Anesthesiology
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Anesthesiology

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Airway Management, Brian C. Spence MD, Director

Although airway management is a fundamental skill set required of and practiced daily by every anesthesiologist, until 2005 a formal airway management curriculum did not exist within our Department. At the request of the resident group, several physicians within our Department known as the "Airway Group" developed a formal curriculum. The key focus of the airway management curriculum is to teach and reinforce both basic and advanced airway management skills. It is a formal curriculum that starts within the very first days of the resident's CA-1 year and progresses through the CA-3 year.

The CA-1s have several didactic lectures on basic airway management skills during their CA-1 tutorial followed by a group airway management session in the simulator. Through this simulation session, the CA-1s are exposed to common clinical airway management scenarios and have the opportunity to practice with several of the airway management tools that are available within the Department. This simulation session is then repeated at 6 months to reinforce many of the airway management scenarios that the CA-1s have been exposed to clinically, as well as to evaluate their progress.

Each CA-1 then rotates through a month-long rotation dedicated to airway management in the second half of the CA-1 year. At the start of the rotation, they are given a thorough syllabus of pertinent airway management articles that they are expected to read over the course of the rotation. During this rotation, the resident is expected to have exposure to many of the airway management tools present in the Department (such as the Glidescope, Bullard Laryngoscope, Aintree catheter, etc) in a non-emergent/elective setting. Dr. Kathleen Chaimberg has also arranged for the CA-1s to attend the ENT surgery clinic during one day of the rotation to learn airway topicalization skills for bronchoscopy. At the conclusion of the rotation, the resident has a one on one simulator session where several complicated clinical scenarios are presented. The purpose is not only for evaluation of performance, but also to solidify the resident's airway management thought process as they prepare to be first responders to airway management calls from several offsite locations.

The last component of the CA-1 airway management curriculum is completion of ATLS. This course exposes the resident to trauma airway management.

At the CA-3 level, there is a two-week elective in airway management. The purpose of this elective is for the CA-3s to gain intense exposure to difficult airway management. Difficult airway cases are selected for the CA-3 resident through the preadmission testing area. The resident is expected to manage these cases in an independent manner with the attending staff physically present for immediate back up and assistance. Many CA-3s appreciate this opportunity to practice and solidify their airway management skills before graduating and being in a solo provider environment.

The other component of the CA-3 curriculum is the surgical airway cadaver lab arranged by Dr. Kathleen Chaimberg. At the beginning of the CA-3 year, the residents have a one-day wet lab on surgical airway management. The morning is spent practicing cricothyrotomies and retrograde wire placement on a simulator. In the afternoon, the residents and four staff are in the Dartmouth Medical School anatomy laboratory practicing cricothyrotomies on cadavers. This unique experience allows the resident to obtain invasive, emergent airway management skills in a controlled environment.

We also have had several equipment acquisitions over the last two years to facilitate our airway management curriculum, under the leadership of Dr. Jinny Hartman. We now have updated our fiberoptic scopes to include two new digital scopes. We also have purchased two Bullard laryngoscopes, two Glidescopes, as well as Aintree catheters. Dr. Hartman has also updated and standardized all of our difficult airway carts for immediate response to difficult airway management calls, in both the operating room and offsite.

We also have continued to expand our yearly airway conference. This year there were over 50 attendees. We had nationally recognized airway management experts present several lectures followed by small group simulator sessions, making for a full-day educational experience. The attendees' reviews were overwhelmingly positive.

We are constantly updating our airway management curriculum and involving more simulator experience for resident teaching. With the help of Drs. Bertrand, Blike, and Andeweg, in the next couple of years, we hope to fully integrate this new teaching tool into a validated and standardized model for teaching airway management skills to residents and staff.

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Ambulatory Anesthesia ~ Jeffrey Shiffrin MD, Director

The Ambulatory rotation provides residents with an experience in which they will acquire a set of skills requreid to appropriately care for patients undergoing anesthesia in an amulatory environment. This must be distinguished from the traditional model of inpatient evaluation in order to account for the special characteristics of the ambulatory situation. In this setting, it is critical to promote efficient care without compromising patient safety. The patient will have been evaluated preoperatively by the Surgeon or a Primary Care Provider, and will usually present to the Anesthesiology team via the Same Day Surgery unit. The Anesthesiology team will perform a comprehensive review of the patient's database, perform a physical examination, and gather any necessary further infomration in order to formulate and implement an anesthetic care plan and follow the aptient through recovery to achieve a safe discharge to home. Careful implementation of this process allows the Ambulatory Anesthesiologist to avoid problems such as patient dissatisfaction, inefficient operating room utilization, unexpected surgery cancellation, unplanned inpatient admissions, unexpected adverse anesthetic outcomes and litigation.

Current trends in health care in the United States show a progressive shift towards ambulatory surgery, and it is therefore critical for the Anesthesiologist in training to develop the skills necessary to function effectively in this changing environment.

At Dartmouth-Hitchcock Medical Center, ambulatory anesthesia will include the following settings:

  • Operating Rooms in the main OR area
  • MRI and CT scanners
  • Interventional Radiology and Nuclear Medicine
  • Endoscopy Suites
  • Pediatric PainFree area
  • Extracorporeal Shock Wave Lithotripsy
  • Minor Surgery area
  • Electroconvulsive Therapy

We are currently in the planning stages for a new Amulatory Surgery Center and hope to report about this in the near future. Stay Tuned!

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Cardiac Anesthesia ~ Gregg Hartman MD, Director

Gregg Hartman, MD

The cardiothoracic anesthesia service has experienced significant changes over the past several years. Nonetheless, it remains a busy and popular clinical service at Dartmouth Hitchcock Medical Center. The section typifies the multidisciplinary approach to the treatment of ischemic heart disease, valvular repair and replacements and complex aortic reconstruction. Mirroring the national decline in off-pump coronary artery bypass, the DHMC volumes in for this approach have diminished thus traditional on-pump revascularization is the norm. Most notable has been the increased in complex aortic surgery requiring deep hypothermic arrest.

Rounding out the distribution of operations are: Surgical procedures for congenital disease, intracardiac masses and shunts, and ventricular remodeling. In addition to cardiac procedures, the service covers the operative arm of the comprehensive thoracic oncology program. Surgeons David Johnstone and William Nugent perform the volume of these procedures that include pulmonary, esophageal and mediastinal mass resections utilizing both traditional "open" and thoracoscopic techniques.

All CA-1 and CA-2 residents rotate through the cardiac service on four-week intervals. The service covers the heart room daily and a second room devoted to either cardiac or non-cardiac thoracic procedures. This serves to provide more than adequate exposure to a wide variety of cardiothoracic surgical procedures. Residents become proficient at invasive monitoring techniques, the management of cardiopulmonary bypass, the use of vasoactive infusions, and the diagnosis and treatment of coagulopathies. Transesophageal echocardiography (TEE) is standard for most cardiopulmonary bypass procedures at DHMC. CA-3s can elect additional, more extensive training for 2-8 week periods during their final clinical year. Many have successfully negotiated the PTEeXAM certification examination. Most cardiac faculty have similarly received certification, and the majority has or are in the process of fulfilling Diplomat status in Perioperative TEE.

Residents are exposed to TEE both intraoperatively and through biweekly conferences held by Drs. Gregg Hartman and Athos Rassias. In addition to intraoperative hands-on exposure and biweekly conferences, residents have the opportunity to be exposed to "Virtual TEE"ิ, an interactive computer-based echocardiography simulator developed by Dr. Hartman. Virtual TEE permits students to manipulate a TEE probe and scan planes within a 3-D environment; view the relationships of the TEE probe; scan plane and heart from any angle within the virtual chest cavity; and view the resultant scan angle. The simulator is also used for illustrations and presentations. Current progress is being made to incorporate this simulator into the ongoing Simulation Laboratory being utilized for clinical scenario training throughout the institution. Ongoing collaborative projects are underway with the Department of Anesthesiology at Beth-Israel Deaconess in Boston and their simulation center. An extensive library of DVDs and videotapes provide the opportunity for independent study. The service is fully integrated with cardiology, permitting collegial exchange and cooperation. New in the operating room this past year is a 4-D TEE system. This unit (one of the few in clinical practice nationally) allows capture, replay and analysis of 3-D images of the heart, surrounding structures, and volumetric display of Doppler color flow derived from blood flow velocities. It represents the cutting edge of TEE imaging.

In addition to the local teaching program, Dr. Hartman is on the Board of Directors of the Society of Cardiovascular Anesthesiologists' (SCA). He has served as one of the co-directors of the Comprehensive Update of Intraoperative Echocardiography held annually in San Diego for the last 5 years. This meeting is for cardiac anesthesiologists, cardiac surgeons, and cardiologists, and showcases numerous nationally known speakers. Recently he has joined the PTEeXAM writing committee. These roles allow him to assure that the DHMC cardiac anesthesia program remains current with the national practice and trends.

