gett DEPARTMENT OF ANESTHESIOLOGY NEWSLETTER Fall Inside This Issue

gett DEPARTMENT OF ANESTHESIOLOGY NEWSLETTER Fall 2008 Inside This Issue Editor’s Note Chair’s Message Pediatric Critical Care: What’s New? ICU Updates Pre-Anesthesia Service for the 21st Century Acute Pain Management Service New 23 Hour IOU Advanced TEE Training Program A Note of Appreciation – Thomas Grove, MD The New Hospital in Photos Our Flourishing CRNA Program CA-1 Rotation at Olive View Anesthesiology Update 2008 CME Program Update on the UCLA Simulation Center Catching up with our Senior Faculty Graduation 2008 Class of 2009 Dr. Robert Kaufman Retires NEWSLETTER COMMITTEE Patricia A. Kapur, M.D., Chair Sharyn Roberts, Department Administrator Wendy Ren, MD and Bita Zadeh, MD, CoEditors Sara Faulds, Managing Editor and Art Director Wendy Ren, M.D., Bita Zadeh, M.D., Samuel Wald, M.D., UCLA Simulation Center, Sara Faulds, Lucelva Mendez, Photographers Departmental Website: http://www.anes.ucla.edu/ Dr. Nina Shapiro, pediatric ENT surgeon, and Dr. Adria Boucharel and Dr. Swati Patel, caring for a bronchoscopy patient Dr. Ryan Crowley teaching TEE techniques to Dr. Corey Downs (CA-2) We are very excited to share with you this year's issue of Editors Note the UCLA Department of Anesthesiology Newsletter. It is filled with new developments in our ever expanding department and ongoing achievements in research, academics and patient care. This issue is also filled with photographs of our beautiful new Ronald Reagan UCLA Medical Center as a backdrop and a special photo gallery of some of our senior faculty. We hope you enjoy this look into the daily life of the UCLA Department of Anesthesiology! UCLA ANESTHESIOLOGY Patricia Kapur, M.D. By Patricia Kapur, M.D. CHAIR’S MESSAGE The Department is also very proud to bring you news of our major new Simulation Education Center, for which faculty member Yue Ming Huang, Ed.D., will be the Administrative Director, working in collaboration with the center's Medical Director, Randolph Steadman, M.D. A tremendous amount of planning has gone into conceptualizing this center and bringing it to fruition, including obtaining generous philanthropic donations, as well as partial support from a large State of California telemedicine grant. In addition, UCLA's Simulation Center has been approved by the ASA Committee on Simulation to offer simulator training programs in fulfillment of the American Board of Anesthesiology's Maintenance of Certification in Anesthesiology requirement. Deborah Dach, CRNA, MS, has written about the important growth and development of our CRNA team. The Department has active educational collaborations Dr. Fahimeh Ziadlorad, Shelley Gierat, with the CRNA and Dina Hunt, CRNA Schools of Nurse Anesthesia at USC, as well as with the School of Nurse Anesthesia of Southern California Kaiser/Cal State Fullerton. James Moore, M.D., the Administrative Director of our Preoperative Evaluation Suite (PES), has written about the evolution of our PES to be more comprehensive as well as to better take advantage of It is a pleasure for all of us in the Department of Anesthesiology, David Geffen School of Medicine at UCLA, to present this newsletter to update our alumni and friends of the Department about the exciting developments of the past year. For those of you who are graduates of our training program, you will enjoy reading articles about the new residency rotations in our liver transplant and affiliated West Los Angeles VA SICU's, written by Dr. William Thompson, Chief Resident, and Dr. Robert Pousman, Director of the WLA VAMC SICU, respectively. Rima Matevosian, M.D., Chief of Anesthesiology at Olive View - Los Angeles County hospital in Sylmar, California, has written an article describing the new regional anesthesia rotation which her department developed for our CA-1 residents and inaugurated during the last academic year. Now that we have moved into our beautiful and modern Ronald Reagan - UCLA Medical Center, we are offering a new patient care paradigm for 23-hour patient stays within our pre-operative preparation and phase 2 recovery suite. This new "unit within a unit" is called the "IOU" or Interventional Observation Unit. Faculty member Victor Duval, M.D., has helped to plan the unit and has written an explanatory article about it. Also in this issue, Judith Brill, M.D., Professor of Pediatrics and Anesthesiology, and Vice Chair for Clinical Affairs for the Department of Pediatrics, shares the developments in the Pediatric ICU, where our residents rotate. Dr. Siamak Rahman's article updates us all on the Westwood Acute Pain Service for which he is our Service Chief. Dr. Ali Salehi's article describes our new post-graduate hands-on TEE training opportunity that Dr. Salehi has developed with the cardiac anesthesiology faculty. 