Spring 2007 Volume 5-1 - UCSF Department of Anesthesia and

Transcription

SPRING 2007 Volume 5.1
A publication of the
Department of Anesthesia
and Perioperative Care
University
of California
San Francisco
A
N
E
S
T
H
E
S
I
A
new s
from
the
chairman
Ronald D. Miller, MD
Professor and Chairman
This newsletter has always sought to convey the Department of Anesthesia and Perioperative Care’s 40-year commitment to excellence – a commitment fulfilled by many individuals acting together. This issue is no exception.
One feature highlights four of our specialty areas: cardiac, pediatric and thoracic anesthesia, as well as an acute
pain service that provides expert pain management for perioperative, postoperative and hospitalized medical patients. Another feature profiles Martin Bogetz, MD, a superb clinician and medical director of the Ambulatory Surgery Center. In addition to his well-earned reputation as a clinician and administrator, Dr. Bogetz has been honored
as one of this institution’s most distinguished educators.
Next, we cover three of our outstanding researchers, from a department the NIH has ranked number one in the
country for NIH funding. Dr. Roland Bainton is at the forefront of describing how drugs get to the site of action via
the blood-brain barrier; Dr. Pamela Palmer is conducting research to identify mechanisms of peripheral and inflammatory-induced pain; and Dr. Christian Apfel – an internationally recognized expert in multi-institutional clinical
studies – exemplifies our efforts to augment our clinical research in several directions.
As we do periodically, we also profile the new faculty members we’ve appointed in response to the continued expansion of the UCSF Medical Center. Some are graduates of our own residency; some are board-certified in critical
care, pain management and cardiac anesthesia; and some are trained at other renowned institutions. In addition,
in the summer of 2006, we welcomed another outstanding and diverse group of residents, who we expect will appreciate our tripling of the number of didactic sessions we offer – sessions that will be smaller and more interactive
than those we offered in the past.
The medical center’s continued expansion has also prompted us to add to our clinical diversity with the appointment of six certified registered nurse anesthetists (CRNAs). These CRNAs are not only well qualified to deliver anesthesia, but also have had two years or more of experience in critical care nursing. They will be a welcome addition
to our anesthesia care team.
All of these articles make clear that there is good reason to believe we can expect another 40 years of innovation
and excellence from the Department of Anesthesia and Perioperative Care.
Featured inside
contents
CLINICAL
SUBSPECIALTIES 2
CLINICAL
RESEARCHERS 6
BOGETZ: COMMITTed
8
TO TEACHING
HONORS &
AWARDS
10
More anesthesia
news
10
2006 ASA MEETING11
new faculty
12
residents
14
Why anesthesia
specialties matter
Working in closely knit
clinical teams – and in a
range of clinical settings
– UCSF anesthesiologists
deliver superior patient
care while providing a rich
learning experience for
residents and medical
students alike.
CHANGING PRACTICE
OF ANESTHESIA 15
University of California
San Francisco
Humanity and
discovery
A revered clinician and
medical director of the
Ambulatory Surgery
Center, Martin Bogetz is
also an honored teacher.
The reason? He fosters
a potent blend of clinical
insight, spirited inquiry
and an emphasis on what
he calls “the humanity of
our profession.”
Crossing the bloodbrain barrier and
other clinical research
journeys
Roland Bainton, Christian
Apfel and Pamela Palmer
are part of a growing clinical research core investigating everything from
new pain management
approaches and perioperative and postoperative
care techniques to the
ways in which drugs
act on the brain.
news
Clinical
SubSpecialties
Provide Exemplary
Care and Education
The Department of Anesthesia helps UCSF earn its
reputation for clinical and teaching excellence by
delivering expert and, where appropriate, cuttingedge care for a broad range of clinical subspecialties.
Working in closely knit clinical teams in hospital
and outpatient settings – and in situations that
range from pediatric through adult surgery, and
from diagnostics through postoperative pain management – specialist anesthesiologists manage
high volumes, complex cases and administrative
duties with, to borrow a phrase, surgical precision.
Not coincidentally, this broad range of activities
also provides residents with a rich learning experience supported by didactic programs and attentive
faculty. Below, we highlight some of this work.
Charles (Chico) Cauldwell, MD, PhD, Chief of Pediatric Anesthesia
Pediatric anesthesia
“Pediatric anesthesia is different,” says
Charles (Chico) Cauldwell, MD, PhD,
chief of pediatric anesthesia at UCSF.
It’s not just that a child’s physiology is
different from an adult’s, or that children
undergoing anesthesia have different
emotional concerns, but it is also a
more family-centered process.
“There’s a style of interaction that
comes with experience – we frequently
have parents present when we put kids
to sleep – and you have to be flexible in
that environment and be able to reassure both the patient and the family,”
says Claire Brett, MD, who is in charge
of anesthesia for pediatric radiology.
Despite those differences, some clinical settings make little distinction between pediatric and adult anesthesia.
In contrast, UCSF has made a strong
commitment to having pediatric anesthesiologists as standard for pediatric
cases, be they inpatient or outpatient
surgeries, diagnostics, or peri- and
postoperative pain management.
Diagnostics
During diagnostic tests, the difference
between children and adults is stark:
“Children can’t hold still,” says Brett.
“And if they’re not motionless, then the
radiologist can’t get a good study.”
Consequently, says Brett, “children
require general anesthesia and, be-
UCSF Department of Anesthesia and Perioperative Care
cause they are always supine, there
are real airway obstruction concerns.”
She also stresses that in radiology,
there’s no recovery room next door
and no easy access to equipment
that is standard in the operating room.
“It requires a different level of vigilance
than the OR, especially since you’re
isolated if you have to call a code, and
the physicians present need to be able
to intervene if there’s a problem.”
