improve their patient care practices. would be difficult to anticipate this type of event the
night before, while reading up on your cases. How-
Analyze practice experience and perform ever, once you have run into this type of difficulty,
practice-based improvement activities using a you should be acutely interested in how others have
systematic methodology. approached similar circumstances, and it is likely that
whatever reports you do find about similar cases will
Again, the best systematic approach to machine- stick in your mind better, having faced the problem
related problems in the OR is thorough knowledge firsthand. You should examine how other clinicians
of the machine and the OR environment, reviewed have approached these problems in the past and com-
daily through the machine check. When you do have pare their methods with your own.
a problem with a machine, you must address it. While
you may not have the means or expertise to rem- Use information technology to manage
edy every problem, you should contact someone who information, access online medical information;
can. Between your hospitals biomedical engineering and support their own education.
department and the machines manufacturer, you will
eventually find someone who can fix the glitch. While the literature on power failure and similar
problems is limited to case reports and letters, it is
Locate, appraise, and assimilate evidence from likely that any problem you face will not be the first
scientific studies related to their patients health of its kind and that someone, somewhere has faced the
problems. same issues and lived to describe the experience. The
best way to access the worlds clinical experience is via
The literature on power failure in the OR is in
the Internet, and this should be a regular part of every
somewhat short supply relative to other clinical
clinicians practice.
parameters. However, patient care in this setting
should be based on the published data and recommen-
dations in more broadly applicable areas.
Monitoring is founded on the American Society of Professionalism
Anesthesiology (ASA) standards for basic monitoring. Residents must demonstrate a commitment to car-
This begins with qualified anesthesia personnel, fol- rying out professional responsibilities, adherence to
lowed by assessment of oxygenation, ventilation, circu- ethical principles, and sensitivity to a diverse patient
lation, and temperature. Beyond that, the anesthesiol- population.
ogist must be familiar with the planned procedure and
the patients comorbidities as they relate to the anes- Demonstrate respect, compassion, and integrity; a
thetic plan. responsiveness to the needs of patients and society
that supersedes self-interest; accountability to
Obtain and use information about their own patients, society, and the profession; and a
population of patients and the larger population commitment to excellence and ongoing
from which their patients are drawn. professional development. 171
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Responsiveness to the needs of the patient is neatly mation exchange and teaming with patients, their
summed up in the motto of vigilance. The anesthesiol- patients families, and professional associates.
ogist must function as the physician in the OR, attend-
ing to the anesthetized patients needs while the sur- Create and sustain a therapeutic and ethically
geon addresses a specific pathology. In this way, the sound relationship with patients.
anesthesiologist is uniquely accountable to the patient
because no other group of physicians has more direct The anesthesiologists interaction with the patient
and immediate control of their patients physiology. may be brief relative to that of other physicians, but
In this case, the vigilant anesthesiologist immediately the relationship should not suffer for that fact. From
recognizes a compromise in the patients respiration the preoperative assessment, the physician should
and quickly addresses it, while protecting her from the encourage the patient to be open and honest to opti-
harm of pain and intraoperative awareness. mize the assessment and should, in turn, be honest
with the patient about plans and expectations for the
Demonstrate a commitment to ethical principles coming procedure, including reasonably foreseeable
pertaining to provision or withholding of clinical risks.
care, confidentiality of patient information, While the risk of failure of an anesthesia machine
informed consent, and business practice. or other mechanism in the OR would not typically be
addressed, the physician should make every effort to
As in any case, the physician must honor the
reassure the patient that when adverse events do occur,
patients privacy and autonomy by keeping informa-
they are handled as effectively as possible, with the goal
tion confidential and ensuring preoperatively that the
of patient care in mind.
patient knows what to expect from the perioperative
experience.
Use effective listening skills and elicit and provide
Demonstrate sensitivity and responsiveness to information using effective nonverbal,
patients culture, age, gender, and disabilities. explanatory, questioning, and writing skills.

These general principles should influence every Following failure of your machine and subsequent
physician-patient interaction, if slightly more subtly in stabilization of your patient, document! In the case of
the operative setting. The anesthesiologist should be an adverse event or near-miss, the events should be
familiar with the patients disabilities, including med- recorded as accurately as possible for future review and
ical, surgical, and substance history, and these should improvement.
influence intraoperative decision making. For exam-
ple, females should be expected to have a higher rate Work effectively with others as a member or
of postoperative nausea and vomiting, patients with leader of a health care team or other professional
hypertension will more likely have labile blood pres- group.
sures requiring tighter pharmacologic control, and
persons of increased age will have decreased require- The machine stopped working, and you are for-
ments for inhalational anesthetics. mulating your plans while hand-ventilating. If you are
However, most of the immediate maneuvers in manually ventilating your patient, then no one in the
the case of a machine failure should be applicable to OR is performing a more critical task. Now is the time
any patient. While the anesthesiologist should have an to assert yourself as doctor of the operating room.
idea of the patients respiratory reserve, any patient You will need the assistance of the surgeon and the OR
for whom the ventilator fails should be immediately staff, and likely outside help, to care for your patient
switched to hand ventilation, if necessary, with an effectively. Call on individuals and assign tasks just as
Ambu-bag, regardless of the state of health. you would in an advanced cardiac life support (ACLS)
code. As professionally as possible, determine with the
Interpersonal and communication surgeon whether and how to proceed with the remain-
der of the operation. If conditions are temporarily
172 skills unsafe to continue, ask him or her to pause. If condi-
Residents must be able to demonstrate interpersonal tions cannot be improved, alert the surgeon that the
and communication skills that result in effective infor- case must end as soon as possible.
 Case 33 Electrical glitch

Systems-based practice Advocate for quality patient care and assist

Residents must demonstrate an awareness of and patients in dealing with system complexities.
responsiveness to the larger context and system of
health care and the ability to effectively call on system Make the most of the precious few minutes spent
resources to provide care that is of optimal value. with the patient during the preoperative assessment.
Inform patients of what to expect.
Understand how their patient care and other In the OR, be attuned to potential problems in the
professional practices affect other health care system. Try to look critically at aspects of patient care
professionals, the health care organization, and usually taken for granted. If a defect is identified in
the larger society and how these elements of the the machine you were using for this case, look at your
system affect their own practice. next machine to see if the same defect is present. If
the machine was simply plugged into the incorrect
The anesthesiologist must be aware of the effect of power supply, see to it that other machines are properly
his or her own actions on other physicians, particularly set up.
the surgeon in the room. Honest and respectful com-
munication sets the tone for a good working relation- Know how to partner with health care managers
ship and can facilitate proper patient care. and health care providers to assess, coordinate,
and improve health care and know how these
Practice cost-effective health care and resource activities can affect system performance.
allocation that does not compromise quality of
care. If you notice problems or ambiguities that might
lead to compromised patient care, address these con-
In this relatively long case, perhaps a more cost- cerns to the proper authority, whether it be the
effective inhalational anesthetic than desflurane might OR coordinator, engineering, or a quality assurance
have been considered. body.

173
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Additional reading 2. Yasney J, Soffer R. A case of power failure in the

operating room. Anesth Prog 2005;52:6569.
1. Chawla AV, Newton NI. Machine and monitor failure
from electrical overloading. Anaesthesia 2002; 3. Welch RH, Feldman JM. Anesthesia during total
57:11341135. electrical failure, or what would you do if the lights
went out? J Clin Anesth 1989;1:358362.