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Combined Leadership Preventive Medicine – Anesthesiology Program ~ Stephen D. Surgenor MD, MS, Resident Coach

The goal of this program is to attract and train anesthesiologists capable of leading change and improvement in systems where people and health care converge. Specifically, this is to be accomplished through the restructuring of existing healthcare systems so that they provide the highest quality of care at the best possible cost.

Several residents have chosen the combined Anesthesiology/Leadership Preventive Medicine Residency Program for their training. John Trummel was the first graduate of this program. His practicum project focused on improving the quality of sedation for endoscopic procedures. Julie Sorensen is just completing her practicum this spring to improve the efficacy of epidural analgesia for patients undergoing thoracic surgery. Xan Abess, who is completing his first year of clinical anesthesia training, will be starting this program next year.

The Program is divided into clinical, academic, and practicum components. The clinical component is fulfilled by work in the Department of Anesthesiology. The academic component is achieved by completing a Master of Public Health degree at the Center for Evaluative Clinic Sciences within Dartmouth Medical School. The practicum component is the final step of this program. Each resident selects a comprehensive patient care improvement project that focuses on enhancing the technical, service, and cost excellence of care for individual patients. Within the Department of Anesthesiology, this is accomplished by having the residents complete the Clinical Scientist Track A using six months of their residency to fulfill the academic component. The practicum component is completed during an additional year of residency.

It is the intent of this combined program to educate residents so they will be able to lead and effect change of the healthcare systems in which they work. To provide better care for individuals with the improvements to the health of populations. Moreover, to provide leadership during the implementation of the core competencies of the American College of Graduate Medical Education within our specialty.

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Critical Care Medicine ~ Stephen D. Surgenor, MD MS, Section Chief

The past two years have demonstrated ongoing growth for Critical Care Medicine at DHMC. The unit now includes 26 ICU beds, with plans for an additional eight beds to be available in the spring of 2008. The Intensive Care Units at Dartmouth-Hitchcock Medical Center continue to be fully compliant, with expectations for the Leap Frog Groups as we provide comprehensive critical care management by a staff comprised of board certified critical care medicine specialists.

We continue to see high quality candidates for our Critical Care Medicine Fellowship programs. These programs now accept up to five Fellows per year. The Fellowship experience at Dartmouth-Hitchcock Medical Center is multidisciplinary with participation by graduates from Anesthesiology, Medicine, and Surgery residencies. The Fellows are an important facet of our efforts to provide high quality and highly accessible Critical Care to this institution. In addition, the Fellows actively participate in leadership and quality improvement efforts that are ongoing in the Section.

Research activities continue to be an important aspect of our Section. Currently there is active research on the utilization of blood transfusions and blood preservation techniques, infectious pneumonia, EEG, and pulse oximetry monitoring strategies, and management of ARD's. We are also nearing completion of a study about the diagnosis of relative adrenal insufficiency and steroid repletion in critically ill patients.

We are also pleased that Critical Care Medicine and the Adult Critical Care Nursing Division were co-recipients of the 2006 DHMC Office of Patient Safety Recognition Award for efforts to reduce blood stream infections, nosocomial pneumonia, and to develop a rapid response team. This Section will continue to provide patients who are critically ill the best care, every time.

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Critical Care Medicine Fellowship ~ Athos J. Rassias MD, Fellowship Director

The Critical Care Medicine section at Dartmouth-Hitchcock Medical School provides two ACGME fully accredited fellowship programs. One program is for persons who are board eligible/certified in anesthesiology, and one program is for those persons board eligible/certified in internal medicine. In addition, we work closely with the section of pulmonary medicine to provide the critical care medicine training for the pulmonary/critical care medicine fellows at DHMC. The section also provides opportunities for individuals who are board certified/eligible in general surgery to obtain critical care certification from the American Board of Surgery.

The overall goal of our Fellowship program in Critical Care Medicine is to train and educate physicians in the care of critically ill patients. The Fellowship is designed to foster both the clinical and the leadership skills necessary to develop and promote a multi-disciplinary approach to Critical Care Medicine.

We have been very successful in recruiting highly qualified fellows for the program. Given the overall growth in faculty members and clinical throughput, the size of the fellowship has grown concurrently. In addition to increased clinical activity, the educational program for the fellows has also developed and expanded. Finally, fellows have successfully collaborated on research projects with close mentoring from faculty members.

The fellowship program continues to look to further solidify its position of strength from an educational, clinical, and research standpoint.

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CRNA Practice ~ Carol Starunko CRNA, Clinical Coordinator

The CRNA section of the Department of Anesthesiology practices a team approach to anesthesia care here at Dartmouth-Hitchcock Medical Center. Presently, we have 19 CRNAs from various backgrounds with many years of experience. We are the primary site for at least one SRNA from the University of New England.

Our clinical responsibilities include general and regional anesthesia for all types of surgical procedures in the Operating Rooms, various offsite locations, and PainFree at the Children's Hospital at Dartmouth.

Our educational responsibilities include precepting SRNAs from the University of New England, D-hart (Dartmouth Helicopter Air Rescue Team) personnel, Same Day Surgery and Post-Anesthesia Care Unity (PACU) nurses seeking to learn or sharpen their airway management skills. We also hold appointments at Dartmouth Medical School as Clinical Educators, and contribute to the clinical education of medical students rotating through Anesthesiology.

CRNAs sit on various departmental and inter-departmental committees including Quality Assurance and Non-Operating Room Anesthesiology, and participate in anesthesia site visits to several outlying community hospitals in northern New England. One of our members has published an article in the Advanced Emergency Nursing Journal, and our present SRNA recently presented a paper at the NEANA.

Our group is dedicated to providing excellent anesthesia care for our patients in a collegial working atmosphere with our MD colleagues, both Faculty and Residents here at Dartmouth-Hitchcock Medical Center.

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International Pediatric Anesthesia Elective ~ Michael L. Beach MD, PhD, Director

Each year one or two senior residents, who have excelled both clinically and academically, have the opportunity to participate in an international anesthesia experience. This rotation is typically a two-week trip to a developing country. Recent trips have been to Laos, Kosovo, Myanmar, Vietnam, Bangladesh, the Philippines, Nepal, Ecuador, Brazil, Peru, Bolivia, and Mali.

Many of our trips are with Interplast, a non-profit organization that provides plastic surgery services to children in developing countries (see www.interplast.org). A typical trip consists of about 12 team members -- anesthesiologists, surgeons, and nurses -- from across the country and the world, with most of the team members meeting for the first time at the airport. At least one Dartmouth attending anesthesiologist participates as well, and is responsible for resident supervision. However, the resident is expected to function as an integral member of the team. Except for oxygen, the team carries almost all necessary supplies. The first day is spent setting up an operating room and selecting patients, with surgeries taking place over the following two weeks. Anesthesiologists are actively involved in the pre-operative evaluation, and post-operative care.

Anesthesia residents additionally have the opportunity to participate with other organizations. Dartmouth Medical School has an ongoing partnership with Kosovo's Ministry of Health, and we recently sent a team there to work in an orthopedic hospital. We have also sent a team to Laos through the York Medical Foundation.

The experience is a valuable one for residents. Residents must be able to deliver safe care in an environment that may not be optimal. Advanced airway equipment and invasive monitoring are not available. Language barriers, cultural differences, and available medical care may limit the pre-operative assessment. There may not be an intensive care unit to handle complications. In this setting, residents must demonstrate ingenuity and flexibility. Developing a working relationship with health care providers from other institutions demands strong communication skills.

This rotation is fully supported by the Department of Anesthesiology and the rotation contributes to the clinical care requirements of the residency. Currently three attending anesthesiologist participate in this rotation.

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Medical Student Education ~ Steven Andeweg, MD and Jinny K. Hartman, MD, Co-Directors

In addition to anesthesiology resident education, another educational mission of the Department of Anesthesiology is the teaching of medical students. The students who come to us work alongside the residents and attending staff for elective rotations of two to six weeks, primarily in their fourth year of medical school. Due to our affiliation with the Dartmouth Medical School, most of the students are from there, however some students come from other medical schools around the country as well.

The objective of the elective in anesthesiology is to provide students with an understanding of how medical knowledge combined with modern anesthetic and perioperative care contributes to the outcome of patients undergoing surgery. Secondary objectives include teaching basic airway techniques, fluid management, invasive monitoring capabilities, and regional anesthesia. Additionally, we hope to identify those students who have an interest in pursuing anesthesiology as a career and to intellectually stimulate other students who may eventually consider entering our medical specialty.