The patient-safety concern is the
most compelling argument for the
use of pediatric anesthesiologists for
pediatric radiology, but it’s hardly the
only one. There’s the communication
concern, that ability to speak with
children and their families – and there’s
the argument that the use of pediatric
anesthesiologists is more efficient.
“Because we concentrate on certain procedures, know the equipment
and have relationships with the other
members of the care team, we tend
to be efficient without sacrificing the
level of care delivered,” says Brett. In
turn, the presence of pediatric anesthesiologists can help busy radiology
departments avoid delays, a particularly significant factor in a high-volume pediatric center like UCSF.
During surgery
During surgery, pediatric anesthesiologists work with general, orthopaedic,
urologic, maxillofacial, otolaryngologic and neurosurgeons on the pediatric
surgeries that make up about a third
of all surgeries performed at UCSF
Medical Center.
Moreover, “the pediatric volume
has exploded at the Ambulatory
Surgery Center (ASC),” says Laura
Siedman, MD, associate director
of the ASC. That explosion has
changed the mix of procedures.
While the emphasis remains on
high-volume, low-acuity cases like
eye exams, lumbar punctures, bone
marrow biopsies and dental work, the
center has seen an increase in cases
such as cochlear implants, mastoid
dysfunction, hernias, undescended
testicles and circumcisions.
In both locations, pediatric anesthesiologists are present every day.
“That’s changed over the last 10 years
in response to demands from both the
(Above top) Maurice Zwass, MD, Director, Pediatric Anesthesia Fellowship Program;
(above) Claire Brett, MD, Pediatric Anesthesia
surgeons and their patients,” says Siedman. And while she acknowledges that
most good anesthesiologists can safely
take care of children, she notes that
there are very real differences in approach. “It’s the difference between the
science and art of anesthesia,” she says.
As one example, she notes that some
pediatric anesthesiologists prefer to
“extubate deep,” which means removing a breathing tube while the children
are still asleep so they can wake up
more gently, with their parents at their
bedside. “It’s a comfort issue,” says
Siedman, noting that most pediatric
anesthesiologists are trained to do this
well, whereas in adults, the physician’s
preference is to have the patient awake
when removing tubes.
Another key difference in pediatric
anesthesia, regardless of setting, is
the more frequent use of a mask to put
children to sleep, as opposed to using
an IV. “A mask is less painful and less
intimidating,” says Cauldwell.
A third difference is that children’s
bodies are constantly developing, and
so can have a changing response to an-
esthetics. “Pediatric anesthesiologists
develop a specialized knowledge about
the complications that can occur in this
context,” says Cauldwell. Studies have
shown that, at least in children under 2,
this specialized knowledge positively
affects patient outcomes.
Cauldwell also believes that as
a small and tight-knit group, the
pediatric care teams of anesthesiologists, surgeons and nurses are
better prepared to deal with all of the
communication issues that accompany pediatric surgeries.
All of those factors enliven the experience for anesthesia residents rotating
on the pediatric anesthesia service
through the ASC, UCSF Medical Center
and Children’s Hospital Oakland. Others
who rotate through include medical students, some pediatric residents and the
pediatric anesthesia fellows (anesthesia
residents who elect to do additional
training after their residency to specialize in pediatric anesthesia).
In the ASC, residents work in a
small, collegial environment and what
Siedman calls “an aesthetically pleas-
news
Jeffrey Katz, MD, Chief of Thoracic Anesthesia
ing, happy place. It’s a good setting
for residents’ first exposure to small
children because they’re usually pretty
healthy kids, making it a little less scary
for residents to get their feet wet before
jumping into the more complex cases.
We also do a lot of postoperative pain
management here, real bread-and-butter pediatric anesthesia.”
During their time at Children’s Hospital Oakland and UCSF Medical Center,
residents experience many different
cases and sometimes very high volumes, with the full range of acuities.
busy place, with 22 beds spread
across two units: eight beds for the
peri- and postoperative care of cardiac patients, and 14 for other medical-surgical patients. Physicians
here see oncology, neurology and
transplant patients, as well as those
suffering from acute, life-threatening
events like seizures.
The difference, says Zwass, between
the pediatric and adult ICUs is the degree to which anesthesiologists and the
primary service co-manage pediatric
patients. The anesthesiologists (and
residents) do everything from central
The Pediatric ICU
lines and intubations to vascular acThe Pediatric Intensive Care Unit (ICU) is cess, access for renal CVVH (continuanother place where residents have the ous veno-venous hemofiltration), and
opportunity for a unique learning experi- high-frequency ventilation oscillators.
As with the other settings, the
ence – though in this case, it’s a choice.
(It’s an elective that residents can take in Pediatric ICU is also a very strong
educational experience for those who
place of the adult ICU.)
“We see the gamut of cases here,” choose it. “It’s different,” says Zwass,
“not just because you learn a lot of
says Maurice Zwass, MD, who atphysiology, but because it’s an emotends in the Pediatric ICU one week
tionally intense environment for the
out of every month. The Pediatric
family and you have to learn how to
ICU treats patients older than newcommunicate in that context.”
borns through young adults. It’s a
Thoracic anesthesia
The department’s thoracic anesthesiologists do some 400 pulmonary
procedures each year, with cases that
include pneumonectomy, lobectomy,
esophagectomy, removal of mediastinal
masses, lung reduction surgery, tracheal resection and minimally invasive
thorascopic pulmonary resections.
These cases have thoracic anesthesiologists wrestling with a number of
significant anesthetic challenges that include establishing adequate separation
of the lungs, maintaining gas exchange
and ensuring circulatory stability during
one-lung anesthesia. “During intraoperative management of one-lung
anesthesia, we focus on advanced lung
separation technology, including double-lumen tube insertion or bronchial
blocker placement,” says Jeff Katz, MD,
who co-leads the thoracic team with
Lundy Campbell, MD.