174
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

34 What do you mean you stop breathing

in your sleep?
Deborah Richman and Vishal Sharma

The case 44). An electrocardiogram shows sinus rhythm, with

peaked P-waves.
Your patient is a 45-year-old, hard-drinking, hard-
You review his screening worksheet: no allergies
smoking, and loud-snoring construction worker fresh
are listed, but surprise, surprise his STOP screen has
from the work site. Appropriately attired in steel toe
four out of four positive answers!
boots, muddy jeans, and a classic yet form-fitting flan-
nel shirt, he and his wife stop by the preoperative
assessment clinic before heading to the steakhouse
for a 16-ounce T-bone with many, many sides. His Patient care
abdomen cascades down his waistline, and his cough Residents must be able to provide patient care that is
reminds you of a bulldozer moving gravel. The patient compassionate, appropriate, and effective for the treat-
is scheduled for shoulder arthroscopy within 2 weeks ment of health problems and the promotion of health.
secondary to a fall he suffered 1 month prior. You ask
him about his accident, and he tells you that he fell Communicate effectively and demonstrate caring
asleep on his lunch break and hit his shoulder against and respectful behaviors when interacting with
the table. His past medical history is nondescript; he patients and their families.
has no medical problems, takes no meds, has no aller-
gies, had no previous surgeries, drinks about a six pack The concerns here are multifocal. In addition to
a day, and smokes about a half pack of cigarettes a day. obesity, the patient demonstrates signs and symptoms
He has chronic shoulder pain, for which he initially of obstructive sleep apnea (OSA) but has a recent
saw the orthopedist, who recommended that he have injury that has him needing surgery to repair it and
shoulder arthroscopy after magnetic resonance imag- hasten his return to active work. So he has two issues
ing revealed a slight rotator cuff injury. During your that need to be addressed and may not be prepared for
interview, a nurse asks for your assistance, and you the first: a sleep consult and workup to get in the way
briefly step out of the room. When you return to your of the second his surgery.
office less than 5 minutes later, your patient is slouched OSA is characterized by repetitive obstruction of
over, snoring louder than Homer Simpson after a night the airway during sleep with apnea lasting more than
at Als Tavern. You ask him about his sleep, and he 10 seconds.
relates to you that he frequently wakes up at night short Why is this clinically significant for anesthesiol-
of breath, has morning sleepiness, falls asleep at work ogists and the patient? OSA is associated with sig-
all the time, and has noticed that he has been having nificant perioperative morbidity and mortality. OSA
headaches more frequently. His wife states that he has is associated with increased risk of difficult intuba-
snored forever, and sometimes in the middle of the tion, postoperative hypoventilation and apnea, and
night, hell wake up huffing and puffing. arrhythmias as well as medical comorbidities such as
You examine him and notice that he is a middle- hypertension, heart disease, obesity, and pulmonary
aged, obese white male with nicotine-stained fingers hypertension. It is important in this situation to
on his right hand. He has a short, thick neck. His heart express concerns about undiagnosed and untreated
sounds are normal and his lungs are clear. His vitals OSA and to refer these patients to experts knowledge-
reveal an elevated blood pressure of 155/84, a heart able about sleep-related disorders to reduce their over-
rate of 65, and a respiratory rate of 10. His weight is all risk from developing complications during surgery 175
143 kg, and his height is 180 cm (body-mass index = and later down the road.
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Although this gentleman seems less worried about  less postoperative (opiate- and sedative-aided)
his overall fitness than Lance Armstrong, it doesnt apneas with extubation to CPAP
necessarily mean that he wouldnt be concerned about
the possibility of having a disorder of sleep. You must The patient should also receive counseling regarding
educate the patient about your concerns of OSA, obe- weight loss, exercise, and smoking cessation and con-
sity, and cigarette smoking and inform the patient trol of systemic hypertension.
about medical care from which he may benefit, even In terms of surgical venue, high-risk patients are
if the patient seems apathetic about his own well- not appropriate for free-standing ambulatory surgi-
being. centers (American Society of Anesthesiologists [ASA]
guidelines). Additionally, the CPAP machine should
Gather essential and accurate information about be brought on the day of surgery for use in the recovery
their patients. period.
Shoulder repairs are generally done under general
History and physical have given us a clinical diag- anesthesia in combination with regional anesthesia
nosis. We need to assess our patient for end organ dam- (interscalene nerve block). This is especially important
age from his clinical sleep apnea and hypertension. in the OSA patient any possible avoidance of opiates
Basic testing includes the following: and sedatives is good.
1. a hemoglobin as an assessment of chronic Obese patients with sleep apnea are at increased
hypoxemia risk for difficult intubation. Advanced airway equip-
2. renal function secondary to hypertension ment may be needed and staff experienced in its use
3. electrocardiogram looking for evidence of should be available. Postop CPAP availability as well as
ischemia, left ventricular hypertrophy, and right postop monitoring and ventilation facilities and opiate
heart strain and benzodiazepine antagonists should be at hand.
4. resting room air oxygen saturation ASA guidelines recommend that patients with
OSA be monitored for 3 hours longer than their non-
Any abnormalities here would suggest further investi- OSA cohorts in recovery, and any episode of desatura-
gations possibly echocardiogram and arterial blood tion warrants another 7 hours in a monitored bed. For
gases, and of course, the aforementioned sleep consult. ambulatory patients, it is best to book them early in the
day to prevent overnight admission for this indicated
Make informed decisions about diagnostic and monitoring.
therapeutic interventions based on patient
information and preferences, up-to-date scientific Counsel and educate patients and their families.
evidence, and clinical judgment.
The risks of untreated OSA should be explained
This patient is being evaluated in the clinic well in to the patient so that he can make an informed deci-
advance of his surgery, and steps should be undertaken sion on whether to continue with diagnostic testing
to optimize him for his surgery. The definitive test for and therapy. With OSA, he is at risk for heart disease,
OSA remains the polysomnogram. stroke, or death.
Develop and carry out patient management plans. Use information technology to support patient
Formal diagnosis of OSA, initiation of treatment care decisions and patient education.
preoperatively, and a specifically tailored anesthetic There are numerous resources online for patients to
plan will offer the patient the lowest risk periopera- utilize to gain information on the diagnosis and treat-
tively: ment of OSA. It is important that you direct the patient
Appropriate continuous positive airway pressure to Web sites with useful information and not Web sites
(CPAP) treatment should be instituted to achieve the steered toward home remedies and miracle drugs that
following: simply have not been proven to work or that might
 decreased airway edema and easier intubation be dangerous. One excellent resource for patients is
 decreased sympathetic tone and lower WebMD (http://www.webmd.com), a patient-centered
176
cardiovascular risk Web site with medical information on a vast array of
 Case 34 What do you mean you stop breathing in your sleep?