2 UCLA ANESTHESIOLOGY “Dr. Grove has been deservedly touted as the "unsung hero" of the Department” information technology to obtain the best preoperative "look" at our patients without having to require them to physically come to UCLA from the broad referral geography which we serve. We also are proud to pay tribute, in Dr. Harvey Rosenbaum's article, to Robert Kaufman, M.D., Clinical Professor of Anesthesiology and Vice Chair for Academic Affairs, who is retiring after 31 years of dedicated service to UCLA. Dr. Kaufman has directed the faculty's academic advancement process for many years. He is an astute clinician, a dedicated educator, and has been a contributor to investigative research in past years. We are fortunate that Dr. Kaufman is continuing to work part-time in the Department following his June 2008 retirement. OR Room 1 the past 12 years, as well as a period of some years prior to that, Dr. Grove has managed all of the clinical staff assignments, both the monthly assignments and vacation schedules, as well as coordinating the Main OR daily assignments with the manpower needs of Santa Monica-UCLA Medical Center, the Medical Plaza Surgery Center, the Jules Stein Eye Institute and the ten or so out-of OR sites for which our Department provides daily clinical coverage. Dr. Grove has been deservedly touted as the "unsung hero" of the Department, but all of us who are touched by his talent and good will in making all of our assignments, know well how important his efforts are to the smooth running of the Department. In addition, for the enjoyment of the Alumni, Drs. Wendy Ren, Sam Wald and Bita Zadeh have provided a photo gallery with captions, of some of our senior faculty. We appreciate all the contributions our senior faculty have made to the clinical and academic life of the Department over so many years. Elsewhere on our website [http://www.anes.ucla.edu/], we hope all of our readers will check out the accomplishments of our Division of Molecular Medicine which is focused on cardiovascular medicine. The DMM has achieved exceptional NIH and other national funding, such as AHA, and has a regular stream of outstanding published manuscripts. We look forward to seeing our alumni at our daylong annual November CME meeting, "Anesthesiology Update 2008", to be held on November 15, 2008, at the Bradley Center on the beautiful UCLA campus. The meeting is chaired by Mitchell Lin, M.D., and Richard Hong, M.D., and will have lively and timely topics to update all of the attendees with valuable information for their practice.² Drs. Jordan Miller, Kianusch Kiai and Marshal Kaplan in the new hospital Alumni will also enjoy reading Dr. Michael Sopher’s article commending Dr. Tom Grove, for Dr. Grove's unique role in our Department. Continuously for Please visit our website at http://www.anes.ucla.edu/ for the latest departmental information 3 UCLA ANESTHESIOLOGY PICU room in RRUMC PEDIATRIC CRITICAL CARE: WHAT’S NEW? supporting children with traumatic brain injuries (TBI). Continuous EEG monitoring also plays a role in the care of these children. New therapies for pediatric patients with TBI include a variety of modalities to cool the patient, vigorous support of the systemic blood pressure, use of biomarkers to determine the extent of the injury and the enhanced monitoring options noted. We have several other devices that now assist us in the care of PICU patients, including the use of the transcranial Doppler to assess children with nontraumatic intracranial strokes or bleeds. We use ultrasound guidance more frequently to improve our success in placing venous and arterial lines in our smaller patients. Additionally, we have a new device for removing fluid continuously as an ultrafiltrate via a percutaneously inserted central catheter (PICC line) or peripheral intravenous lines. This system, called Aquadex, allows us to remove fluid without inserting a large Muharkhar catheter and is more hemodynamically well tolerated than hemodialysis or continuous veno-venous hemofiltration. The Pediatric Critical Care Division remains actively involved with clinical and laboratory research. On the clinical side we remain a founding member of the Collaborative Pediatric Critical Care Research Network, an NIH funded group of six PICU clinical research centers spread throughout the country. Our most recent study, the CRISIS Prevention Trial, looks at the use of immune modulating agents (metoclopramide, zinc, selenium, and glutamine) for the prevention of nosocomial sepsis and infection in high risk PICU patients. Other ongoing studies include investigating parental bereavement after a child’s death, a morbidity outcome tool, an electronic continuous insulin-dosing tool, various ventilatory algorithms and a data collection of all PICU admissions in the various centers.