Katz stresses that in many cases,
thoracic anesthesiologists work with
patients from preop evaluation and
assessment of postsection lung function through intraoperative management and postoperative pain control.
Because thoracic surgeons have to
break and spread ribs, postoperative
pain management using epidural analgesia is particularly critical because
its use enhances recovery from surgery – all of which makes for a challenging rotation for residents.
“I think residents really enjoy the
rotation,” says Katz. “During thoracic
surgery, they are involved with a lot of
manual manipulation of airways and
physiology, and then, at the end, have
to restore the patient to baseline, which
can require a lot of complex management. They also work on easier, less
intimidating cases where pulmonary
dysfunction is moderate…. In addition,
they have a concentrated experience
working with the thoracic surgical
team, a close working relationship that
enables the development of teamwork
and better patient outcomes.”
Acute Pain Service
“Despite the wide recognition of pain as
the fifth vital sign, only a few hospitals
outside of the major academic medical
centers have functioning pain services,”
says Dan Burkhardt, MD, chief of the
Acute Pain Service at UCSF Medical
Daniel Burkhardt, MD, Director, Acute Pain Service
Center. The service establishes anesthesiologists as the pain management
experts for perioperative, postoperative
and hospitalized medical patients.
Anesthesiologists on the service
conduct rounds in the morning; in
the afternoon, they do new consults,
procedures and follow-up visits. In the
process, they administer a variety of
regional anesthesia techniques to a high
volume of patients, including thoracic
and lumbar epidurals, and peripheral
nerve catheters, such as femoral nerve
and sciatic nerve blocks. They also consult on a variety of medical and surgical
pain crises, which present opportunities
for the use of novel analgesics such as
low-dose oral ketamine.
In addition, the service is instrumental in crafting pain management policies and procedures for
the entire medical center. Anesthesiologists write and critique order
sets, evaluate adverse outcomes
(such as drug concentration errors)
and have input into policy decisions designed to improve patient
safety. Policies range from nurse
training programs to creating protocols for the administration of analgesics throughout the hospital.
“Unlike in the OR, where the administration of pain medication is primarily
in the anesthesiologist’s hands, in perioperative or postoperative care, nurses
are a bigger part of the team, and
residents have to learn how to write
clear orders for protocols and dose
titrations,” says Burkhardt.
The clinical work combines with the
policy role to provide residents with a
unique experience. In addition to having
direct perioperative and postoperative
experience – a significant portion of the
anesthesia boards – they have the opportunity to learn how to set up and run
a pain service, something they would
not likely find in other teaching hospitals.
“Despite the wide recognition of pain
as the fifth vital sign, only a few hospitals
outside of the major academic medical
centers have functioning pain services.”
Cardiac anesthesia
Cardiac anesthesiologists at UCSF
keep busy, completing 300-350
adult cardiac procedures and 50-75
heart and lung transplants (the second largest lung transplant service
in the country), and helping with
nearly a dozen ventricular assist
devices each year.
“The procedures range from the
routine to the most complex – those
requiring cardiopulmonary bypass
and special monitors, such as transesophageal echocardiography,” says
Isobel Russell, MD, PhD, chief of
cardiac anesthesia. Cardiac anesthesiologists also do pediatric cardiac
surgery, which can be particularly
challenging because of the frequent
occurrence of pulmonary hypertension. (Russell is also a pediatric cardiac anesthesiologist.)
The range of procedures creates
a rewarding rotation for residents.
In an evaluation of the rotation,
one resident wrote: “I loved actually doing the work (evaluating the
patients perioperatively, developing
the anesthetic plan, executing and
adjusting it, doing the procedures,
following up postoperatively on the
patients in the ICU the next day)….
Dr. Russell’s handout was excellent
and should be the gold standard for
resident orientation packets.”
news
Clinical Researchers
Pursue Important
New Work
Christian Apfel, MD, PhD
“The Department of
Anesthesia and Perioperative
Care has exceptionally strong
faculty and an excellent academic
environment,”says Apfel.
Clinical researchers in the UCSF Department
of Anesthesia and Perioperative Care are making discoveries that not only have implications
for safer and more effective anesthesia and pain
management, but also, perhaps, for more effective therapeutic treatments.
Christian Apfel
During his residency in Germany in the early 1990s, Christian Apfel,
MD, PhD, conducted a series of patient interviews that made it clear
to him that postoperative nausea and vomiting (PONV) has significant implications for quality of care (e.g., patient discomfort, rupturing sutures and aspirative pneumonias), as well as for efficiency and
costs (slowing down the discharge process).
Frustrated by prior research that only identified an unwieldy list of
risk factors for PONV that are easily confounded by other variables,
Apfel set out to find independent predictors. He ultimately developed and validated a four-factor risk score – female, nonsmoker,
history of nausea and vomiting, and use of narcotics after anesthesia
– that many European anesthesiologists have adopted as a risk-adjusted method for using prophylactic antiemetics.
From there, Apfel began work that would shed more light on the
clinical effectiveness of various antiemetics. His large, multicenter
study used a factorial approach and found that the antiemetics he
studied acted independently of one another and independently of
the patients’ baseline risk.
The results, published in 2004 in the New England Journal of Medicine, concluded: “Because antiemetic interventions are similarly
effective and act independently, the safest or least expensive should
be used first. Prophylaxis is rarely warranted in low-risk patients,
moderate-risk patients may benefit from a single intervention, and
multiple interventions should be reserved for high-risk patients.”