medical topics designed to inform patients. Another a sleep report, which confirms the presence of OSA
is the Web site of the American Sleep Apnea Associa- and quantifies its severity. Benumof and colleagues
tion (http://www.sleepapnea.org), which provides use- reported on the interpretation of a sleep study in The
ful information and written literature on OSA and its New ASA OSA Guidelines, published in 2007: the
treatment. results of a sleep study are reported as events and
indices. An apnea event is no airflow for more than
10 seconds; an hypopnea event is a tidal volume less
Medical knowledge than 50% of the control awake value for more than
Residents must demonstrate knowledge about estab- 10 seconds; a desaturation event is a decrease in the
lished and evolving biomedical, clinical, and cog- SpO2 greater than 4% and an arousal event can be
nate (e.g., epidemiological and social-behavioral) sci- clinical (vocalization, turning, extremity movement)
ences and the application of this knowledge to patient or a burst on the EEG. Indices are events per hour;
care. the apnea hypopnea index (AHI) is the number of
times the patient was either apneic or hypopneic per
Demonstrate an investigatory and analytic hour; the oxygen desaturation index is the number
thinking approach to clinical situations. of times the patient had a decrease in SpO2 greater
than 4% per hour and the arousal index is the num-
Further findings to be looked for on physical exam ber of times the patient aroused per hour. The severity
are signs of pulmonary hypertension and hypoxemia, of OSA is most universally expressed in terms of the
such as clubbing, cyanosis, ruddy facies, loud P2, RV apnea hypopnea index, in which 620 is mild, 1540 is
heave, and right heart failure (enlarged liver, distended moderate, and 40 is severe and is scored 1, 2 and 3
neck veins, and peripheral edema). These advanced respectively.
findings would warrant further investigation with arte- Using these data, the sleep physician will then
rial blood gases and echocardiogram. decide whether to place the patient on therapy for
The STOP questionnaire, developed by Chung OSA, which includes CPAP. CPAP has been the main-
et al. and published in the Journal of Anesthesiology [5], stay of treatment for patients with OSA, but it is only
confirms our suspicion. STOP corresponds to the fol- in severe OSA that it has been shown to have signifi-
lowing questions: cant benefit. CPAP is administered via an oral/nasal or
1. Do you snore loudly (louder than talking or loud oronasal face mask. Surgical intervention is sometimes
enough to be heard through closed doors)? necessary for patients with severe OSA and patients
2. Do you often feel tired, fatigued, or sleepy during who have OSA symptoms that are refractory to high
daytime? levels of CPAP and anatomy amenable to surgical
3. Has anyone observed you stop breathing during intervention.
your sleep (Honey, you stop breathing at night)? Use the PSG results to arrive at an OSA score, and
4. Do you have or are you being treated for high use this for clinical decision making. The score consists
blood pressure? of the sum of two components:

When incorporating other factors, such as body-mass Component 1: severity of OSA 1 = mild, 2 = mod-
index, age, neck circumference, and gender, the STOP- erate, and 3 = severe
Bang screen has a very high sensitivity for detect- Component 2: the higher of the following two scores
ing patients who have OSA and serves as an effective
screening tool.
Polysomnography (PSG) incorporates electroen- Surgical
cephalogram monitoring, chest and abdominal pres- Postop opiate need invasiveness/anesthesia
sure for respiratory effort, an electrooculogram for 0 = None 0 = None/local anesthesia
NREM sleep versus REM sleep, capnography for air- 1 = Low dose oral 1 = Superficial/regional
flow determination, pulse oximetry for the detection of anesthesia
oxygen saturation or desaturation, and an electrocar- 2 = High dose oral 2 = Peripheral/GA
diogram for the determination of arrhythmias. After 3 = Parenteral/neuraxial 3 = Airway/major/ 177
the sleep study, all these raw data are converted into abdominal/GA
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Practice-based learning patients have a right to informed refusal of testing or

procedures (autonomy is one of the four principles of
and improvement medical ethics).
Residents must be able to investigate and evaluate their
patient care practices, appraise and assimilate scientific Demonstrate sensitivity and responsiveness to
evidence, and improve their patient care practices. patients culture, age, gender, and disabilities.

Analyze practice experience and perform Dont threaten him with, If you dont get your
practice-based improvement activities using a sleep apnea treated, you may get a head injury next
systematic methodology. time!

Incorporate the STOP questionnaire in preopera-

tive screening to readily detect patients with undiag-
Interpersonal and communication
nosed OSA. skills
Residents must be able to demonstrate interpersonal
Locate, appraise, and assimilate evidence from and communication skills that result in effective infor-
scientific studies related to their patients health mation exchange and teaming with patients, their
problems. patients families, and professional associates.
Several studies were used in this case. Use effective listening skills and elicit and provide
information using effective nonverbal,
Professionalism explanatory, questioning, and writing skills.
Residents must demonstrate a commitment to carry-
Document clearly your thoughts in the chart,
ing out professional responsibilities, adherence to eth-
including reason for referral, expected change in man-
ical principles, and sensitivity to a diverse patient pop-
agement, and the calculation of the OSA score. Also
ulation.
include risks and benefits discussed with the patient.
Demonstrate respect, compassion, and integrity; a
Work effectively with others as a member or
responsiveness to the needs of patients and society
leader of a health care team or other professional
that supersedes self-interest; accountability to
group.
patients, society, and the profession; and a
commitment to excellence and ongoing Book this patient first case in the day of his ambu-
professional development. latory surgery. Send appropriate information to the
sleep center, including urgency, as it is a preoperative
Inform the patient of your suspicions of undiag-
assessment. Keep the surgeon informed of the need
nosed sleep apnea and the risks both perioperatively
for further testing, possible previously unknown risks
and long term. Offer advice on how to proceed as well
involved, and the need for change of venue or anesthe-
as evidence-based information as to the importance of
sia plan.
following this up preoperatively.

Demonstrate a commitment to ethical principles Systems-based practice

pertaining to provision or withholding of clinical Residents must demonstrate an awareness of and
care, confidentiality of patient information, responsiveness to the larger context and system of
informed consent, and business practice. health care and the ability to effectively call on system
Ask the patients permission to refer him to a sleep resources to provide care that is of optimal value.
center or suggest that the patient ask his personal Understand how their patient care and other
physician to refer him. professional practices affect other health care
Should the patient elect to defer sleep evaluation, professionals, the health care organization, and
respectful discussion of an appropriate anesthesia plan the larger society and how these elements of the
178 and the increased risks, including that of admission system affect their own practice.
and possible postoperative ventilation, is appropriate
 Case 34 What do you mean you stop breathing in your sleep?

OSA still remains underdiagnosed and poorly sult/study spot for a CTR would use up the urgent
treated because of the issues with testing and treat- slots in the sleep clinic, making them unavailable to
ment. Sleep studies are not readily available in all parts other patients like our Mr. Jolly, whose management
of the country, and CPAP can be costly, uncomfort- depends on the severity of his OSA.
able, and embarrassing, causing patients to discon-
tinue therapy. Know how to partner with health care managers
and health care providers to assess, coordinate,
Practice cost-effective health care and resource and improve health care and know how these
allocation that does not compromise quality of activities can affect system performance.
care.
It is not enough to just screen for OSA (or other
Having this patient canceled on the day of surgery common diseases that impact perioperative out-
because of lack of optimization or admitted postopera- comes). One has to have an organized and easily nego-
tively has high economic impact on the institution, the tiable referral system for these patients to get the indi-
patient, and his insurance. It may also cost the family cated workup without extensive delays in surgery or
time off work. cost to the patient or institution.
Remember, too, that if he were having a carpal The patient did indeed have severe OSA with an
tunnel release (CTR), a preop sleep study would not apnea-hypopnea index of 37 and oxygen desaturations
change management, except for early booking, which down to 82%. His surgery was performed early in the
can be done anyway with the clinical suspicion of OSA. morning in the main operating room with interscalene
The maximum OSA score for CTR surgery would be 4, block and general anesthesia. He was extubated to his
so it is acceptable to proceed in a free-standing ambu- CPAP machine and discharged home after an unevent-
latory center, and the procedure is done under local ful 6-hour stay in recovery.
anesthesia with minimal sedation. Using a sleep con- He and his wife now sleep peacefully at night.