² By Judith Brill, M.D. The UCLA PICU provides multidisciplinary care to critically ill and injured pediatric patients with medical and surgical problems. Formerly housed in two geographically separate units (a 12 bed and an 8 bed unit), we now have a new, state of the art PICU at Ronald Reagan Medical Center. This new unit has 24 beds; 6 beds will be dedicated to patients undergoing cardiac surgery procedures and the remaining 18 beds will continue to house all other critically ill children. In recognition of the limited pediatric beds available in the replacement hospital, the general pediatrics service moved in April 2008 to Santa Monica-UCLA. It is essential that critical care services are also available in that setting, so a 4 bed PICU opened in May 2008, with a 10-12 bed unit to follow in approximately two years. It is clear that competition for PICU beds is fierce, because so many UCLA programs now require intensive care for their patients, including pediatric trauma, liver and small bowel transplantation, epilepsy surgery, congenital heart surgery, orthotopic heart transplantation and craniofacial surgery, among others. Pediatric Critical Care will certainly have an improved environment in the new hospital: all rooms are private and spacious, with natural light and windows. A family member is now able to room-in with a sick child, thus supporting our mission to provide family-centered care to all children. There has been an explosion of new monitoring options in ICU care for children, particularly for those with traumatic and non-traumatic brain injuries. We now employ tissue oxygen monitoring, as well as cerebral and somatic oximetry when 4 UCLA ANESTHESIOLOGY ICU UPDATES 7 East ICU By William C. Thompson, IV, M.D. One of the recent additions to the UCLA Department of Anesthesiology’s training in critical care is the 7 East Intensive Care Unit. The rotation, affectionately known as the LICU, is a joint venture with the Department of Surgery and involves the care of end stage liver disease patients at all stages of the transplant continuum. As such, the patient base is a mix of pre-transplant patients (including both acute hepatic failure and chronic liver disease) and post transplant patients who range from those immediately post-op to those who have received liver transplants in the past and again find themselves in need of ICU level care. Not surprisingly, the rotation is a demanding one, where anesthesiology residents become the primary caretaker of some of the most critically ill patients in the hospital. Residents quickly gain experience managing multi-system organ failure, including ventilatory management, renal replacement therapy and blood product therapy. As well, there are ample procedural opportunities, which can be more complex than the situation usually faced in the operating room, given the patient population’s inherent coagulopathy secondary to their hepatic failure. Early experience in performing intubations and airway management in the non-operating room environment is, as well, a common feature of the rotation. Given the challenging nature of the end stage liver disease patient population, and the fact that this type of experience would be near impossible to replicate at most other academic medical centers in the United States, the educational potential of this experience is considerable for anesthesiology residents. Of course there is another advantage as well, despite frequently long days on service, the rotation is organized such that anesthesiology residents do not take in house call for this month. And there is nothing like being able to return home at the end of a long, taxing day.