Since his arrival at UCSF in 2006, Apfel has continued to expand
his body of work. For one, he will study UCSF patients to validate,
adjust or develop a new predictive risk model for PONV in the United
States. “I expect differences,” he says, “because of the way medicine is practiced here, as opposed to Europe. In particular, in the US,
there are many more outpatients who take oral opiates significantly
more often for postoperative pain control after ambulating.” Based
on the new risk model, Apfel hopes to develop risk-adjusted prophylaxis to prevent PONV in UCSF patients and beyond.
In addition, Apfel will study rescue treatments for PONV because data indicate that rescue treatments can be at least as,
if not more, effective than prevention. “We don’t even know the
minimally effective dose of ondansetron and how long it takes until we can expect an effect,” Apfel says. He believes patients who
get relief from ondansetron as a rescue treatment will get this fairly
instantaneously, and that patients who don’t should therefore be
offered other rescue treatments much sooner than the current
practice of 15 minutes to an hour.
Recruited to build up and lead a perioperative clinical research core, Apfel is excited about the range of clinically relevant
studies that core is pursuing. The studies go beyond PONV to
include: investigating a novel analgesic for patients undergoing
hip surgery; testing whether oral care can decrease the bacterial
load and the incidence of pneumonia
in long-term ventilated patients; and
pursuing novel approaches for identifying and treating occult hypoperfusion in trauma patients.
“This is exciting work,” says Apfel. “The
Department of Anesthesia and Perioperative Care has exceptionally strong faculty
and an excellent academic environment.
Anybody – junior faculty, fellows or senior
residents – who would like to pursue innovative and exciting clinical research are
free to contact me, and I will be happy to
assist and mentor where I can.”
Pamela Palmer
When Pamela Palmer, MD, PhD,
arrived at UCSF as a newly minted
PhD, her research interest was peripheral inflammatory mechanisms.
But as a physician managing her
patients’ pain, Palmer began to have
a more immediate concern: the opioid tolerance that her pain patients
would develop. “It shifted my direction because I need to do something
clinically relevant,” she says.
She began her new research focus
by trying to pin down who, exactly,
was developing a tolerance. This
eventually led to Palmer conducting a
retrospective study on patients in the
UCSF Pain Management Center who
had entered without ever having been
on opioids for chronic pain.
The randomized study (the only
one of its kind in relationship to aging)
revealed that two years after treatment
had begun, patients over 60 (average
age 69-70) had decreased pain scores
with dramatically less opioid escalation
than those under 50 (average age 40)
Pamela Palmer, MD, PhD
who, despite opioid escalation, saw
little or no drop in their pain scores.
“The clinical implication is that until
we find a magic bullet for tolerance,
we need to be very wary of giving opioids to younger folks because there
may be no long-term benefit and there
can be a long-term downside, such as
hormonal disturbances,” says Palmer.
She does note, however, that these
types of findings apply only to chronic
pain, not cancer pain or intermittent,
severe exacerbations.
Having established the “who,”
Palmer is now turning her attention to
the “what”: the molecules involved in
the process. “Tolerance is a neuron’s
memory that it has seen a drug before
and can adapt, but older neurons can’t
do that type of molecular gymnastics,”
she says. Consequently, working in the
lab with a variety of opioids, Palmer
is looking at the proteins that regulate
opioid tolerance and is trying to determine ways to “trick nerve receptors
into thinking they’re old.”
“Tolerance is a neuron’s
memory that it has seen
a drug before and can
adapt, but older neurons
can’t do that type of
molecular gymnastics.”
Roland Bainton
While Apfel and Palmer focus on
specific clinical concerns, Roland
Bainton, MD, PhD, is trying to understand a fundamental question for
anesthesiologists – and, in fact, all of
medicine: How do drugs act on the
brain? “Although we use drugs often,
we have an incomplete understanding of how they affect the nervous
system,” says Bainton.
What we do know is that all drugs
have to pass from the bloodstream to
the brain by crossing the blood-brain
barrier (BBB), a single epithelial layer
whose explicit evolutionary purpose
seems to be to keep invaders (like
drugs) out of the brain. The BBB was
long believed to be an inert wall. But
thanks in part to Bainton’s identification of a gene in fruit flies that clearly
modulates the blood-brain barrier’s
response, we now know the BBB is
a more reactive barrier. He published
the results of his work in Cell.
Bainton’s discovery of the fruit fly
gene – named moody – was the first
to identify a transmembrane signaling protein at the BBB junctions
that could be linked to influences
on behavior. Now, Bainton and
colleague Mark Schumacher, MD,
PhD, are searching for what they
believe is a likely gene homologue
in humans. Should they find the
homologue, there could be implications for the treatment of diseases
like Parkinson’s, Alzheimer’s and
drug-resistant epilepsy.
“The discovery could give us a novel way of affecting how drugs enter
the human nervous system and might
allow physicians to better control
the secondary toxicity of drugs with
therapeutic potential,” says Bainton.
“And if we could enhance drug departure (how drugs can get in and out of
the brain) in elderly people, this might
be one way of helping them recover
more easily from anesthesia.” Though
he knows those results are a long way
off – “it’s more science fiction at this
point” – he is, nevertheless hopeful.
For his efforts, Bainton received a
$50,000 Hellman Family Award – an
internal campus award – as well as
ongoing support from the department. “I’m very grateful to Dr. Miller
for supporting this work,” he says.
news
Martin Bogetz
A Commitment to Teaching
“We want our students to connect
with patients.... If we ignore or are
oblivious to that, it’s easy to lose sight
of the humanity of our profession.”
Many medical student rotations in anesthesia emphasize techniques, such as tracheal intubation.