179
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Additional reading a report by the American Society of Anesthesiologists

Task Force on Perioperative Management of Patients
1. Chung SA, Yuan H, Chung F. A systemic review of
with Obstructive Sleep Apnea. Anesthesiology
obstructive sleep apnea and its implications for
2006;104:10811093.
anesthesiologists. Anesth Analg 2008;107:15431563.
4. Joshi GP. Ambulatory surgery for the patient with
2. Benumof JL, The new ASA OSA guideline. ASA
sleep apnea syndrome. ASA Refresher Courses
Refresher Courses in Anesthesiol 2007;35:1;113.
Anesthesiol 2007;35:97106.
3. Gross JB, Bachenberg KL, Benumof JL, Caplan RA,
5. Chung F, Yegneswaran B, Liao P, et al. STOP
et al. Practice guidelines for the perioperative
questionnaire: a tool to screen obstructive sleep apnea.
management of patients with obstructive sleep apnea:
Anesthesiology 2008;108:812821.

180
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

35 Please prevent postop puking

Neera Tewari and Vedan Djesevic

The case I reassured Mrs. B that I would do everything in my

power to decrease her chance of getting PONV again.
Mrs. B, a 52-year-old woman with a strong family
I let her know that I would administer a volatile-free
history of breast cancer, underwent a workup that
anesthetic, supplemented by a number of antiemetic
revealed a carcinoma of the right breast, and she is
medications, and minimize the use of perioperative
now scheduled for a right mastectomy. After seeing her
opioids. Her anesthetic would be a total intravenous
chart the day before her proposed surgery, I noticed
infusion of propofol, and she would get aprepitant,
that she had no other significant medical problems.
dexamethasone, and ondansetron perioperatively. I
The challenge for me would be to prevent postopera-
also let her know that I would speak with her surgeon
tive nausea and vomiting. The common thread in her
about using local anesthetics at the surgical site to min-
surgical history was postoperative nausea and vomit-
imize narcotic use.
ing (PONV) I was ready to face this challenge and
I explained to her my multifaceted approach to
provide this patient with a nausea-free anesthetic.
combat nausea and vomiting, but unfortunately, I
On the morning of surgery, I met Mrs. B. She was
couldnt guarantee it I could only try my level best.
a pleasant lady with big blue eyes and curly blond
She seemed relieved and was very happy to be included
hair. I immediately noticed that she was anxious and
in the plan. Usually they dont explain all this, she
uneasy because she was constantly massaging her fin-
stated.
gers throughout our conversation. Being a biochemist
and having gone through two surgeries prior to this
one, she was well aware of the risks of anesthesia and,
more important, the postoperative nausea with which Medical knowledge
she was always afflicted. Mrs. B was at high risk for PONV because she had mul-
tiple risk factors for postoperative nausea and vomit-
ing. She had a history of PONV, and she was a non-
Patient care smoker and of female gender. In addition, the surgery
I knew I was going to have a challenge coming to was going to be longer than an hour, and it was breast
work, but I didnt realize I would be facing an exten- surgery, both of which are surgical risk factors for
sive family history of postoperative nausea and vom- PONV. Some of the anesthetic risk factors that con-
iting. I reassured her that I would do everything in tributed to her PONV in the past were use of nitrous
my power to make this a vomit-free experience. It was oxide, use of volatile anesthetics, and the adminis-
important for me that I gain her trust right before the tration of intraoperative and postoperative opioids. I
operation and let her know that I was well aware of her explained all these factors to her but also let her know
concerns and fears. Not only was she having an impor- that, on a positive note, many new antiemetic therapy
tant surgery, but her postoperative comfort level was regimens have been developed in recent years.
essential, as well.
I inquired extensively about her surgical and family
history. She told me, Doctor, I had PONV after my Practice-based learning
tonsillectomy with ether, my mother had it after her
cholecystectomy with halothane, and my grandmother and improvement
had it during her labor with chloroform. I want this to Right before we went into the operating room, I 181
be the first operation without it. Please! gave Mrs. B a pill called Emend (aprepitant), a new
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

neurokinin antagonist that significantly reduces post- I gave Mrs. B a dose of a potent nonsteroidal anti-
operative nausea and vomiting at 24 hours and 48 inflammatory drug (30 mg of ketorolac), as well.
hours after surgery. After the Emend, I gave her a good
dose of benzodiazepines to calm her anxiety and wor-
ries. For her induction and maintenance of anesthe- Professionalism
sia, I decided to use propofol. I placed a laryngeal It was very comforting to see Mrs. B emerge from her
mask airway. I avoided nitrous oxide and inhalational surgery comfortable and without any nausea or vomit-
anesthetic and minimized my intraoperative opioids. I ing. She was pain-free and at ease. She was pleased and
asked Dr. S, her surgeon, to infiltrate a fair amount of surprised that we were able to curb her genetic predis-
local anesthetic to decrease the need for postoperative position toward postop nausea. It was a rewarding day
opioids. In addition, following the newest guidelines for me, knowing that I used my knowledge and pro-
for management of postoperative nausea and vomit- fessionalism to combat one of the oldest complications
ing, I gave Mrs. B a steroid (4 mg of dexamethasone) postsurgery.
at the beginning of the surgery and a serotonin antag- Note in this case how we cut to the chase on four
onist (4 mg of ondansetron) and an antidopaminer- of the six core clinical competencies. By now (youve
gic drug (0.625 mg of droperidol) toward the end gone through 38 cases), you should be thinking com-
of the procedure. To minimize my use of opioids, petencies and be able to do this yourself.

182
 Case 35 Please prevent postop puking

Additional reading 2. Diemunsch P, Gan TJ, Philip BK, et al. Single-dose

aprepitant vs ondansetron for the prevention of
1. Gan TJ, Meyer T, Apfel C, et al. Society for
postoperative nausea and vomiting: a randomized,
Ambulatory Anesthesia guidelines for the
double-blind phase III trial in patients undergoing
management of postoperative nausea and vomiting.
open abdominal surgery. Br J Anaesth
Anesth Analg 2007;105:16151628.
2007;99:202211.