² Dr. Gundappa Neelakanta with Dr. Jacques Neelankavil (CA-2) New VA ICU Rotation By Robert Pousman, M.D. The New Year brought many changes. including our new surgical ICU rotation to the West LA VA. No longer are our residents traveling to Long Beach for this experience. Starting January 14th, two residents began rotating on a 4-week block in a newly created service to the VA. The residents function on this new ICU service as collaborating consultant intensivists that participate in the care of all surgical ICU patients. They are joined by dedicated ICU attendings to round out the team. The ICU attendings have been three anesthesia faculty members, Dr. Michelle Braunfeld, Dr. Maggy Riad and Robert Pousman, D.O., along with two surgical attendings, Drs. Stelzner and Hirai. Additional anesthesiology faculty members Dr. Stephen Eskaros. and Dr. Anahat Dhillon, will replace the surgeons in Fall 2008. Surgical subspecialities including cardiothoracic, vascular, neurosurgery, general surgery, head/neck and oncologic services provide patients for ICU care. The ICU residents gain valuable experience in perioperative medicine as they assist in the management of respiratory care, ventilator management, hemodynamics, fluids and electrolytes, acid/base, nutrition, infectious disease issues, etc., as well as various invasive procedures. This is combined with bedside teaching and lectures. The residents also present one brief lecture during their rotation at the West LA VA department of anesthesiology morning conference. This pioneer program has brought new enthusiasm to our department for a greater role in participating in intensive care/perioperative medicine and allowing anesthesiologists to contribute further to a specialty which historically they helped create.² 5 UCLA ANESTHESIOLOGY Dr. Johnathan Pregler and Sandra Cano, RN By James Moore, M.D. PRE-ANESTHESIA SERVICE ST FOR THE 21 CENTURY next to the Ambulatory Surgery Center. There to greet patients are clinic staff members Belinda Curry and Carlos Eason. They check in clinic patients and assist them with completing their paperwork. Some of the essential functions of the Preanesthesia Evaluation Service include communicating with other physician offices to coordinate appointments and retrieve medical records, and Ms. Curry and Mr. Eason do much of this important work. Usually a nurse or an anesthesiology resident physician performs the patient evaluation. The nurses who keep the service running smoothly include Nancy Dolan, Anne Horne and Cindy Pearson. Although much of their time is spent gathering Preanesthesia nurses Cindy Pearson (l) the patient and Anne Horne (r) collaborate on a history and patient’s medical work-up performing a physical examination during the patient interview, a significant portion of their work occurs outside the interview room and even after the patient leaves, seeking and collating records from other offices and outside facilities in order for the information available on the day of surgery to be complete. Although it is essential to the safe administration of anesthesia care, the preanesthesia evaluation has become increasingly challenging. In contemporary medicine, most patients undergoing elective surgery are not admitted ahead of time. Typically, a patient arrives on the day of surgery shortly before the scheduled operation. The wide variety of operations and procedures done under anesthesia care at the UCLA Medical Center includes some of the most complex surgical procedures, and many of our patients are medically complicated, making the preanesthesia evaluation particularly challenging. Detailed patient information helps the anesthesiologist optimally plan the patient’s anesthesia care. The UCLA Preanesthesia Evaluation Service works to ensure that patients have appropriate diagnostic testing and medical management prior to surgery. The service also makes important medical records, including outside documents, available to caregivers on the day of surgery. Historically, the UCLA Preanesthesia Evaluation Service processes between 4,000 and 6,500 patients per year, including patients having outpatient surgery, major inpatient operations, and diagnostic and therapeutic medical procedures. Patients having outpatient surgery tend to be healthier than those needing admission after surgery, and inpatient operations with significant perioperative morbidity often require a more extensive medical work-up. Thus the Preanesthesia Evaluation Service sees approximately 80% of patients having surgery in the Main Operating Room Suite at Westwood and roughly 20% of patients from the Ambulatory Surgery Center. UCLA’s Preanesthesia Evaluation Suite is located in the 200 Building of the Medical Plaza at Westwood, 6 UCLA ANESTHESIOLOGY “…the Preanesthesia Evaluation Service is looking toward the future and is undergoing a paradigm shift in its operations.” Nurse Practitioner Lisa Tritico and Nurse Cindy Pearson Residents in anesthesiology rotate through