“We [the Department of Anesthesia] don’t want our
rotation to only be technically oriented,” says Martin Bogetz, MD, medical director of the Ambulatory
Surgery Center at UCSF Medical Center. “We want
our students to connect with patients.... If we ignore
or are oblivious to that, it’s easy to lose sight of the
humanity of our profession.”
Bogetz’s commitment to imbuing his students with
a combination of technical skills and the human side
of doctoring has earned him widespread recognition
and respect, including the Academic Senate’s 20042005 Distinction in Teaching Award – one of the most
prestigious awards on this most prestigious of campuses. At a place where intellectual brilliance and
technical know-how are entry passes, his colleagues
recognize him for that – and more.
“Marty is one of the nicest
people you’ll ever meet in your life
– a great person and a great physician,” says Tamara Maimon, director of the Academic Senate. “He
is not only a stellar teacher, but
a stellar citizen on campus.”
Martin Bogetz, MD, Director,
Ambulatory Surgery Center,
with then medical students
Emily Ginsburg and
Lindsay Mazotti
A climate for discovery
and reflection
“I like to create a climate for discovery
and enjoyment – a positive, hands-on
and safe learning environment where
people don’t feel embarrassed to ask
questions,” says Bogetz.
He also asks students to reflect
carefully on their learning experience by writing about something
that surprised, inspired and moved
them during their anesthesia rotation. The answers are revealing.
Students write about a mother crying as her child is anesthetized in
her arms, and how scared patients
can be and how much they appreciate a hand to hold and a few minutes of personal contact. Students
also comment that the department’s
residents and faculty are exemplary
role models for how the best practitioners are in touch with patients’
emotional and physical needs.
Bogetz notes that there are many
in the department who share his
strong commitment to teaching, noting in particular that he and Manuel
Pardo Jr., MD, Sol Shnider Endowed
Chair for Anesthesia Education,
strive to pass their commitment on to
residents. “One of the things we have
residents do is list, on a 3-by-5 card,
one attribute of a great teacher; we
then help them emulate that attribute
[when teaching medical students].”
The results speak for themselves.
In addition to the Academic Senate
recognizing Bogetz’s work, of the nine
core clerkships for UCSF medical
students, the students have consistently ranked anesthesia first or second for each of the last four academic
years. In addition, in 2006, of the nine
medical schools in California, UCSF
was tied for the highest percentage
of medical students who chose anesthesia as a specialty.
The numbers imply a genuine compliment to the department, but Bogetz
doesn’t believe that transforming all
medical students into anesthesiologists is the ultimate goal. “We’re better served by helping those who go on
to other specialties understand what
we do,” he says.
Senior resident Mark Carlisle, MD, right, on regional anesthesia rotation, in preparation
for ultrasound-guided nerve block under the supervision of attending physician
Olga Afonin, MD, Assistant Clinical Professor.
The Ambulatory Surgery Center
As medical director of the Ambulatory
Surgery Center (ASC) at UCSF Medical Center, Bogetz and Associate Director Laura Siedman, MD, oversee
a very active service.
Across four operating rooms and
two procedure rooms, anesthesiologists administer a range of anesthetics for both pediatric and adult
procedures. In the last decade, the
center has gone from a predominant
focus on ophthalmology and hand
surgery to balancing those procedures with others, such as otolaryngologic and urologic procedures in
children, sports medicine, and adult
and pediatric dentistry, as well as diagnostic procedures (e.g., bone marrow biopsies, eye examinations) and
electroconvulsive therapy.
“Anesthesia for electroconvulsive
therapy can be tricky,” says Bogetz,
“because you have to balance the
anesthetic to prevent awareness and
a substantial increase in blood pressure, but not prevent the seizure.”
Because the volume in the ASC is
increasing – and physical space is
limited – the emphasis is on safe, efficient patient throughput. The focus
on efficiency gives residents who
move through the rotation a glimpse
into what private practice might look
like. Siedman says work in the ASC
also focuses residents on how to
administer efficient anesthesia with
minimal postoperative pain. “They
have to be cognizant of how patients
will feel at home, as opposed to inpatients, who have IVs that allow us to
better manage pain,” she says.
news
FACULTY HONORS,
AWARDS, APPOINTMENTS
2006
UCSF Department of Anesthesia and
Perioperative Care tops rankings for
NIH funding for the third year in a row!
Jill Antoine, MD
Extramural Appointments:
Chair, American Society of
Anesthesiology Committee on Trauma
and Emergency Preparedness
Appointment, American Medical
Association Council
Appointment, National Disaster
Life Support Executive Committee
Sakura Kinjo, MD
Campus Award:
UCSF REAC Award 2006
Jacqueline Leung, MD
Extramural Appointment:
Grant Reviewer, Research Grants
Council, Chinese University,
Hong Kong
Extramural Award:
Transition in Geriatric Care, Donald W.
Reynolds Foundation (PI: Johnston)
James Marks, MD, PhD
Elected into the Institute of Medicine,
National Academy of Sciences, 2006
Renee Navarro, MD
Campus Appointment:
UCSF Women Liaison Officer for
UCSF Faculty
American Association of Medical
Colleges Committee on Women
in Medicine
Manuel Pardo Jr., MD
Campus Appointments:
Vice Chair, UCSF Department of
Anesthesia and Perioperative Care
Director, Division of Education,
UCSF Department of Anesthesia
Greg Stratmann, MD
Extramural Honor:
Ellison C. Pierce Jr., MD, Research
Award, Anesthesia Patient Safety
Foundation
John Taylor, MD
Campus Appointment:
Director, Post-Anesthesia Care
Unit (PACU)
Jeanine Wiener-Kronish, MD
Campus Appointment:
Member, Dean of the UCSF School
of Medicine’s Task Force for Basic
Science: Pathways to Discovery
Member, Foundation for Anesthesia
Education and Research (FAER) Board
William Young, MD
Campus Award:
Integrative Research Award, UCSF
Sandler Program in Basic Sciences
External Advisory Board, International
Anesthesia Research Society Frontiers
in Anesthesia Research Award,
2006-2007
more anesthesia news
Welcome to our six new CRNAs!