183
 Part 1 Contributions from Stony Brook University under
Case Christopher J. Gallagher

36 Mr. Whipple and the case of the guy who

likes to mix a few vikes with his vodka
Misako Sakamaki and Brian Durkin

The case So it seems like this patient is one of those that

leads you to say, Is that him? Oh, no! Here he comes
You are consulted the week before surgery by the surgi-
again . . . what do I do now? When taking care of a so-
cal oncologist about another one coming for surgery
called challenging patient like this one, it is particularly
for pancreatic cancer. You remember fondly the last
important to establish a good doctor-patient relation-
one, who drove everyone crazy, from the preoperative
ship. Gaining trust from a patient like this would be a
admission area nurses to the guy who held open the
first major step toward effective patient care (and will
hospital door as he left for home and let it slam him
also make your perioperative life a little easier). After
in the rear. He had his big life-saving cancer surgery
all, this patient has a cancer that is threatening his life,
and was lucky to get out of the hospital alive and that
and now he has to undergo major surgery. He is most
meant that someone had to keep the staff from killing
likely scared, anxious, and emotionally devastated. Be
him. This is the dreaded narcotic user and abuser who
compassionate he needs your help!
will tax your professionalism to the nth degree. You
remember those days back in high school, when they Gather essential and accurate information about
showed those black-and-white movies about people their patients.
who fell ill to the needle? Today, they dont dress as
nice, may actually not use a needle, and may actually After establishing a good rapport with the patient,
get their opioids from the same guy who gives you a flu now its time to get to know him. All we now know
shot. They live among us, and yes, they are often your is that he has a major cancer and is a longtime nar-
patient. cotic user (is he really an abuser?). We need to know
The Whipple procedure (did Dr. Whipple succumb in detail about his other medical issues, cancer history
to pancreatic cancer? I think he did) is a long, tedious (stage and prognosis), and pain management history.
operation performed occasionally at your institution Is this patient a real narcotic abuser/seeker, or is he
by a surgeon who likes to keep the patient dry. Dont a pseudo-abuser he may be not addicted, but actu-
follow those rules you usually follow. Urine output ally undertreated (because his doctors are negatively
is not that important. I dont want them to bleed too biased against him and are denying adequate opioid
much. These are the words of this surgical oncologist, coverage), and he is only seeking adequate pain relief.
who also doesnt want you to use local anesthetic in the Talk to the patient and also contact his personal medi-
epidural for the first 24 hours postoperatively. cal doctor, oncologist, and pain management specialist
What are you to do for this patient? Can his post- to get a full picture of this patient before you come up
operative pain be effectively managed? with an effective anesthetic plan.
We also need to know if he has any toxic habits:
Patient care a patient with substance use disorders to alcohol,
Residents must be able to provide patient care that is marijuana, or nicotine will show a higher incidence
compassionate, appropriate, and effective for the treat- of dependence on other substances than the general
ment of health problems and the promotion of health. population. In fact, nearly 70% of opioid addicts in
the United States are dependent on either cocaine
Communicate effectively and demonstrate caring or other habituating substances. Opioid-dependent
and respectful behaviors when interacting with patients with superimposed cocaine dependence may
184 patients and their families. present additional problems for us, including hemody-
namic instability and extreme emotional lability.
 Case 36 Mr. Whipple and the case of the guy who likes to mix a few vikes with his vodka

Make informed decisions about diagnostic and Perform competently all medical and invasive
therapeutic interventions based on patient procedures considered essential for the area of
information and preferences, up-to-date scientific practice.
evidence, and clinical judgment.
Place adequate intravenous access, a thoracic
Assuming that this patient has no other medi- epidural catheter (without making a wet tap!), and an
cal issues, the main concern for him and his anes- arterial line and secure the airway appropriately.
thesiologist is how to establish effective perioperative
pain management. A patient like this usually has a Work with health care professionals, including
very high tolerance to opioids, and he would not only those from other disciplines, to provide
require a very high dose of narcotics perioperatively, patient-focused care.
but may not even adequately respond to narcotics
without significant unwanted side effects. I would talk Involve the surgeon, the pain management special-
to this patient about the use of neuraxial analge- ist, the oncologist, and possibly a psychiatrist prior to
sia (thoracic epidural) for effective perioperative pain the patients surgery to come up with the most effec-
control. Discuss with the patient what the alternative tive plan. For example, talk to the surgeon preop and
option is (intravenous patient controlled analgesia) explain to him or her how important it would be to
and explain the risks and benefits of each option. Make use epidural analgesia/anesthesia intraoperatively. We
sure the patient has no contraindication to neuraxial understand that surgeons are concerned with the pos-
anesthesia. sible hemodynamic changes associated with epidural
sympathetectomy during the case. Discuss with the
Develop and carry out patient management plans. surgeons the risks and benefits of using an epidural
catheter during the case. If hemodynamics are an issue,
The plan is general anesthesia plus epidural anes- we can always administer narcotics without local anes-
thesia/analgesia and the use of a multimodal analgesia thetic during the case.
for the best perioperative course.
If there is no contraindication and the patient
consents (and you really hope he does!), I would Medical knowledge
place a thoracic epidural catheter in this patient pre- Residents must demonstrate knowledge about estab-
operatively. I would then dose his epidural catheter lished and evolving biomedical, clinical, and cognate
with local anesthetics prior to surgical incision. If the (e.g., epidemiological and social-behavioral) sciences
patient has not taken his usual dose of oral opioid on and the application of this knowledge to patient care.
the morning of surgery, I would also administer the
equivalent dose of opioid at the beginning of surgery. Know and apply the basic and clinically
Use multimodal/balanced analgesia: pain is medi- supportive sciences that are appropriate to their
ated by various mechanisms; therefore, in addition to discipline.
narcotics, we should be using different drugs tar- This is an opioid-dependent patient who is coming
geting distinct mechanisms, for example, anti- for a major abdominal surgery. First, adequate peri-
inflammatories (nonsteroidal anti-inflammatory operative pain control is important, and not only for
drugs, cyclooxygenase-2 inhibitor), N-methyl d- the patients comfort it would also affect the postop
aspartate receptor antagonists (low-dose ketamine), course: uncontrolled pain would place a patient at
and alpha-adrenergic mediated analgesias (clonidine). higher risk for postop cardiopulmonary complication
Use information technology to support patient and might prolong the patients hospitalization.
care decisions and patient education. While this patient would certainly require a much
higher dose of narcotics perioperatively, this does not
Even though there are no bibles or official guide- mean you just load him with buckets of intravenous
lines for acute pain management in opioid-dependent narcotics. Narcotics have dose-dependent detrimen-
patients, numerous clinical studies have been done, tal side effects such as nausea and vomiting, respira-
and there seems to be general consensus among the tory depression, and decreased gastrointestinal (GI) 185
experts. Use evidence-based medicine. motility. This patient is undergoing major abdominal
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

surgery the use of mega-dose intravenous nar-

cotics would slow down his GI recovery. Also, use of Demonstrate respect, compassion, and integrity; a
high-dose narcotics can induce opioid-induced hyper- responsiveness to the needs of patients and society
algesia. that supersedes self-interest; accountability to
Neuraxial administration of opioids offers a more patients, society, and the profession; and a
efficient method of providing postop analgesia than commitment to excellence and ongoing
parental or oral opioids. Epidural doses of morphine professional development.
are roughly 10 times more efficacious than the same Respect the patient and be compassionate. Your
dose of morphine given parentally. Therefore signif- patient might be a drug addict, but he is your patient,
icantly greater levels of analgesia can be delivered to and he needs professional help from you. He deserves
those patients recovering from more extensive proce- the best care, just like any other patient.
dures where postop parental opioid doses would be
expected to be very high. Demonstrate a commitment to ethical principles
Use of neuraxial analgesia/anesthesia has also been pertaining to provision or withholding of clinical
shown to be beneficial for cancer-related surgery by care, confidentiality of patient information,
decreasing the incidence of cancer recurrence. This informed consent, and business practice.
is believed to be due to suppression of the stress
response. Make sure the patient has informed consent. This
Nonopioid analgesic adjuvants may also be used means that the patient should have an understanding
to reduce opioid dose requirements and provide of the risks and benefits of each therapeutic option and
multimodal analgesia. Nonopioid analgesics include alternative. Follow health insurance portability and
anti-inflammatory drugs, low-dose ketamine (0.5 accountability regulations for patient confidentiality.
mg/kg), and alpha-adrenergic-mediated analgesia When filling out your billing forms, be ethical bill
(clonidine). only what you did.