the Preanesthesia Evaluation Service as part of their education. While working on the service, residents learn to assess the patient’s preexisting medical conditions along with the proposed surgery to direct further diagnostic testing and to optimize the patient’s preoperative medical status. Residents learn to discuss patients’ concerns and their options for anesthesia care and pain control, and they gain experience in explaining to patients what to expect during the course of anesthesia care. Nurse practitioner Lisa Tritico oversees nurse management for the clinic. She also assists the nurses in fulfilling clinical duties, and she takes an active role in developing and maintaining relationships with other physician offices and their personnel. An attending anesthesiologist works in the clinic and reviews each patient evaluation, reassessing the work-up as new information is obtained until the evaluation is complete. The clinic faculty members also create the curriculum for the residency rotation and develop clinical preanesthesia protocols, such as the department’s new guidelines for noninvasive cardiac testing for elective surgery. Full-time faculty anesthesiologists who have recently staffed the Preanesthesia Evaluation Service include Dr. Robert Kaufman, Dr. Parisa Partownavid, Dr. Johnathan Pregler and Dr. Fahimeh Ziadlourad. The Medical Director is Dr. Harvey Rosenbaum, and the Administrative Director is Dr. James Moore. With the recent move of Westwood’s inpatient services to the new Ronald Reagan UCLA Medical Center, the Preanesthesia Evaluation Service is looking toward the future with a paradigm shift in its operations. As healthcare systems strive for ever-increasing efficiency, minimizing unnecessary delays and last-minute cancellations on the day of surgery is critical. To this end, the UCLA Preanesthesia Evaluation Service is working to process even more patients. To accomplish this and also considering that a clinic visit for preanesthesia consultation may be inconvenient to the patient, and the essential information that impacts the preanesthesia decision-making is the medical history, obtainable without having the patient physically present - the Preanesthesia Evaluation Service is transforming into a “virtual” clinic. While selected patients will still be seen in person, in the future most evaluations will not require the patient to appear in the clinic, but will Clinical Staff Belinda Curry and Carlos Eason involve reviewing medical records, calling the patient by telephone and new innovations such as having a patient complete the medical history questionnaire online, either at home or in a surgeon’s office. Scheduling fewer patient visits while creating a comprehensive, protocol-driven evaluation process using electronic documentation tools should allow the service to process more patients in a consistent fashion, optimizing perioperative patient safety and reducing problems associated with delays and cancellation of surgery.² 7 UCLA ANESTHESIOLOGY Drs. Mitchell Lin, Siamak Rahman and James Moore ACUTE PAIN MANAGEMENT SERVICE AT UCLA MEDICAL CENTER By Siamak Rahman, MD The Acute Pain Service, a division of the Department of Anesthesiology, was established many years ago, but has undergone major changes in recent years. The Acute Pain Service at the Ronald Reagan UCLA Medical Center is now committed to providing our patients with multiple options for postoperative pain management to help them to recover from their surgeries. This task is possible to achieve because of the help from our residents, other faculty members and CRNAs, who enthusiastically inform us of potential candidates who would benefit from our services. We carefully select our patients by going over the surgical schedule for the following day or by referral from the surgical team or our colleagues in the Preanesthesia Evaluation Service (also referred to as PES). Complexity of surgeries, multiple co-morbidities and patients with special needs, such as those who are currently taking multiple pain relievers or those who have known sensitivities to certain pain relievers, requires that we carefully customize our plan for each patient. The Acute Pain Service (APS) is comprised of four faculty members, one nurse practitioner and two residents who rotate through the service. The faculty generally rotate on a weekly basis and the residents rotate every four weeks to provide continuity of care. As the number and variety of procedures that we perform on the service has increased dramatically over the past few years, it follows that