The medical students are assigned to work with an attending anesthesiologist each day. The students accompany their attending anesthesiologist and the anesthesiology resident in performing preoperative assessments of patients and participate in the perioperative anesthetic care of the patients assigned to each anesthesia care team that day. The students receive one-on-one teaching from the attending anesthesiologists, as well as reading assignments. They attend weekly Grand Rounds lectures that review interesting topics in anesthesiology and the latest research in the field, as well as case conferences that discuss interesting patient management situations. The students also attend either daily or weekly didactic education lectures that the residents receive.

After they complete their elective rotation, a few students pursue a month-long sub-internship. The students not only receive additional teaching and hands-on exposure to anesthetic management, but they also accompany the residents who are on call one night per week. Most of these students are those who intend to pursue an anesthesiology residency and have a heightened interest in learning about the specialty.

Something new added by Dr. Hartman in 2006 was the Anesthesia Interest Group (AIG) for Dartmouth Medical students. It was created to share out Department's enthusiasm for the field of Anesthesiology with medical students who are interested in learning more about the specialty of Anesthesiology. The DHMC AIG provides a forum for students prior to participating in the clinical rotations to experience the spectrum of clinical practice in Anesthesiology and therefore provide opportunities for education, mentorship, and hands-on clinical experience with Anesthesiology faculty and residents.

We hope all the medical students who work with us, whether or not they become anesthesiologist, come away with an appreciation of how we use our knowledge of human physiology and pharmacology to provide safe and compassionate care to the patients who are entrusted to us.

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Moderate Sedation Team ~ Patricia Barr RN, Moderate Sedation Liason

In September 2004, the Moderate Sedation Program was developed to provide anxiolysis and analgesia safely to adult cataract surgery patients experiencing anxiety and pain related to their surgery.

The Moderate Sedation Team is made of up registered nurses (Same Day Nurses) who have volunteered to be specialty trained and educated in Moderate Sedation techniques and monitoring to broaden their realm of patient care. We have been lucky enough in attracting many dedicated volunteers to build a solid, flexible, efficient, and caring team over the past three years.

Each volunteer receives the following specialty training and education before joining the team:

  • ACLS
  • PALS for nurses working in pediatric environment
  • Moderate sedation Adult and Pediatric online course
  • Simulation course
  • Orientation for each RN to the OR and sedation procedures
  • Yearly conferences provided by the Anesthesiology Department

Initially, the Team began by treating the ophthalmology adult patient population under the same protocol as many ambulatory surgery centers across the nation. This population included patients having cataracts surgery, trabeculectomy procedures, bleb revisions, and temporal artery biopsies. The RN interviews/screens all patients pre-operatively to access and identify any potential risk factors before the patient goes to surgery. The Moderate Sedation nurses are able to provide one-on-one care for these patients with the ongoing support of our staff anesthesiologists who are available 24/7.

Due to the success of the Moderate Sedation program for Ophthalmology patients and demand from other services, the Moderate Sedation program expanded into other clinical areas such as Pediatrics, Neurosurgery, and Urology.

Common pediatric procedures, such as VCUGs (voiding cystourethrograms) and MRIs were identified as procedures that fit criteria for the Moderate Sedation Team. For VCUGs, the Team's role is to assist anesthesiology with induction and post procedure care. A Moderate Sedation team member assumes care in radiology when the propofol is turned off and the child is emerging from anesthesia. For MRIs, a Team member assists anesthesiology with pre- and post- operative care and induction of the pediatric MRI patient in the MRI suite. The Team is able to provide care to six additional children allowing CHaD PainFree Anesthesiologists to provide care for another caseload in the PainFree Unit.

The entire Moderate Sedation program has been a tremendous success, but this year is especially notable. Since July 2006, the Moderate Sedation Team has been able to provide sedation to approximately 90 adult stereotactic frame patients for frame placement. The following story genuinely relates our success with this patient population:

Patricia Barr, RN and Moderate Sedation Liaison: "….after a particularly difficult frame placement with a patient undergoing radio surgery for a brain tumor, Marianne Adkins, RN came to me frustrated that we had yet again watched a patient suffer significantly during this procedure. Most of the staff in SDP has heard or seen the reactions of patients who have had to endure this procedure without sedation. The most stoic patients are anxious and afraid of what placing the frame will entail. In our roles as health care providers, we know that we cannot always take away a patient's fears totally. The fear of cancer or of impending surgery will cause a patient much anxiety. However, the fear of a painful procedure such as a frame placement can be treated effectively and safely."

"I went to talk with Catherine Jensen about Same Days' concerns. She heard us and together with the help of Corey Burchman, MD (Director of Neuro Anesthesia) we put together a program to utilize the expertise of the Moderate Sedation Team for this population of patients."

In our next report, you will likely read about the other Moderate Sedation initiatives currently under development:

  • Bone Marrow Aspirations and Biopsies
  • Acute Pain Service
  • Non-Operating Room Anesthesia (NORA)

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Neurosurgical Anesthesia ~ Corey A. Burchman MD, Director

Neuroanesthesia remains a vital and busy aspect of the anesthesia residency experience. With upwards of 1000 cases in FY 2006, the neurosurgical service continues to provide a forum of opportunity for anesthetic management of complex intra- and extra-cranial neurosurgical procedures. Resident experience was honed with over 3800 hours of both adult and pediatric procedures in 2006, a 22% increase over the previous year. Fifteen percent of the total represents pediatric neurosurgical cases.

The six neurosurgical full-time faculty and their six residents work intimately with our neuroanesthesia team, and provide exposure to the full breadth of neurosurgery, including procedures involving cerebrovascular and neoplastic disease, pituitary, spine, movement disorder, epilepsy, and stereotactic surgery.

Residents in anesthesia have the unique opportunity of interacting not only with the neurosurgical team intraoperatively, but collaborate in a multidisciplinary fashion with neuroscientists and engineers of the Dartmouth Epilepsy Program. Electrophysiological monitoring (somatosensory and motor evoked potentials, intraoperative EEG monitoring, electromyography, and brainstem auditory evoked potentials) are frequently and straightforwardly used. In this way, residents gain the appreciation for assessment of the functional status of the nervous system during altered states of consciousness.

Like most of the advances in medicine, state-of-the art knowledge in neurosurgical anesthesia is a moving target. Advances in brain chemistry, neuroprotection, and a more fundamental understanding of neurophysiology have led to an explosion in medical literature. The changing nature of CA-2 and CA-3 curriculum manuals is a reflection of this rapid knowledge evolution.

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Northern New England Cardiovascular Disease Study Group, Cantwell Clark V, MD

This is the tenth year of on going data collection for the Cardiac Anesthesia Registry that is coordinated through the Northern New England Cardiovascular Disease Study Group. As of this year there are over 18,000 cases entered in this Registry. The Registry is important both at Dartmouth-Hitchcock Medical Center and throughout the Northern New England region for initiating regional patient safety programs, improving clinical care, facilitating continuous process change and improvement, guiding clinical decisions, and redesigning existing processes of care, all in effort to reduce adverse outcomes after cardiac surgery.

Specific to the Anesthesia Registry, several regional activities have taken place over the last several years. Communication among anesthesia groups across the region is facilitated by conference calls and attendance at the regional multidisciplinary meetings held three times per year. Basic epidemiology about key processes, such as invasive hemodynamic monitors, use of transesophageal echocardiogram, use of antifibrinolytics, use of beta blockade, inotrope support, and intra-operative balloon pump use are examples of topic areas that have been shared and discussed. In addition, several outcomes are examined such as incidence of post-operative atrial fibrillation, stroke, and mediastinitis; as well as time to extubation. These conference calls have been an excellent catalyst for quality improvement across the region.

Dr. Steven D. Surgenor presented an abstract and published an article describing the joined and independent effects of low hematocrit during cardiopulmonary bypass, and red blood cell transfusions, on morbidity and mortality in the coronary artery bypass population. This work elegantly tied together, and uniquely explained, a number of the articles and observations that have dealt with low hematocrit, transfusion, and outcomes in this patient population over the last ten years.

Currently, a multidisciplinary group of nurses, physicians, several different specialties, and perfusionists are working together using a dataset that is a combination of the Surgical, Perfusion, and Anesthesia registries to understand the relationship of hemodilutional intra-operative anemia, red cell transfusions and adverse outcomes after CABG surgery. The NNE is a nationally recognized leader in this research.

Finally, the Anesthesia Registry has been useful for patient safety initiatives. For example, a guideline developed for safe placement internal jugular catheters has been developed by the Quality Assurance committee of this Anesthesiology Department at Dartmouth-Hitchcock Medical Center. This information was shared across the region during a recent Registry conference call.