Demonstrate sensitivity and responsiveness to

Practice-based learning patients culture, age, gender, and disabilities.
and improvement Talk to the patient and try to understand why he is
Residents must be able to investigate and evaluate their doing what he is doing why is he taking so much pain
patient care practices, appraise and assimilate scientific medication? What is his understanding of his illness,
evidence, and improve their patient care practices. and how is it affecting him physically, emotionally, and
socially?
Locate, appraise, and assimilate evidence from
scientific studies related to their patients health
problems. Interpersonal and communication
There have been only a small number of published
skills
Residents must be able to demonstrate interpersonal
reviews that address the treatment of acute pain in
and communication skills that result in effective infor-
patients with substance abuse disorders, and fewer
mation exchange and teaming with patients, their
have focused specifically on perioperative pain man-
patients families, and professional associates.
agement in opioid-dependent patients.
Create and sustain a therapeutic and ethically
sound relationship with patients.
Professionalism
Residents must demonstrate a commitment to car- Always address patients by name (not just, Hi,
rying out professional responsibilities, adherence to sir), introduce yourself, shake hands, look profes-
ethical principles, and sensitivity to a diverse patient sional (no coffee-stained coat!), and give the patient
186 population. your undivided attention.
 Case 36 Mr. Whipple and the case of the guy who likes to mix a few vikes with his vodka

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 of
explanatory, questioning, and writing skills. care.
To establish effective anesthetic and perioperative
plans, we need to know the patient in full picture. We Good patient care ultimately leads to cost-effective
need to get the information we need so that we can health care. In this case, effective perioperative pain
provide the best care for the patient. Ask proper ques- management would reduce the length of postanesthe-
tions and listen to what the patient says. Some patients sia care unit time, fasten postsurgical recovery, and
dont know the direct answers to your questions, but thereby minimize the length of intensive care unit
they may give you clues. stay.

187
 Contributions from Stony Brook University under Christopher J. Gallagher Part 1

Additional reading
1. Mitra S, Sinatra R . Perioperative management of acute
pain in the opioid-dependent patient. Anesthesiology
2004;101:212225.

188
Part Contributions from the University of

2 Medicine and Dentistry of New Jersey

under Steven H. Ginsberg
 Part 2 Contributions from the University of Medicine and Dentistry of New
Case Jersey under Steven H. Ginsberg

37 Burn, baby, burn

Anesthesia inferno
Jeremy Grayson and Stephen Lemke

The case myself. I take a thorough history, keeping in mind that

not everyone is a doctor. I limit the amount of medical
It was pediatric ear-nose-throat (ENT) day, and my
jargon but also dont dumb it down too much, as either
first case was a 6-year-old girl with obstructive sleep
extreme can be offensive. Based on the conversation, I
apnea for tonsillectomy and adenoidectomy. While I
adjust my vocabulary accordingly. Goal number two:
was setting up the room, Disco Inferno was playing
try not to freak out the little girl. This can be a chal-
on the radio, and I struggled to contain my urge to
lenging task, to say the least. I blew up a latex glove,
dance. After greeting my patient and her family in the
adorned it with a smiley face, and let her play with it as
holding area and taking a thorough history and phys-
I washed my hands. I sat down on the bed next to her
ical, we proceeded to the operating room. Following a
and put my stethoscope on her stuffed giraffe. Then I
boring mask induction with oxygen, nitrous oxide, and
let her listen. Decreased breath sounds on the right,
sevoflurane, Mom gave her munchkin a kiss and was
she said (OK, maybe she didnt). Finally, making sure
escorted back to holding. We intubated using a 5.5-mm
my stethoscope was nice and warm, I listened to her
uncuffed endotracheal tube, confirmed proper place-
heart and lungs. By the time my attending showed up,
ment, and auscultated a leak over the trachea at 20 cm
the patient was happily playing with her glove, and the
of water. Music, please! exclaimed the surgeon. I
parents were pretty sure we werent going to kill their
dialed up isoflurane in a 50-50 mixture of oxygen and
daughter. Moms happy, Dads happy, and the patient is
nitrous oxide and sang along We didnt start the fire;
happy . . . mission accomplished.
it was always burning since the world was turning
and before I knew it, the first tonsil was out. Suddenly, Gather essential and accurate information about
there was a loud pop, and my patients mouth looked their patients.
like the Fourth of July.
So far, it may seem as though I have accomplished
nothing. Not true, my friend. I blew up a balloon and
Patient care played with a stuffed animal. I also carefully gathered
Residents must be able to provide patient care that is all the information needed to plan my anesthetic. She
compassionate, appropriate, and effective for the treat- lets just call her Suzie, so I can stop saying she is 6
ment of health problems and the promotion of health. years old, weighs 20 kg, was a full-term vaginal deliv-
ery; Suzie has no medical problems or recent illnesses,
Communicate effectively and demonstrate caring
has never had surgery, and has no family history of
and respectful behaviors when interacting with
problems with anesthesia. I also found out that Suzie
patients and their families.
snores like a 747 and has been sleepy and daydreaming
Establishing good rapport is critical, especially for at school, which, according to Mom, is why she needs
pediatric anesthesia. Goal number one: get Mom and a tonsillectomy. On physical exam, I noted no obvious
Dad to confidently put their childs life in my hands. anatomic abnormalities other than two big, meatball-
Im keenly aware of this fact as I approach the patient sized, grade +4 kissing tonsils.
and her family. Right now, my attending is still yawn- Make informed decisions about diagnostic and
ing and wiping the crust from his eyes. Its my time therapeutic interventions based on patient
to shine. I got a good nights sleep, shaved, and even information and preferences, up-to-date scientific
brushed my teeth. I smile as I enter the room and con- evidence, and clinical judgment. 191
fidently shake both parents hands while introducing
 Contributions from the University of Medicine and Dentistry of New Jersey under Steven H. Ginsberg Part 2