The Department of Anesthesia and
Perioperative Care is proud to announce the addition of six new certified registered nurse anesthetists
(CRNAs) to its clinical staff, effective January 2007.
Historically, nurse anesthetists
have played a vital role in the development of accepted anesthesia
techniques, and have been administering anesthesia to patients for
more than 100 years.
10
At UCSF, CRNAs have facilitated
our clinical care and educational
mission for more than 30 years, especially at San Francisco General
Hospital and the San Francisco
Veterans Affairs Medical Center.
Contributing to UCSF Medical
Center at Mount Zion’s resurgence,
CRNAs have worked as part of the
department’s strategy to deliver
safe and effective anesthesia for
cases with an emphasis on cancer
and women’s health.
And finally, at the Moffitt-Long
Hospital, CRNAs like Jay Beebe
have convinced the department of
the value of increasing the number
of CRNAs on our clinical staff. We
have been joined by the following
Merritt College graduates: Amanda
Gatske, David Goff, Leigh-Ann
Langford, Candacean Lansenderfer, Doanh Ly and Mercy Santos.
The 101st American Society of Anesthesiologists
Annual Meeting was held at McCormick Place in
beautiful Chicago, Illinois, this year, and was attended by thousands of anesthesiologists and
other medical professionals from around the
country and the world. Over the last two years,
the ASA has developed a broader focus to its
meeting, with the introduction of subspecialty
education tracks, including ambulatory anesthesia, cardiac anesthesia, critical care medicine,
neuroanesthesia, obstetric anesthesia, pain medicine, pediatric anesthesia and regional anesthesia.
2006 ASA
Annual Meeting
These areas were explored in a variety of settings,
including panel discussions, problem-based learning
discussions, point-counterpoint sessions, oral presentations and poster discussions, special events,
refresher courses and workshops. As always, the
UCSF Department of Anesthesia and Perioperative
Care was well represented in many of these areas.
2006 committees
Scientific Content Subcommittee
on Critical Care
Neal Cohen, MD, MPH, MS
Task Force on Infection Control
Robin Stackhouse, MD
Committee on Trauma and
Emergency Preparedness
Jill Antoine, MD
Committee on Obstetrical Anesthesia
Samuel Hughes, MD
Task Force on the Future Paradigms
of Anesthesia Practice in 2025
Ronald D. Miller, MD, Chairman
2006 point-counterpoint
Ultrasound Guidance Is the Standard
of Care for Central Line Insertion
Manuel Pardo Jr., MD
2006 refresher courses
Treating Pain Patients with Opioid
Tolerance: From Mechanisms to
Clinical Practice
Pamela Palmer, MD, PhD
Intracranial Vascular Disease:
Anesthetic Concerns and Management
Adrian Gelb, MB, ChB
Mechanical Ventilatory Support in 2006:
Getting the Most from the Ventilator
Michael Gropper, MD, PhD
An Update Regarding Transfusion
Medicine
Ronald D. Miller, MD, Chairman
Infection Control for the
Anesthesiologist: Is There More
Than Handwashing?
2006 panels
Making Perioperative Care Safe
Daniel Burkhardt, MD
The Role of the Anesthesiologist
in End-of-Life Care
Neal Cohen, MD, MPH, MS
Chloroprocaine Spinal Anesthesia:
Current Status
Kenneth Drasner, MD
Role of Anesthesiologists in Detecting,
Managing and Training for Emergency
and Disaster Events
Jill Antoine, MD
Clinical Challenges
Linda Liu, MD
11
news
NEW
ANESTHESIA
FACULTY
(Front row from left) Sakura Kinjo, MD; Lee-Lynn Chen, MD; Valli Mummaneni, MD;
(back row from left) Ravi Joshi, MD; George Pasvankas, MD; Matthew Cirigliano, MD;
(not pictured) Jill Antoine, MD; Jonathan Claassen, MD; Melanie Henry, MD;
Jennifer Lee, MD; Thoha Pham, MD
Career Faculty
Jill Antoine, MD
Associate Clinical Professor
Joined Faculty July 1, 2006
Medical School:
Uniformed Services University of the
Health Sciences F. Edward Hébert
School of Medicine
Bethesda, Maryland
Internships:
Advanced Training (Bush Masters)
Uniformed Services University of
the Health Sciences
Bethesda, Maryland
Advanced Training (Medical
Management of Chemical Casualties)
US Army Medical Research Institute
of Chemical Defense
Aberdeen Proving Ground, Maryland
Advanced Training (Army Medical
Department Officers Advanced
Course)
US Army
Advanced Training (Medical Effects
of Nuclear Weapons)
Armed Forces Radiobiology
Research Institute
Bethesda, Maryland
Residencies:
General Surgery
Tripler Army Medical Center
Honolulu, Hawaii
Anesthesiology
Walter Reed Army Medical Center
Washington, DC
Fellowship:
Pediatric Anesthesiology
Children’s National Medical Center
Washington, DC
Previous Employment:
Faculty Member
Brigham and Women’s Hospital
Boston, Massachusetts
12
Lee-Lynn Chen, MD
Assistant Clinical Professor
Joined Faculty August 1, 2006
Medical School:
University of Rochester School
of Medicine and Dentistry
Rochester, New York
Internship:
Preliminary Medicine
University of California, San Diego
San Diego, California
Residency:
Anesthesiology
University of California, San Francisco
San Francisco, California