We are pleased that several of the new members of the Cardiac Anesthesia group at DHMC are expressing interest in being involved in this on going Registry. There are many opportunities for epidemiologic research into the utilization of anesthesia techniques to improve outcome during cardiac surgery, such as transesophageal echocardiography, hemodynamic monitoring, intra-operative beta blockade, extubation times, and the transfusion medicine.

This Anesthesia Registry is indebted to the hard work of Drs. Thomas M. Dodds and Mary P. Fillinger who were instrumental in bringing this Registry to reality during the 1990s.

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Obstetrical Anesthesia ~ John W. Arbogast III, MD, Director

John W. Arbogast, MD

The total number of deliveries performed at Dartmouth-Hitchcock Medical Center has remained relatively constant for the last decade or so. The hospital handles between 1000 and 1200 births per year, with nearly 40% being covered by the high-risk obstetrical service known as Maternal Fetal Medicine. The remaining births are managed by obstetricians, residents, and/or midwives. The Department of Anesthesiology is involved, for either labor analgesia or surgical anesthesia, with at least 50% of all deliveries here at DHMC.

Labor analgesia service is provided on demand. Techniques vary per provider preference and clinical situation but typically involve the use of intrathecal opioids, continuous and patient controlled epidurals, and combinations of each. Our goal is to provide fast, reliable and safe pain relief for the parturient.

The anesthesia service also participates in all elective, urgent, and emergent operative deliveries in one of two dedicated operating rooms located in the Birthing Pavilion. A team approach led by a member of the Anesthesiology Department allows for efficient high quality care in crisis situations. In-situ team training, using sophisticated simulators and scenarios, is part of an exciting and novel approach to improving patient safety during OB emergencies here at Dartmouth-Hitchcock Medical Center.

Senior Anesthesiology residents, rotating on the OB anesthesia service, work closely with the entire Birthing Pavilion staff. Daily interactive rounds, consultation with all high-risk patients as well as routine analgesia consultations and all operative procedures requiring anesthesia, describe a typical day on the service. While all members of the Anesthesiology staff provide attending coverage for OB, there are at least three anesthesiologists with special interest and/or training in caring for the obstetrical patient.

In addition, residents can rotate through the Obstetrical service during their PGY 1 year as an elective, gaining valuable experience from a non-anesthesia perspective.

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Pain Management ~ Gilbert Fanciullo MD, Director

Gilbert Fanciullo, MD

The Pain Management Center at Dartmouth-Hitchcock Medical Center has continued to grow and evolve. We provide care for acute, chronic, and cancer pain patients and serve as a resource for our hospital, our community and for a large part of both New Hampshire and Vermont. We are a section within the Department of Anesthesiology and function in an inter-disciplinary fashion, integrating the specialties of neurosurgery, psychiatry, physical medicine and rehabilitation, behavioral medicine, oncology, nursing, and social work in an organized and directed approach to managing patients with pain. We are active in clinical pain research areas with principle emphasis on the use of opioids in chronic pain and in the development of new computer applications for assessment and management of patients with chronic pain.

We have recently developed and proven validity and reliability of the CAP (Computerized Assessment of Pain) tool, the ICQOL (Interactive Computer Quality of Life) measuring tool, and in 2007, deployed POET (Pain Outcome Evaluation Tool), whereby we will be collecting electronic data on every outpatient seen by the Pain Management Center.

Dr. Fanciullo has recently edited a special supplement of the journal Pain Medicine entitled "Computer and Information Technology in the Assessment and Management of Patients with Pain". Dr. Fanciullo was elected by the membership of the American Pain Society to the Board of Directors. Additionally, he has been assigned by the American Academy of Pain Medicine to co-chair a national committee charged with developing actionable recommendations to providers treating patients with opioids. Dr. Beasley has continued to direct our very successful fellowship program and receives approximately 70 applications per year for our three fellowship positions. Dr. Beasley is an active member of multiple national committees addressing fellow and resident education in pain medicine. The section has published approximately 25 articles in peer-reviewed journals over the course of the last 3 years, and approximately 5 book chapters. Our fellows are actively involved in research and frequently publish journal articles, and present abstracts at national meetings. We have continued our role as national leaders in the areas of clinical care, education, and clinical research.

We are currently approved for five pain fellows and have residents from anesthesiology, neurosurgery, orthopedic surgery, and other sections, who rotate through our service. We offer medical student electives for students from Dartmouth Medical School, and have had medical students from other medical schools rotate on our service as well. We have developed a vertical integration-educational program for Dartmouth Medical School and teach 2nd and 3rd year medical students, while 4th year medical students have an option of doing a rotation on the pain service.

We recognize our primary role as achieving excellence in patient care and to that end; we provide the right care to the right patient, at the right time, all the time, to the best of our ability. Our full time faculty includes: Dr. Robert Rose who continues as the Medical Director; Dr. Gilbert Fanciullo, Section Chief; Dr. Ralph Beasley, Director of our Fellowship and Education program; Dr. Daniel Graubert, Director of Interventional Pain Medicine; Dr. Julie Sorensen, Director of Acute Pain Medicine; and Dr. Tabitha Washington who has joint duties within the Pain Management Center and the Dartmouth Medical School. Our faculty is diverse, has a variety of special interests, and offers a balanced mixture of medical, psychological, physical medicine, and invasive modalities that is unique to pain training and treatment, as it exists today in the United States. We are active participants in the spine center and work closely with the palliative medicine service. We have a pediatric pain program that is unique in New England outside of Children's Hospital in Boston. Our interventional pain medicine program involves training in all pain modalities including neurolysis, implantation of spinal infusion systems, and spinal chord stimulating devices. We are on the cutting edge of clinical research and are thus able to provide our patients with the most current treatments available, anywhere in the world. Our program is unique and exemplary, and innovation and caring are the rules.

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PainFree Program ~ Joseph P. Cravero MD, Section Chief

The PainFree program at CHaD continues to meet the challenge of providing sedation services for children undergoing procedures or tests outside the operating room within our medical center. With the help of local charities, the Ronald MacDonald Charities of Eastern New England, and local charities, the PainFree program was created by members of the DHMC Department of Anesthesiology in the Fall of 2001. PainFree continues to offer sedation/anesthesia and stress control for any child requiring a therapeutic or diagnostic procedure at the Children's Hospital at Dartmouth (CHaD). Virtually every section of the hospital that performs tests or procedures on children has utilized this innovative program. The largest numbers of patients are referred from the Radiology Department (CT scanner, MRI scanner, interventional radiology procedures), but patients are also sent from a variety of services such as pediatric nephrology, pediatric oncology, pediatric cardiology, audiology, rheumatology, ENT surgery, dentistry, plastic surgery, pediatric dermatology, pediatric orthopedics, and general pediatric surgery. The program provided care for over 1,900 procedures last year with an expected growth of another 5-10% this year. In the past year, we have added additional RN sedation providers to our team in order to accommodate the continued increase in requests for our services. We have also instituted fully "off-site" sedation for MRI scans (with separate sedation providers) in order to meet the demand in that area. The sedation suite includes a patient intake area, admission bed, a fully equipped anesthesia location, and procedure room, and two recovery beds - all in one child-friendly environment. The staff of the program includes two registered nurses, a patient care technician, a child life specialist, and an administrative assistant who work with anesthesia attending anesthesia staff, residents, and certified registered nurse anesthetists. The physical environment combined with the expert and caring sedation team has vastly improved the experience for patients and increased the efficiency of our procedure providers.

The PainFree Program actually represents a unique blending of several services including pediatrics, nursing, Child Life, and anesthesiology. The program is designed to provide the level of care that each patient require, be that simple emotional support or distraction, any level of sedation, or general anesthesia. The plan for each patient takes into consideration the child's medical as well as emotional status, family situation, and the procedure to be performed. Input is received from family, local pediatrician, Child Life specialists, and anesthesiologist in order to formulate an appropriate intervention for any given patient. The result has been skyrocketing patient, family, and provider satisfaction and marked improvements in effectiveness and efficiency of interventional and diagnostic procedures for children at CHaD.

Anesthesiology residents, pediatric residents, and medical students all rotate through the service, which offers a unique insight into the management of rapid turnover cases and the necessity to adapt to various environments and procedure demands. In addition, the service has provided a venue for clinical investigation into the delivery of pediatric sedation care, yielding numerous abstracts, papers, and national presentations. We are constantly looking for opportunities to adapt new sedation medications, digital entertainment technologies, and other distraction techniques for the purposes of improving the global experience and efficiency of our system. This program has led the nation in the use of potent ultra-short acting sedatives and analgesics and applying these medications to sedation cases. We have also led the Anesthesiology Department in the provision of on-line resources for patients coming to our medical center for sedation. We look forward to continuing to improve our "virtual" PainFree experience in the coming years. Through all of these changes, the ultimate goal of the service remains the elimination of stress and pain (suffering) from the hospital experience for children at CHaD.