It sounds like Suzie has obstructive sleep apnea, so Suzie was still sedated and intubated and promised
I peruse the chart to look for a sleep study. Indeed, them that we would take the tube out once the swelling
polysomnography confirms the diagnosis. Since Im a subsided to the point that there was a leak around the
stellar resident (just ask me), my attending assumes endotracheal tube.
that Ive read the most recent American Society of
Anesthesiologists guidelines pertaining to periopera- Use information technology to support patient
tive management of obstructive sleep apnea and con- care decisions and patient education.
gratulates me for not heavily sedating the kid, pre-
When my attending was a resident, around the time
disposing her to airway obstruction and apnea in the
Lincoln was shot, people didnt have tonsils, let alone
holding area. I smile and nod, and whisper to the
the Internet. The night before the case, I did a literature
nurse, Cancel the Versed as he walks away. Just
search to look up the latest tonsil gossip and, of course,
kidding, I didnt order Versed; the great rapport I
check out what was going on with Britney Spears. Just
established with Mom, Dad, and Suzie will be premed-
before fire erupted, I couldve been surfing the Web on
ication enough. I did, however, read all about tonsil-
my phone.
lectomy and adenoidectomy and was well prepared for
the case. I also read about airway fire, although it is Perform competently all medical and invasive
rarely seen with this particular surgery. I know that it procedures considered essential for the area of
requires three components: ignition (such as an elec- practice.
trocautery device), fuel (tonsillar tissue, gauze, etc.),
and an oxidizing agent (oxygen or nitrous oxide). I had all necessary, and potentially necessary,
equipment ready to go. This means a proper laryn-
Develop and carry out patient management plans. goscope blade, endotracheal tube, breathing circuit,
and bag. All medications were drawn up according to
Although I hadnt planned on setting my patient Suzies weight, with a 21-gauge needle on those that
ablaze or losing my composure, both happened in that could be injected intramuscularly. I also looked up
order. The fire abated as quickly as it started, and the which drugs could be given through the endotracheal
surgeon pulled out the electrocautery device with a tube. I calculated her fluid requirements, checked the
hunk of flaming tonsillar tissue. I immediately stopped monitors and equipment, put the IV in a vein and the
fresh gas flow by disconnecting the breathing circuit, endotracheal tube in the trachea twice and demon-
extubated, then reintubated with a size 5 cuffed tube. strated how to deal with an airway fire. I believe I
Together with the ENT surgeon, we surveyed the dam- performed all procedures competently, although Im
age. Although the pharyngeal mucosa was clearly en slightly biased.
fuego, the patient was hemodynamically stable and
the airway was secure, so the surgery was completed. Provide health care services aimed at preventing
Postop, even with the cuff deflated, there was no audi- health problems or maintaining health.
ble leak. I obviously couldnt extubate. Suzie was trans-
As a general rule, I try not to set my patients on fire.
ferred to the prenatal intensive care unit (PICU) for
Besides that, I give antibiotics when appropriate, wash
further care.
my hands, use clean equipment, and keep my patient
warm (Ill admit, usually not this warm). Lighting the
Counsel and educate patients and their families. kid on fire segues perfectly with trying to get Dad to
quit smoking. Im pretty sure I shouldnt bring this up
Before the surgery, Mom and Dad wanted to know
now, but the health impacts of secondhand (and even
why Suzie couldnt eat breakfast and were also con-
thirdhand, as I just learned on my iPhone) smoke on
cerned about anesthesia awareness. I explained the
kids are well documented, and this subject should be
naught per oris guidelines and how pancakes are bad
broached prior to her leaving the hospital.
for the lungs. I assured them that I would carefully
monitor her vital signs and use a bispectral index mon- Work with health care professionals, including
itor. After the surgery, we had a lot of explaining to do. those from other disciplines, to provide
192 Along with the surgeon, my attending and I discussed patient-focused care.
the days events with the parents. We explained why
 Case 37 Burn, baby, burn

Any case in which we share the airway with surgery radius of the lumen to the fifth power for turbulent
demands complete collaboration. Once a fire occurs, flow. Hows that for droppin some knowledge!
we must decide together whether its safe to continue
the case and also how to manage Suzie postoperatively. Know and apply the basic and clinically
After agreeing to keep her intubated and sending her supportive sciences that are appropriate to their
to the PICU, I remained involved with her care. With discipline.
surgery, nursing, and respiratory therapy present, I
Being familiar with the anatomy of the pediatric
spoke about the implications of the airway fire to make
airway is very important for this case. In kids, again,
sure we were all on the same page.
the narrowest part of the airway is at the cricoid carti-
lage. For this reason, endotracheal tube sizing is crit-
Medical knowledge ically important. Too large a leak may make ventila-
tion difficult and put everyone in the operating room
Residents must demonstrate knowledge about estab-
to sleep. Too small a leak can place the child at risk
lished and evolving biomedical, clinical, and cognate
for postextubation stridor. Classic teaching is to refrain
(e.g., epidemiological and social-behavioral) sciences
from using cuffed endotracheal tubes in kids less than
and the application of this knowledge to patient care.
8 or 9 years old. However, I read a study that found
no difference in the incidence of long-term sequelae
Demonstrate an investigatory and analytic or postextubation stridor in PICU patients with cuffed
thinking approach to clinical situations. versus uncuffed tubes. Instead, the author believes
the occurrence of mucosal edema to be more closely
What couldve happened here? As I mentioned pre-
related to using too large a tube or having a long
viously, three components must be present for fire to
surgery. In light of this, I reintubated with a cuffed
occur: fuel, an ignition source, and an oxidizing agent.
endotracheal tube, trying to create a less combustible
Although I had no control over the first two, I couldve
surgical environment equivalent to room air.
limited my FiO2 and turned off the nitrous oxide after
induction. Apparently, the oxygen index of flamma-
bility, or the percentage required to support combus- Practice-based learning
tion, is between 25% and 30%. I auscultated a cuff leak and improvement
over the trachea at 20 cm of water. Last night, I read
Residents must be able to investigate and evaluate their
in an article by Mattucci and Militana [4] that with a
patient care practices, appraise and assimilate scientific
cuff leak of less than 12, the pharyngeal concentrations
evidence, and improve their patient care practices.
of nitrous oxide and oxygen are equal to that of the
inspired mixture. If the leak is greater than 12, the pha- Analyze practice experience and perform
ryngeal gas concentration equals that of room air. In practice-based improvement activities using a
other words, with a cuff leak of 20, its unlikely that this systematic methodology.
could be the culprit. What I neglected to do is recheck
for a leak after the ENT surgeon put in the mouth gag At this point in my residency, Ive done roughly 30
and repositioned the head. This, too, can increase the tonsillectomies and was beginning to feel pretty cozy.
leak. Although Ive never said in my vast experience or
I also knew not to extubate her at the end of the in my practice to my attending, I have indeed begun
case without a leak around the endotracheal tube. Now to cultivate my own style. I have seen all too often
pay attention: in a child, the narrowest portion of the the emergence delirium that can be caused by mainte-
funnel-shaped airway is at the cricoid cartilage, and nance with sevoflurane. Last time I gave too much nar-
the lack of a leak meant that on extubation, her air- cotic, this time I roasted my patient. Without a doubt,
way could close up or get really, really narrow where the traumatic events of today are forever burned into
the tube was once stenting it open. Airway swelling is memory and will affect my practice tomorrow. Just
worse in children as every millimeter of swelling, in when I thought I couldnt be any more of an obsessive-
an already narrow airway, increases resistance, and this compulsive control freak, so that others may learn
resistance is inversely proportional to the radius of the vicariously through me, we hosted an interdepartmen- 193
lumen to the fourth power for laminar flow and to the tal meeting involving anesthesia, ENT, operating room
 Contributions from the University of Medicine and Dentistry of New Jersey under Steven H. Ginsberg Part 2