Fellowship:
Critical Care Medicine
Matthew Cirigliano, MD
Clinical Instructor
Medical School:
New York University School
of Medicine
New York, New York
Internship:
Internal Medicine
Beth Israel Deaconess Medical Center
Residency:
Anesthesiology
Massachusetts General Hospital
Fellowship:
Cardiothoracic Anesthesiology
Emory University School of Medicine
Atlanta, Georgia
Faculty Member
Atlanta, Georgia
Jonathan Claassen, MD
Clinical Instructor
Medical School:
University of North Carolina Chapel
Hill School of Medicine
Chapel Hill, North Carolina
Internship:
Emergency Medicine
East Carolina University
Greenville, North Carolina
Residency:
Anesthesiology
Melanie Henry, MD
Medical School:
Tulane University School of Medicine
New Orleans, Louisiana
Internship:
Internal Medicine
Reading Medical Center
West Reading, Pennsylvania
Residency:
Anesthesiology
Fellowship:
Pain
Ravi Joshi, MD
Assistant Professor in Residence
Medical School:
Harvard Medical School
Internship:
Preliminary Medical Internship
Residency:
Anesthesiology and Critical
Care Medicine
Fellowship:
Atlanta, Georgia
Sakura Kinjo, MD
Joined Faculty May 1, 2005
Medical School:
University of the Ryukyus
School of Medicine
Okinawa, Japan
Internships:
United States Naval Hospital
Okinawa, Japan
Medicine/Pediatrics
University of Texas
Houston, Texas
Residencies:
Anesthesiology
Okinawa, Japan
Anesthesiology
University of Texas
Houston, Texas
Rotation
Texas Heart Institute
St. Luke’s Episcopal Hospital
Houston, Texas
Critical Care Medicine Rotation
M.D. Anderson Cancer Center
University of Texas
Houston, Texas
Pediatric Anesthesiology Rotation
Texas Children’s Hospital
Houston, Texas
Obstetric Anesthesiology Rotation
Lyndon B. Johnson General Hospital
Houston, Texas
Fellowship:
Clinical Pain
University of California, Davis
Davis, California
Instructor
Department of Anesthesiology
Okinawa, Japan
Jennifer Lee, MD
Clinical Instructor
Medical School:
New Jersey Medical School
Newark, New Jersey
Internship:
Internal Medicine
Mount Sinai Medical Center
New York, New York
Residency:
Anesthesiology
Valli Mummaneni, MD
Joined Faculty September 18, 2006
Medical School:
Northeastern Ohio Universities
College of Medicine
Rootstown, Ohio
Internship:
Transitional Medicine
Aultman Hospital
Canton, Ohio
Residency:
Care Medicine
Cleveland Clinic Foundation
Cleveland, Ohio
Staff Anesthesiologist
Providence Hospital
Southfield, Michigan
Clinical Instructor
Assistant Professor
Atlanta, Georgia
George Pasvankas, MD
Clinical Instructor
Medical School:
Mount Sinai School of Medicine
New York, New York
Internship:
Medicine
Winthrop-University Hospital
Mineola, New York
Residencies:
Care Medicine
Thoha Pham, MD
Medical School:
Temple University School of Medicine
Philadelphia, Pennsylvania
Internship:
Transitional Medicine
Crozer-Chester Medical Center
Upland, Pennsylvania
Residency:
Anesthesiology
Fellowship:
Pain
13
news
Ryan Bradley, MD
Medical School:
University of California,
San Francisco School
of Medicine
Danton Char, MD
Medical School:
of Medicine
Sarah Cocoma, MD
Medical School:
Loyola University
Chicago Stritch School
of Medicine
Brian Dennis, MD
Medical School:
of Medicine
Allison Duffy, MD
Medical School:
University of Wisconsin
School of Medicine and
Public Health
Lonnie Fender, MD
Medical School:
University of Miami
Leonard M. Miller School
of Medicine
Harold Fong, MD
Medical School:
of Medicine
Matt Giudice, MD
Medical School:
Davis School of Medicine
Jason Greenberg, MD
Medical School:
University of Chicago
Pritzker School
of Medicine
Andrew Itkin, MD
Medical School:
University of Nebraska
College of Medicine
Xa Johnson, MD
Medical School:
University of Illinois
Urbana-Champaign
College of Medicine
Irfan Kathiriya, MD
PhD, Molecular and
Developmental Biology
Medical School:
University of Texas
Southwestern
Medical School
Hannah Kwon, MD
Medical School:
University of Michigan
Medical School
Mark Latronica, MD
Anna Logvinova, MD
Medical School:
Medical School:
I.M. Sechenov Moscow
Los Angeles David Geffen
Medical Academy
School of Medicine
Jessica McDermott, MD
Medical School:
of Medicine
Arun Prakash, MD
PhD, Immunology and
Molecular Oncology
Medical School:
New York University
School of Medicine
Nina Rahklin, MD
Medical School:
of Medicine
Erica Straus, MD
Medical School:
of Medicine
Binbin Wang, MD
Medical School:
Mount Sinai School
of Medicine
Shelley Wu, MD
Medical School:
Louisiana State
University School
of Medicine
Susan Yoo, MD
Medical School:
Albany Medical College
UCSF ANESTHESIA
RESIDENTS
Class of 2009
Patrick Guffey, MD
Medical School:
University of Michigan
Medical School
14
Mark Thoma, MD
Medical School:
Davis School of Medicine
Anesthesia has come a long way since Arthur Guedel, MD, developed the “Eye Signs of Anesthesia”
during World War I, a technique to determine the
depths of anesthesia by observation. Today, the
constant need for more refined techniques pushes
researchers and educators to discover and teach
about a startling array of clinical advances.