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Palliative Medicine ~ Ira Byock MD, Section Chief

Vision

We envision a world in which attention to comfort and quality of life are integral within health care for people who are ill or injured as well as their families, and in which illness, care giving, death and grief are accepted as normal, healthy aspects of the lives of individuals, families and communities.

Mission

The Palliative Care Service is committed to improving comfort and quality of life for patients and families with life-limiting illness or injury and complex needs who are served by DHMC, the Dartmouth Alliance and providers in our region.

The Palliative Care Service advances this mission through providing and modeling excellent clinical care, as well as through research, education, and participation in community-based efforts to improve access to and quality of palliative care in our region.

The Section of Palliative Medicine maintains active clinical inpatient and outpatient consultation services. Section members teach at all levels of medical education at Dartmouth Medical School and affiliated programs. Members conduct research in clinical care and delivery of health services. Consistent with its Mission, the Section contributes to development of a regional network to continuously improve quality of palliative care and service delivery.

The Palliative Care Service

Nationally, in September 2006 the American Board of Medical Specialties (ABMS) formally recognized Hospice and Palliative Medicine as a new subspecialty. The application to ABMS was sponsored by an unprecedented ten specialty Boards, including the American Board of Anesthesiology. The Palliative Care Service at DHMC provides specialized interdisciplinary care to patients with serious, potentially life-limiting conditions and their families. Our service complements disease-modifying medical treatments to enhance quality of life by controlling pain and other symptoms of illness, optimizing function, as well as by helping with difficult decisions, and offering guidance related to living with serious illness and an uncertain future.

The Palliative Care Service works with patients' primary medical teams to manage pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient's and family's needs, values, beliefs and culture. We strive to practice in patient-centered ways.

We are available around the clock, seven days a week, for consultations for hospitalized patients at DHMC. We see outpatients during weekdays in DHMC specialty clinics, including the Norris-Cotton Cancer Center. Additionally, there is always a Palliative Care Service physician on call and available for phone consultation to clinicians locally and regionally.

Our Team

The Palliative Care Service at DHMC brings together specialist physicians, advance practice nurses, social work and spiritual care professionals, rehabilitation, rehabilitation and complementary therapists and carefully selected and trained community volunteers. Team members work together to address the often-complex needs of seriously ill patients and their families. The goals are to prevent and relieve suffering and improve quality of life for patients and their families, regardless of the stage of the disease or treatments they are receiving.

During the past two years, the section and clinical Palliative Care Service have continued to grow in carefully considered directions. The staff of The Palliative Care Service now includes 2.8 FTE specialty physicians, and 3.15 FTE specialty advanced registered nurse practitioners. Yvonne Corbeil, a nurse administrator with extensive experience in hospice and palliative care program development, oversees our efforts to develop new programs and outreach to regional hospitals, home health, and hospice programs.

The Palliative Care Service

Physicians:

  • Ira Byock MD, Director
  • Sharona Sachs MD, Director of Clinical Services
  • Frances Brokaw MD, Director of Education
  • Diane Palac MD

Nurse Practitioners:

  • Lisa Stephens MSN, APRN
  • Marie Bakitas ARNP, DNSc, FAAN
  • Peggy Bishop MS, APRN
  • Paula Caron MS, APRN

Pastoral Care Coordinator:

  • Linda F. Piotrowski MTS, NACC certified

Care Management/Bereavement Coordinator:

  • Donna L. Soltura MSW

Healing Arts Therapist:

  • Briane Pinkson, LPN

Director of Network and Program Development:

  • Yvonne Corbeil

Volunteer Program Manager:

  • Wendy J Sichel MEd.

Palliative Care Program Manager:

  • Terry Fisher MPH, CPCU

Administrative Assistants:

  • Kim DeVillers
  • Dorothy Allen

Inpatient Consultation and Continuing Care

The Palliative Care Service is consulted to participate in care for patients with serious illness hospitalized at DHMC. We see patients throughout the hospital, including specialty medical, surgical, and cardiac intensive care units. We see patients of all ages, from centenarians to young children and neonates. Members of the palliative care team work alongside cancer specialists, surgeons, medical sub-specialists, and pediatric and adult critical care intensivists. A primary focus is treatment of pain and other distressing symptoms, such as nausea or shortness of breath. We also assist patients and their families to cope with bad news and improving comfort and quality of life with progressive illness. Practical services and restorative therapies help patients adapt to changes in their functional ability to maintain daily routines.

Serious illness confronts people with challenging decisions about which treatments to choose and develop an individualized patient-centered plan of care. Beyond responding to physical aspects of illness, the Palliative Care Service helps families navigate the, sometimes frightening, journey through illness. Clinicians assist patients and families to clarify and express their own values and preferences, and apply them in making treatment choices consistent with their values and goals.

Skillful anticipatory guidance can help people with life-threatening conditions, prepare for the possibility of disease progression, and explore matters of life completion.

Outpatient Palliative Care

The whole-person and family-centered approach to care described above for hospitalized patients is available in the outpatient setting and in follow-up after hospital discharge.

Palliative Care Service clinicians see patients by appointment within ambulatory cancer center clinics, as well as in medical and surgical clinics at Dartmouth-Hitchcock Medical Center. Most often, patients can be seen on the same day and in tandem appointments with specialty physicians, advanced practice nurses, radiation therapists and others.

The Palliative Care Service works closely with regional home health and hospice programs to ensure continuity of care between the hospital and home, ensuring comprehensive attention to symptoms and offering support for families in care giving and in grief. Special attention is given to preventing foreseeable problems and responding to emergencies among patients being cared for at home.

Within the Norris-Cotton Cancer Center, the Palliative Care Service is contributing to developing interdisciplinary specialty clinics for patients with common types of cancers, such as thoracic, gastrointestinal, head and neck and primary brain tumors. Dr. Byock has been appointed Associate Director for Survivorship and Palliative Care facilitating an integrated approach to patient-centered care throughout the course of cancer diagnosis and treatment.

Education and Training

Education and training is an essential component of the mission of the Section of Palliative Medicine. Physician, advance practice nurse and network, and program development faculty maintain an active schedule of lectures and presentations to pre-clinical and clinical audiences within Dartmouth Medical School, and regional facilities, as well as to the public.

Clinical rotations with the Palliative Care Service are popular among DMS 3rd and 4th year medical students. A one-month rotation on the inpatient Palliative Care Service is mandatory for first year Anesthesiology residents. Fellows in Pain Medicine rotate for a minimum of 2 weeks and follow a set of continuity patients through clinics and intervening hospitalizations. We offer 2 and 4-week rotations for DHMC residents in internal medicine, psychiatry, and pediatrics, as well as fellows in subspecialties. As space permits, we welcome physicians-in-training, nurses, advance practice nurses, pastoral care and social work trainees from other colleges and universities for clinical rotations and observerships.

We are actively preparing to launch a Clinical Fellowship in Palliative Medicine to help train a next generation of physician specialists committed to providing outstanding interdisciplinary palliative care for seriously ill patients and their families.

Research and Quality Improvement

The section is active in advancing clinical care and delivery of health services through research and quality improvement projects. Members are pursuing studies and developing new programs to broaden the knowledge base in palliative care, enhance providers' skills, improve treatment and redesign health care microsystems to expand access and raise quality.

Current and planned research and quality improvement projects include:

Marie Bakitas ARNP, DNSc, FAAN

  • ENABLE II Project, empowering cancer patients and families through education and advance care planning
  • Neuropathic pain following cancer treatment
  • Building systems, policies and procedures to make advance care planning and documentation of advance directives routine within DHMC

Margaret Bishop MSN, ARNP and Lisa Stephens MSN, ARNP

  • Comfort Pack Survey of regional hospice program practices for emergency medications in the home. Description of current practices and development of regional protocols and resources.

Ira Byock MD

  • Survivorship and Palliative Care at the Norris Cotton Cancer Center: Integrating patient-centered care within mainstream oncology.
  • Use of patient-generated health status information to expand the scope of care and advance patient-centered aspects of care for patients with serious illnesses, including life-threatening cancers.
  • Integrating palliative aspects of care and shared decision-making for patients with advanced illness and complex needs within regional Dartmouth-Hitchcock clinics.
  • Investigating the impact of life completion activities on quality of life of patients with advanced, incurable illness patients and experience of bereaved family members.

Yvonne Corbeil

  • The North Country Palliative Care Collaboration. A project to advance hospice and palliative care services in the North Country with co-investigators from the Weeks Medical Center in Lancaster, the Littleton Regional Medical Center and the North Country Home Health and Hospice in New Hampshire, and the Northeastern Vermont Regional Hospital and Caledonia Home Health Care and Hospice in St. Johnsbury, Vermont.