staff, and PICU staff to discuss the case. It was hoped My dad is a highly intelligent man but can barely
that this would facilitate safer care in the future. use a cell phone. He despises technology. Being a
millennial resident, Ive acknowledged technological
Locate, appraise, and assimilate evidence from advances as my friend. Playing Tiger Woodss golf in
scientific studies related to their patients health the operating room is just bad form, but being able to
problems. access the seemingly infinite resources on the Web has
revolutionized medicine.
In my reading, I found that there are two main
reasons for doing a tonsillectomy in a child: chronic (First authors note: Tiger Woods golf may be losing
pharyngitis and obstructive sleep apnea. Knowing how some popularity for other reasons, as well).
both conditions can affect anesthetic management is
crucial. If Suzies obstructive sleep apnea was associ- Professionalism
ated with other comorbid conditions or syndromes, I
Residents must demonstrate a commitment to carry-
wouldve used information technology to ensure that I
ing out professional responsibilities, adherence to eth-
was prepared to deal with those issues. After the case,
ical principles, and sensitivity to a diverse patient pop-
I changed my pants and did a literature search to see
ulation.
how others have dealt with this issue. I was delighted
that I remembered to stop fresh gas flow, disconnect Demonstrate respect, compassion, and integrity; a
the circuit, extubate, and then reintubate. responsiveness to the needs of patients and society
that supersedes self-interest; accountability to
Obtain and use information about their own
patients, society, and the profession; and a
population of patients and the larger population
commitment to excellence and ongoing
from which their patients are drawn.
professional development.
In my vast experience with tonsillectomies, I have
We should always be cognizant of this. Before see-
cared primarily for ASA-I and -II patients and, occa-
ing the patient, I remembered that asking the nurse if
sionally, a child with Downs syndrome. We are very
my patient was a FLK (funny-looking kid, for those of
fortunate in that we treat a very ethnically diverse
you not hip to the lingo) is unprofessional. I also tried
group of patients. As you might expect, many kids with
not to ignore Suzie during the initial encounter or tell
obstructive sleep apnea are obese. This is the perfect
her to suck it up when she started crying on the operat-
opportunity to educate parents about the benefits of
ing room table. When the Bovie exploded, I didnt tell
healthy eating, exercise, and weight loss.
the surgeon that his mistake was going to cost me my
Apply knowledge of study designs and statistical 12:00 tee time at Beth Page Black or that it would take
methods to the appraisal of clinical studies and me a couple months to get back there. I did my best to
other information on diagnostic and therapeutic deal with the situation in a respectful manner, realizing
effectiveness. that Im a patient advocate as well as part of the peri-
operative team. Later, I reported the event to the anes-
I have to be honest, whenever I hear terms like thesia quality assurance committee so that we could
Kruskal-Wallis test or chi squared, I vomit a little into review the case at our next meeting and also make it the
my mouth. Well, get your ondansetron, because in topic of an upcoming multidisciplinary conference.
the age of the six Core Clinical Competencies and
evidence-based medicine, understanding basic statis- Demonstrate a commitment to ethical principles
tical analysis is a must for truly being able to interpret pertaining to provision or withholding of clinical
journal articles and studies. Speaking of vomiting, in care, confidentiality of patient information,
my literature search, I found that prevention of postop- informed consent, and business practice.
erative nausea and vomiting is key for tonsillectomies.
While flipping through the chart, I noticed that
Use information technology to manage this patient was self pay. However, I did not walk out
information, access online medical information, of the holding area and tell the medical student to
194 and support their own education. take care of this one; apparently its on the house!
or announce it to everyone, infuriating the Joint
 Case 37 Burn, baby, burn

Commission for Accreditation of Hospitals. I didnt I nodded compassionately when they spoke. When
replace my sevoflurane vaporizer with enflurane or Mom asked me how the anesthesia works and how
use cheaper drugs because of the patients socioeco- I know how much to give, I didnt reply, Why, are
nomic status. Ive already taken my cultural compe- you some sort of amateur pharmacologist who spent
tency classes for the year and know this would not last night huffing butane out of a brown paper bag? I
be ethical. After the case, I explained to the parents gave a basic explanation and was prepared to tailor the
what happened and helped them understand why discussion based on verbal and nonverbal cues, being
Suzie would remain intubated until the airway edema mindful not to scare little Suzie. Aside from taking a
resolved. detailed history and physical, I also wrote a legible,
full account of the airway explosion, including how it
Demonstrate sensitivity and responsiveness to was dealt with and the rationale for keeping Suzie intu-
patients culture, age, gender, and disabilities. bated until the swelling resolved.
Again, I took my cultural competence classes for Work effectively with others as a member or
the year, so I know that if the family only spoke Span- leader of a health care team or other professional
ish, for example, it would be inappropriate to commu- group.
nicate without an interpreter. I also know that using
the patients 14-year-old brother as the interpreter is When fire broke out, I had to act decisively, with
inappropriate. Our hospital has official translators on confidence and without hesitation. I knew it was my
staff to provide that service, and if, for some reason, the job to stop gas flow, disconnect the breathing cir-
only Icelander is not available to translate for young cuit, extubate, and resecure the airway. Along with
Bjork and her mom because shes back in Reykjavik on the surgeon, my attending and I surveyed the damage
holiday, I know that the telephone interpreter is avail- and made a joint decision to continue with the case.
able 24/7/365! Later, I called the pediatric intensivist to give a detailed
report of the transpired events and to ensure that a
bed would be ready for Suzie. Continuity of care was
Interpersonal and communication further established as my attending and I transported
her to the PICU and gave report to all residents, fel-
skills lows, nurses, and respiratory personnel who would be
Residents must be able to demonstrate interpersonal involved. Finally, I visited her on a daily basis until dis-
and communication skills that result in effective infor- charge so that I could see the effects of my care beyond
mation exchange and teaming with patients, their the operating room.
patients families, and professional associates.

Create and sustain a therapeutic and ethically

sound relationship with patients.
Systems-based practice
Residents must demonstrate an awareness of and
Before meeting Suzie and her parents the morn- responsiveness to the larger context and system of
ing of surgery, I stopped by the bathroom and made health care and the ability to effectively call on system
sure I looked as professional as possible. I didnt want resources to provide care that is of optimal value.
to walk in looking like I spent the night sleeping on
42nd Street, hair tussled and smelling like a distillery. Understand how their patient care and other
Nothing instills fear in a parent like a hungover, dirty professional practices affect other health care
resident. professionals, the health care organization, and
the larger society and how these elements of the
Use effective listening skills and elicit and provide system affect their own practice.
information using effective nonverbal,
explanatory, questioning, and writing skills. This is one reason I visited Suzie postoperatively.
Not only did I have a vested interest in her health, but
When speaking with my patient and her family, I I was also interested to see how the PICU team would
purposely made eye contact with Suzie and both par- manage her care. I learned that although airway fire 195
ents. To show them that my head was in the game, is a rare complication, it has serious effects, not just
 Contributions from the University of Medicine and Dentistry of New Jersey under Steven H. Ginsberg Part 2

for the health of our patient, but also for the entire know, intractable nausea and vomiting is a major cause
system. This unplanned admission was expensive and for unplanned hospital admission.
consumed many valuable resources. Complications
directly, and indirectly, contribute to the ever escalat- Advocate for quality patient care and assist
ing cost of health care and insurance. patients in dealing with system complexities.
For the anesthesia team, our role with respect to
Practice cost-effective heal