Changing
Practice of
Anesthesia 2006
To support those efforts, on the weekend of September 29, 2006, the Department of Anesthesia
and Perioperative Care at the University of California, San Francisco held its annual Changing Practice
of Anesthesia conference. The three-day conference
in downtown San Francisco brought together physicians, researchers and students from around the
globe in a successful effort to update attendees on
some of the most significant advances in the field.
Alex Evers, MD
Keynote speech by Alex Evers, MD
Oanh H. Ha, MD, this year’s conference program director, began the
weekend with a welcome speech.
Her talk was followed by the keynote
address, which each year honors Stuart C. Cullen, MD, the first chair of the
UCSF Department of Anesthesia and
Perioperative Care. Alex Evers, MD,
Henry E. Mallinckrodt Professor and
head of the Department of Anesthesiology at Washington University in St.
Louis, delivered this year’s keynote,
entitled “Operating Room Productivity: An Anesthesiology Perspective.”
Evers earned a degree in biochemistry from Yale University and a medical degree from New York University
medical school. He completed an
internship and residency in internal
medicine at Michael Reese Hospital
in Chicago, and a residency in anesthesia and a fellowship in critical care
at Massachusetts General Hospital in
Boston. In 1983, he began his career
at Washington University as a fellow
in the laboratory of Philip Needleman.
Evers was recently elected to the
Institute of Medicine of the National
Academy of Sciences, one of the
highest honors an anesthesiologist
in the United States can receive.
Focusing on target molecules,
Evers studies the mechanisms
through which anesthetics depress
the nervous system. By identifying
particular proteins, he observes in
detail the interactions of specific
agents and helps us better understand the mechanisms of anesthesia
and its effects on consciousness.
On Saturday, workshops included:
A successful three-day event
Over the course of the three-day
event, attendees were treated to a
wide range of lectures, workshops,
interactive panels and small discussion groups. On Friday, the
topics included:
• Pediatrics, moderated by Maurice
Zwass, MD
• Obstetric anesthesia, moderated
by Samuel C. Hughes, MD
• Transfusion issues, moderated
by Elizabeth A. Donegan, MD
• Anesthetic and surgical issues
in transplant surgery, moderated
by Claus Niemann, MD
• Pain, moderated by Daniel H.
Burkhardt, MD
• Perioperative issues, moderated
by Jeanine Wiener-Kronish, MD
• Ambulatory anesthesia, moderated
by Errol P. Lobo, MD, PhD
• Neuroanesthesia, moderated by
Susan M. Ryan, MD, PhD
• Technology and imaging, moderated by John M. Taylor, MD
The conference ended on Sunday
with another round of interactive
workshops that included: Ultrasound
Workshop for Regional Anesthesia;
Pediatric Anesthesia Cases; Difficult
Airway Cases; Equipment, Surface
Anatomy and Regional Anesthesia;
and Basic Transesophageal Echocardiography (TEE). Please note that next
year, because the American Society of
Anesthesiologists Annual Meeting will
be in San Francisco on October 13-17,
we will not hold the Changing Practice
of Anesthesia conference. Look for it
to return in 2008.
15
Critical Care Medicine and Trauma
June 7-9, 2007
Fairmont Hotel
Course Director:
Michael A. Gropper, MD, PhD
Professor and Vice Chair
Department of Anesthesia and
Perioperative Care
Director, Critical Care Medicine
UCSF Medical Center
Course Co-Chairs:
Rochelle Dicker, MD
Assistant Professor in Residence
Department of Surgery
San Francisco General Hospital
Mark Eisner, MD, MPH
Associate Professor, Department
of Anesthesia, Department of
Medicine Division of Occupational
and Environmental Medicine &
Division of Pulmonary and
Critical Care Medicine
UCSF Medical Center
Challenges of Managing Pain
Symposium (ChaMPS)/Pain
Grand Rounds
First Thursday of every quarter
5 p.m.-7 p.m.
Herbst Hall, UCSF Medical
Center at Mount Zion
1600 Divisadero St.
San Francisco
Faculty Coordinator:
Pamela Palmer, MD, PhD, Professor
of Anesthesia and Perioperative Care
Director, UCSF PainCARE-Center for
Advanced Research and Education
Program and registration information:
mountzion.ucsfmedicalcenter.org/
pain_management/rounds.html
Department Chairman
Editor-in-Chief
Ronald D. Miller, MD
Executive Editor
Marge O’Halloran
Editor
Morgen Ahearn
Designer
Andrew Boettcher
Principal Writer
Andrew Schwartz
Writers
Michael Pakes
Morgen Ahearn
Photographers
Christine Jegan
Brant Ward
Anesthesia News
is published by the UCSF
521 Parnassus Avenue
Room C-450, Box 0648
San Francisco, CA 94143-0648
415/476-2131
www.anesthesia.ucsf.edu
Send all inquiries to
[email protected]
© 2007 The Regents of the
Julin Tang, MD, MS
Director, Critical Care Medicine
San Francisco General Hospital
Produced by University Publications,
a unit of UCSF Public Affairs
#PR 619, 5/07
Printed on 50% recycled paper (15%
post-consumer) with soy-based ink.
Program and registration information:
www.cme.ucsf.edu
A
N
E
S
T
H
E
S
I
A
new s
Department of Anesthesia and
Perioperative Care Grand Rounds
First and Third Wednesdays
of every month
6:30 a.m.-8:00 a.m.
Room C 701, 521 Parnassus Ave.
San Francisco
Box 0648
San Francisco, CA 94143-0648
www.anesthesia.ucsf.edu
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PAID
San Francisco

Spring 2007 Volume 5-1 - UCSF Department of Anesthesia and

Transcription

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