Regional Network and Program Development

Our Section reaches out to Dartmouth-Hitchcock Affiliates and other regional providers to enhance communication and continuity of care, teaching, sharing resources and collaborating in studies and developing programs to better care for seriously ill patients and families in northern New England.

The Palliative Care Service has begun extending technical assistance to support colleagues in expanding palliative care resources and capacity at the Norris-Cotton Cancer Center North, in St. Johnsbury, Vermont. In conjunction with clinicians in St. Johnsbury, we are also providing clinical consultation for patients cared for at NCCC North.

We have developed plans and a grant proposal for a three community North Country Consortium involving the hospitals and home health and hospice programs in St. Johnsbury, Vermont and Lancaster and Littleton, New Hampshire.

Striving to Deliver the Best Care Possible: One Person at a Time

Excellence in care is delivered one person and one family at a time. In active collaboration with our colleagues in the specialties and subspecialties of medicine, surgery, and pediatrics, the Palliative Care Service at DHMC strives to deliver the best care possible to each patient and family we serve. While keeping our clinical focus on the next patient and family we service, we recognize opportunities to study, innovate and contribute to improving care locally, regionally and nationally. In so doing we hope to "raise the bar," of expectations and outcomes for people who are seriously ill, those living with the frailty of advanced age, as well as for families in their care giving and in times of grief.

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Pediatric Anesthesia ~ Joseph P. Cravero MD, Director

Joseph P. Cravero, MD

The Children's Hospital at Dartmouth (CHaD) anesthesia care team continues to evolve and expand in order to meet the demands of a very active surgical and pain management program – over 2,900 anesthetics (involving all pediatric subspecialties) have been performed during the past fiscal year for children 18 years of age or under. The pediatric anesthesiology sub-section embraces the challenge of providing the required anesthesia care by incorporating the latest techniques for general and regional anesthesia as well as innovative anesthesia/sedation solutions outside the operating room.

While all members of the DHMC Department of Anesthesiology provide anesthesia for children, the pediatric anesthesiology section consists of a core group of eight anesthesiologists who have a unique commitment to perioperative pediatric care. This group provides anesthesia in the CHaD operating suites, pediatric and neonatal ICUs, and delivers sedation for procedures performed literally anywhere in the Medical Center through the PainFree Program. As part of a multidisciplinary effort with the post-operative nursing personnel and the pain service, the section has increased the overall use of regional anesthesia techniques (including epidural, caudal, and spinal modalities) for both operative anesthesia and postoperative pain management. Over ninety percent of pediatric urology surgical patients now receive a regional anesthetic of some type. The pediatric anesthesia group is investigating new modalities for assuring appropriate placement of regional catheters including the use of intraoperative epidurograms and ultrasound techniques. In addition, the pediatric team remains intimately involved (along with the Anesthesiology Department Pain Service) in the management of postoperative pain for inpatient pediatric patients and offers both inpatient and outpatient consultation for pediatric patients with chronic pain complaints.

The pediatric anesthesiology section continues to actively support the pediatric intensive care unit (PICU) and the intensive care nursery (ICN) at CHaD. Staff and residents from the anesthesiology department provide comprehensive airway management expertise as well as pain/sedation consultation for these units for both chronic and acute needs of the patients in these units.

Research projects in the areas of perioperative pain control and anesthesia emergence phenomena in children are ongoing. New investigations are looking at the use of ultrasound for placement of pediatric regional anesthesia. The section is part of a landmark multi-center study to determine the rate of complications related to regional anesthesia. In addition, we have received generous support from the National Patient Safety Foundation, Agency for Health Care Research and the NIH to pursue studies of safety and efficacy involving the delivery of sedation services for children. As well as ongoing funding to evaluate the ability of various providers to rescue patients from critical events related to sedation care using pediatric patient simulation technology. On the basic science front, section members are currently involved as co-investigators on an NIH sponsored research project to determine the nature and severity of traumatic head injury due to various mechanisms in children using a pig model. Finally, members of the section produce a newsletter regarding pediatric sedation that is delivered via the internet to over 5,000 pediatricians and anesthesiologists around the world. In the past year, members of the team have presented work in this area to the ASA Annual Meeting, the Society for Pediatric Anesthesia Winter meeting, the Post Graduate Assembly, and several national meetings on patient safety. The section has contributed to 10 book chapters involving topics from general care of pediatric perioperative patients to sedation of pediatric patients and post-operative care of pediatric surgical patients. One member has been primary editor on a textbook involving anesthesia for children with syndromes.

Besides these clinical and research efforts, the pediatric anesthesiology section continues to serve a clinical teaching role for medical students, pediatric residents, and anesthesiology residents. The staff takes pride in providing an aggressive on-line curriculum that addresses both the physiological and emotional considerations for the perioperative and operative care of the pediatric patient and family.

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Post Anesthesia Care Unit (PACU) ~ Carter P. Dodge MD, Medical Director and Theresa L. Vota RN, BSN, Unit Leader

The Post Anesthesia Care Unit (PACU) is the largest critical care unit in the Medical Center. Twenty-two beds with full non-invasive and invasive monitoring capability are used to provide post-surgical and other specialized care for over 11,000 patients annually. In addition to routine adult and pediatric anesthesia recovery services, the PACU provides a flexible overflow resource for Adult Critical Care, Cardiology, Same Day Surgery, and Pediatric Intensive Care. The Unit remains active in the acute pre- and postoperative management of renal transplant patients, as well as providing other specialized care for patients receiving electro-convulsive therapy, cardioversion and intra-arterial thrombolytic therapy, and non-surgical procedures requiring anesthesia.

Patient care is provided by registered nurses, aided by specially trained unit technicians. The PACU's management structure includes a Unit Leader and a shared governance council structure, supported by the Perioperative Management Team. The PACU staff is actively involved in peer review and other quality improvement activity, both its own and that of the Department of Anesthesiology. Ongoing efforts seek to critically examine the recovery process, with a goal of defining and creating an ideal path for safe and efficient recovery from anesthesia.

Recent scientific research efforts have included the effects of sevoflurane on children's emergence from anesthesia and optimal pediatric epidural solutions. We are currently planning efforts to improve the quality of the management of postoperative discomfort – pain, nausea, and vomiting.

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Pre-Admission Testing Program ~ Cantwell Clark MD, Director

The philosophy of the Dartmouth-Hitchcock Medical Center's Pre-Admission Testing Clinic is to insure that our patient population is ready for surgery. Our clinic is staffed by anesthesiologists, nurses, and office support personnel. The preoperative patient will come to the PAT clinic approximately two weeks prior to the scheduled surgery date. At the PAT clinic, all necessary paperwork and diagnostic information is completed. This includes possible lab work, EKG, and chest x-ray. In addition, all patients will take our state of the art health quiz. This is an automated survey, which asks simple medical questions designed to direct the ordering of appropriate preoperative lab tests. Also in the PAT center, nurses laboriously review medications with patients and enter these medications into the DHMC patient computer system (CIS). This is the main mechanism of how all caregivers know what medications patients are on.

We are proud of our detailed and comprehensive anesthesia consult service. When triggered by our surgical colleagues, the patient will meet with one of our Anesthesia Staff. The goal of this interview is to help manage complex pre-surgical medical dilemmas, such as the need for advanced cardiac evaluation and anticoagulation therapies.

We are also excited that we have instituted a system for bypassing healthy patients from the clinic. This has resulted in a reduction in waiting times, decrease stress on clinic resources, and allowed us to focus on the more critically ill patients.

Our future continues to look bright. We are expanding the role of the electronic record system, with automation of critical cardiovascular drug ordering. Other projects in the works include an internet based health quiz and an educational resource center for patients.

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Resident Education ~ Marc L. Bertrand MD, Program Director

The cornerstone of the Department of Anesthesiology's academic mission continues to be resident and medical student education. The training program as a whole grew substantially over the past two years, both in size as well as in the availability of clinical, educational, and research opportunities. We have integrated a number of enhancements into our educational program that have had a positive impact on both the Clinical Base Year and the Clinical Anesthesiology program.

The Clinical Base Year (CBY) has become the most competitive point of entry into anesthesia training programs across the country, including DHMC. Our RRC is slowly moving towards a mandatory, integrated four-year program and it appears that our ability to support a high quality Clinical Base Year for all residents entering the program will most likely be one of the criteria for RRC designation as a "Center of Excellence." In recognition of these factors, the decision was made to increase the size of our CBY group for the first time since it's inception in 1997. We listed five Clinical Base Year positions in the 2007 Match and once again filled all positions offered.

The most significant curricular change to the CBY over the past two years was the expansion of the Critical Care Medicine experience to two separate rotation blocks. The move to increased critical care exposure in the PGY-1 year was principally motivated by the consistently high quality evaluations of this specific clinical experience. It also helps address the increased amount of critical care time mandated by the new Program Requirements, scheduled to take effect in July 2008.

The CBY curriculum for the upcoming academic year is composed of forty-seven weeks of mandatory "core" rotations, two weeks of "elective" time and three weeks of much appreciated vacation. Core rotations include general internal medicine, cardiology, oncology, emergency medicine, general surgery, pediatrics, adult critical care medicine, clinical pathology, perioperative medicine, palliative care, and clinical anesthesiology. A selective option for the core pediatric requirement is offered allowing each resident to choose either the Inpatient Pediatric Ward or the PICU rotation. Elective options are available in adult critical care medicine, ENT, and various consult service electives including echocardiology, endocrinology, gastroenterology, infectious disease, nephrology, pulmonary medicine, and rheumatology. Interestingly, for the past two academic years all CBY residents have requested echocardiology for their elective time thus positioning themselves to take full advantage of the biweekly departmental TEE conference.

In the clinical anesthesia realm, case volumes available for resident training have continued to show steady growth of 5% per year with over 21,500 anesthetics provided by department members during FY '06. We have seen significant increases in the resident case experience with intrathoracic procedures, clinical neuromonitoring (EEG, SSEP, and MEP), TEE, and regional anesthesia in both the adult and pediatric populations. The resident group has easily satisfied all RRC minimum case requirements by the end of their CA-2 year for the past five years running, and I anticipate that our current group of CA-2 residents will achieve this goal yet again. The routine use of the resident cumulative case summary, updated on a monthly basis and appended to the daily case assignment sheet, has helped ensure that all residents complete training with an appropriate balance of case types and procedural experience.

The Regional Block rotation, under the direction of Dr. Brian Sites, is in its fifth year as a required CA-2 rotation. For the '06-'07 academic year virtually all of the CA-3 resident group elected to spend an additional two months on the Regional Block rotation. What was once a soft clinical experience for the resident group has become one of the top regional experiences in the nation. The resident on rotation is free from other OR duties and is expected to identify potential block candidates on the days' schedule, evaluate and consent the patient, and perform the regional block under faculty supervision. Care of the patient for the operative procedure is assumed by the anesthesia team in the OR and the resident is then available to perform another block. Our 2006 graduating class averaged 230 peripheral nerve blocks performed over the course of their training.

We saw our first two residents complete the CA-3 TEE track in the '03-'04 academic year. Each resident participant spent two months during their senior year focused on performing and interpreting TEE exams in the clinical setting as well as some additional time on the cardiac rotation. They logged 170 and 230 TEE exams respectively, attended the one-week SCA-sponsored instructional course, and sat for the certification exam in the spring of their CA-3 year. Although we had no senior residents interested in pursuing this opportunity in '04-'05, we currently have two CA-3 residents, Drs. Will Surber and Adrienne Williams, actively engaged in the TEE Track for the '06-'07 training year.

Two new rotations, the Airway Rotation and the Non-Operating Room Anesthesia (NORA) Rotation, have come online over the past two years. The Airway Rotation, under the guidance of Dr. Brian Spence and the airway group, is currently in its second year as a mandatory CA-1 experience. Resident case assignments for the one-month rotation are tailored to allow multiple opportunities to become more facile with a number of different airway management devices including the intubating LMA, light wand, Aintree intubation catheter, fiberoptic scope, Glidescopeฎ and Bullardฎ laryngoscope. The resident on rotation also spends a clinic day with one of our ENT surgeons performing topicalizations and indirect laryngoscopies on selected oral cancer patients.

The NORA rotation, under the direction of Dr. John Trummel, was introduced at the CA-3 level for the '06-'07 academic year. The provision of anesthesia services outside of the traditional operating room setting has grown at a double-digit pace for the past two years. The case types encountered during this rotation include GI endoscopy, diagnostic and interventional radiology, interventional cardiology and in vitro fertilization procedures. The remote nature of many of these sites, as well as the relatively high incidence of significant medical issues, poses a particular challenge for those providing off-site care. In addition, the off-site environment provides a rich arena for exploring issues related to systems-based practice.

The International Pediatric Anesthesia elective continues to provide our residents with the unique opportunity to practice anesthesia in a third world setting. We received prospective approval from the ABA in 1997 for this educational opportunity and were able to sponsor at least one trip/year since that time. Two recent additions to the faculty, Drs. Corey Burchman and Cantwell Clark, have joined our existing group of three faculty trip leaders allowing for an expansion of international opportunities for the resident group. In 2006, four residents participated in the international elective: Drs. Cain, Larson, Redborg, and Surber. Trip destinations included India, Laos, China, and Vietnam respectively. This has been an extraordinary opportunity for all involved and will continue to be offered, as the opportunity arises, and on a competitive basis, to interested members of our CA-2 and 3 resident groups.

The use of simulator-based training in the anesthesia program has continued to expand on a yearly basis. Last year's introductory tutorial program for CA-1 residents utilized the DHMC Simulation Center for the anesthesia machine review, ACLS certification, sedation certification, LMA training, and the difficult airway training session. The simulator is also being utilized to satisfy some of the airway competency criteria developed by Dr. Spence and the airway group. Additionally, all CA-1 residents spend one of their first days on the cardiac rotation working through the central line simulation program developed by Drs. Gregg Hartman and Steve Andeweg. For this coming year, all CA-1 residents will participate in a full-day training session in the Simulation Center prior to commencing their clinical activities.

The department continues to sponsor on-site Anesthesia Crisis Resource Management (ACRM) training for all anesthesia residents utilizing the space and equipment resources of the DHMC Simulation Center. The full-day ACRM1 experience is a mandatory part of the CA-2 curriculum, and in conjunction with the ATLS certification course, is designed to help residents improve their crisis management and team building skills. ACRM2, a follow-up course for CA-3 residents, was recently introduced for the '06-'07 training year. The ACRM2 course is intended to provide CA-3 residents with the opportunity to review critical event management principles and practice their application in the simulated setting, thereby reinforcing the learning achieved during the ACRM1 course. A secondary goal of ACRM2 is documentation that all resident participants have achieved a minimum level of competency in the multidimensional aspects of ACRM. Competency is assessed utilizing both a team performance self-assessment, as well as individual performance assessments provided by the course faculty.

Resident involvement in departmental research has increased dramatically over the past two years. The introduction of our quarterly research conference, providing a venue for the presentation of projects in various stages of development to the department for discussion, seemed to be the catalyst for increased resident interest. We continue to support all residents interested in the Clinical Scientist Track (CST). Dr. Tabitha Washington did a superb job with her CST project titled "A systematic assessment of the quality of most commonly used chronic pain websites", completed over the course of the '05-'06 academic year. We currently have two CA-2 residents, Drs. Koff and Chinn, who have been working on CST projects as CA-2 residents.

Dr. Kirsten Redborg, another member of the CA-2 class, was recently accepted into the CST for her CA-3 year. Dr. John Trummel recently completed the Leadership Preventive Medicine (LPM) program, and joined the Department of Anesthesiology at the faculty level. Dr. Julie Sorensen is in the process of completing her practicum year after integrating a Pain Management fellowship into her LPM program. Dr. Xan Abess is the newest member of the LPM program. Xan is currently in his CA-1 year of training and is looking to complete his clinical anesthesia training prior to commencing with his MPH studies.

At the administrative level, support staff coverage of residency-related issues has been augmented to the 1.5 FTE level. Four new Associate Directorships were introduced in 2006 to increase oversight and focus improvement efforts in the areas of resident education, simulation training, portfolio development, and resident recruitment. The faculty members that have taken on these additional roles include:

Steven Andeweg, MD: Associate Director, Simulation Training
Kathleen Chaimberg, MD: Associate Director, Resident Education
Lisabeth Maloney, MD, MS: Associate Director, Portfolio Development
Jennifer O'Flaherty, MD., MPH: Associate Director, Resident Recruitment

The impact of their efforts in support of the program can already be seen in many of the enhancements and successes mentioned above.

We remain committed to nurturing a dynamic environment that promotes the learning, teaching, and practice of the clinical, intellectual, and ethical aspects of our specialty. Given the extraordinary level of faculty commitment to resident education, our outstanding facilities, and increasingly diverse clinical caseload, I believe that our program is well positioned to be recognized as a "Center of Excellence".

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Regional and Orthopedic Anesthesia ~ Brian D. Sites MD, Director

Brian D. Sites, MD

Our goal is to provide safe and effective pain relief for our community. We are committed to using the latest in ultrasound and imaging technology to achieve this end. Through non-opioid based regional techniques, our primary objectives are to optimize patient satisfaction, minimize morbidity, and improve perioperative efficiency.

There has been tremendous activity over the past two years in our orthopedic and regional anesthesia program. With the addition of many new talented surgeons, we have expanded our services to meet the demands of new techniques and increased volumes.

First and foremost, our internationally recognized DHMC regional anesthesia service has expanded its daily team to include one fellow, two residents, three nurses, and a staff anesthesiologist. We now have five fully monitored and equipped procedure bays to facilitate our expanding case numbers. We offer ultrasound-guided pain relieving procedures for a wide variety of orthopedic, plastics, vascular, and general surgical patients. We have aggressively expanded our continuous peripheral nerve block repertoire to include supraclavicular and interscalene catheters. Our regional anesthesia fellowship is entering its third year with competitive candidates applying from many outstanding institutions.

We have increased our block volumes to 180 per month. Dartmouth-Hitchcock Medical Center Anesthesiology residents are graduating in the 100th percentile for regional anesthesia cases performed. During their rotation on the service, residents have no official OR responsibilities. Instead, they focus on the science of peripheral regional anesthesia. As part of the month long rotation, each resident participates in a research project. These projects have ranged from database analysis to national presentations.

Our research activities center on the utilization of ultrasound to facilitate the performance of regional anesthesia. Current areas of active investigation include:

  1. Can ultrasound replace the nerve stimulator?
  2. Creation of a training intervention to minimize the ultrasound guided regional anesthesia learning curve
  3. Defining the competencies involved in ultrasound guided regional anesthesia
  4. Categorizing ultrasound artifacts associated with regional anesthesia
  5. Novel approaches to the ankle block
  6. Peripheral nerve tumor imaging with high frequency ultrasound
  7. Development of probe stabilizing devices
  8. Development of training software
  9. Development of new intrathecal catheters
  10. Maintenance of a prospective database that currently has over 5000 patients
  11. Identifying the reasons for block cancellations
  12. Improving the efficacy of thoracic epidural performance

Current areas of excitement include the unveiling of our home based catheter service. Starting in March 2007, we now allow certain patients to go home with indwelling peripheral nerve catheters. This allows many days of pain relief in comparison to the 18-24 hours offered by single injections. Finally, an exciting area of professional development into 2008 and 2009 will include the expansion of the regional anesthesia services for breast surgery.

Regional Fellowship

The Regional Anesthesia Fellowship is a one-year non-accredited program combining six months of regional block anesthesia training and six months as junior staff in the Department of Anesthesiology. When training in our regional anesthesia suite, the fellow will have no operating room responsibilities. As a junior staff member, the fellow's responsibilities will include performing solo cases as well as supervising residents and CRNAs.

The regional anesthesia suite is a dedicated unit located adjacent to the operating theatre. We have five fully equipped nerve block rooms. We have the latest in high-resolution ultrasound and nerve stimulator technology. The fellow will be responsible for performing and supervising both peripheral and neuraxial blocks.

Our main area of research interest is the role of ultrasound in nerve localization and novel intrathecal catheters. The fellow will have the opportunity to participate in various ongoing clinical projects.

Since the inception of the Fellowship in July 2005, we have had three successful graduates, and have two fellows due to graduate the summer of 2008.

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Research in Anesthesia ~ Mark P. Yeager MD, Director

The Anesthesia Research Laboratory maintains a highly productive basic science and clinical research enterprise. Our basic science research is focused on the pathophysiology and treatment of acute and chronic pain while the clinical research investigates mechanisms and control of systemic inflammatory responses to trauma and infection. The quality and importance of this research are underscored by the many grant awards received by Joyce DeLeo, PhD from the National Institutes of Health, as well as private foundations, and by the presentation of the William L. Garth endowment to Mark Yeager, MD in recognition of his research accomplishments.

The basic science program is an integrated effort directed towards understanding interactions between pain, pain treatments, and the immune system. Current investigations of mechanisms that lead to chronic neuropathic pain have led to important insights into spinal responses to pain and to potential therapeutic interventions. These investigations focus on how cells in the spinal cord and cells of the immune system respond in vitro and in vivo and on the use of novel treatments to modify cellular responses and treat painful neuropathic conditions. Among their many achievements, Dr. DeLeo and her colleagues have demonstrated that central neuroimmune activation, as defined by increases in spinal cytokines and glial activation, and inflammation play a key role in generating and maintaining chronic pain after peripheral nerve or central nerve root injury. Dr. DeLeo's research has important clinical implications for both prevention and treatment of chronic neuropathic pain including such widespread conditions as chronic lumbar radiculopathy.

The Research Laboratory also supports ongoing clinical studies based in the Department of Anesthesiology. These investigations form a unified effort directed towards understanding the physiologic impact of trauma and sepsis on patient outcomes with special reference to glucocorticoid control of systemic inflammatory responses. We have recently completed studies to investigate glucocorticoid control of systemic inflammatory responses in normal individuals, during and after cardiac surgery, and during and after systemic sepsis. These studies have added new and important data to this growing literature. Other recent publications have tested the effect of transient systemic inflammation on cardiac, hormonal, and leukocyte functional responses with special emphasis on the emerging interest in loss of physiologic variability as a sign of disease. The latter study is part of an emerging field that uses mathematical models of non-linear dynamics to test for increased functional regularity during systemic diseases as a way to evaluate and potentially treat disease states, such as sepsis, that have remained resistant to standard therapies. This model may be particularly applicable to patients who are cared for by the Critical Care Medicine specialists in the Department of Anesthesiology.

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Trauma Anesthesia ~ Jeffrey S. Shiffrin MD, Director

Trauma anesthesia, though not a formal clinical rotation, is a crucial component of resident education and experience. Trauma anesthesia is often overlooked, possibly because traumatic injuries occur sporadically, intermixing erratically with the scheduled activities of the day. However, the impact of trauma has enormous socio-economic implications. CDC data from 2003 show accidents are the fifth leading cause of death in all Americans, and the primary cause of death in individuals from 1 to 35 years of age. Unintentional injury accounts for more years of potential life lost (YPLL) before age 65 than any other illness. 2.22 million years in 2004. The death rate from unintended injury in 2004 was 37.7 per 100,000, half of what it was in 1950, the rate has been increasing yearly since 1992.

In 2004, there were 112,000 unintentional injury deaths. The estimated average cost per injury death was $1.1 million in 2005. Economic costs are over 100 billion per year. Clearly, trauma has a huge impact on society.

Because of the individual and socioeconomic impact, resident training in trauma anesthesia is valuable in saving lives and returning traumatically injured individuals back to a good quality, productive life. The curriculum includes didactics on mechanisms of injury, shock/trauma physiology, and socioeconomic impact. Specific objectives include management of traumatized airway, homeostasis and uncontrolled hemorrhage, coagulation and fibrinolysis, metabolic derangement resulting from shock, hypothermia and rapid resuscitation, and finally the impact of activation and release of various mediators of the inflammatory cascade. Dartmouth-Hitchcock Medical Center's trauma committee is comprised of physicians from General Surgery, Orthopedics, Neurosurgery, Pediatrics, Anesthesiology, Emergency Medicine, as well as representatives from Nursing, Hospital Administration, and D-HART (Dartmouth-Hitchcock Air Rescue Team), thus providing a multidisciplinary approach to overall trauma management.

In addition to the trauma lecture series, all residents take the ACS, Advanced Trauma Life Support course, and function as an integral member of the Trauma Team in the emergency department and Ors. All residents participate in the crisis management simulation course. Clinically, all residents receive their fare share of adult and pediatric trauma cases, primarily while on call. Generally, these are the times of the most intense interactions between staff and residents. DHMC is the regional Level 1 trauma care facility with over 1200 D-HART helicopter transports per year and it continues to grow each year. There is not a lot of knife and gun club activity in northern New England, but more than enough blunt traumas to provide an intimate understanding of the impact traumatic injury has on the human body.

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Vascular Anesthesia ~ Kathleen Chaimberg MD, Director

Kathleen Chaimberg, MD

Working with a group of nationally recognized leaders in the field of vascular surgery, our residents enjoy the benefits of being exposed to the leading edge of surgical technology while caring for some of the most challenging and medically complex patients. Of note, Dartmouth is one of only five centers in the country performing endovascular procedures to treat aneurysm or dissection of the thoracic aorta. These cases are, by definition, complex and often involve the use of TEE as well as lumbar drain placement for CSF pressure monitoring and management. In addition, DHMC is a participant in national clinical trials evaluating the efficacy and outcomes of carotid stenting in the awake patient.

Junior residents rotating through the vascular rooms have the opportunity to gain considerable knowledge and confidence as they design, implement, and manage an anesthetic plan for patients who often have multiple major co-morbidities. Senior residents often elect to spend several months during their CA3 year caring for these challenging patients, refining their clinical skills of preoperative evaluation and perioperative management as they prepare to leave residency and embark upon their own careers as "consultants" in anesthesia.

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