our residents are having a much greater and more comprehensive experience by the end of their rotation. The APS offers pain management on a 24-hour basis for postoperative patients. The two residents alternate taking calls from home, and their efforts in the post-operative management of patients with epidural catheters is the main reason for the high satisfaction among our patients and our surgical colleagues. Dr. Oren Erlichman (CA-2), Tsione Holly, Nurse Practitioner, Dr. Siamak Rahman, Dr. Parissa Partownavid and Dr. Jamie Eto (CA-3) Tsione Holly, a nurse practitioner, joined our team in November 2007. She has proven to be very helpful in orienting the new residents on the service, maintaining continuity of care, decreasing the residents’ workload during day shift and building working relationships with other nurses on different services. The residents complete their rotation with an understanding of how to assess and manage acute post-operative pain, trauma pain, cancer related pain and acute exacerbation of pain in patients with chronic pain who need to be admitted to the hospital. They become competent in the pharmacologic management of pain as well as interventional pain management. We would like to thank our chair, Dr. Kapur, for all her support and vision, which encouraged us to improve our service to become a model inpatient pain service.² 8 UCLA ANESTHESIOLOGY NEW 23-HOUR INTERVENTIONAL OBSERVATIONAL UNIT By Victor Duval, M.D. The new Ronald Regan UCLA Medical Center is designed to be a state of the art facility with the ability to offer patients the latest in cutting edge treatments and procedures, with the goal of minimizing recovery time so that they may return to their normal daily activities faster than ever before. This paradigm shift requires a new approach to the management of patients within the hospital. An essential component to this approach is served by a 12 bed unit for overnight observation of patients undergoing minimally invasive and various simple surgical procedures. The Interventional Observation Unit will accommodate patients in a centralized location where they can be monitored by a team of dedicated, experienced nurses for a period of less than 24 hours after their procedure. Unlike observation areas in outpatient surgical centers, this unit will allow physicians to order and follow up any tests that are normally performed only on inpatients; from routine blood tests to advanced imaging, such as echocardiography and magnetic resonance. Although the primary responsibility for the patient’s management will rest on the admitting physician, The Department of Anesthesiology provides oversight for this unit much like an open intensive care unit model. This is to ensure that the level of care is continuously maintained at the highest level and that the daily operational components run smoothly at all times. In short, the Interventional Observation Unit has the potential to ultimately allow physicians to care for their patients with an unprecedented level of efficiency.² Dr. Wendy Ren and Angela Culvert, RN, AN-1, Charge Nurse of IOU RRUMC OPERATING ROOM OPEN HOUSE SATURDAY, OCTOBER 25, 2008 11:00 a.m. – 2:00 p.m. • • Simulator Demonstrations in the Main OR area Vendor Stations with product demonstrations Trained dogs used to comfort pediatric patients available in kids petting area • The Open House will be held in the RRUMC OR area. Please take the West Elevator to the third floor. Light refreshments will be served in the Staff Lounge on the third floor. PARKING: Go to the information booth on Westwood Boulevard for parking instructions for Ronald Reagan UCLA Medical Center Alumni, update your mailing information at: http://www.anes.ucla.edu/alumnimailinglistinfo.html 9 UCLA ANESTHESIOLOGY Drs. Ali Salehi and Dorothea Hall assessing TEE ADVANCED TEE TRAINING PROGRAM enrolled for a minimum three-month period, two days a week that can be extended, based upon the individual’s progress and need. There will be a maximum of two trainees at any given time. The program is targeted for practicing anesthesiologists and critical care physicians in practice. They must be board eligible/certified and have an active license. It is expected that the applicants have some experience in the use of echocardiography. Our first trainee started in Nov 2007. By Ali Salehi, M.D. with contributions by Wendy Ren, M.D. In recent years Transesophageal Echocardiography has begun to play a more integral role as a monitoring as well as a diagnostic tool, not only in the care of patients undergoing cardiac surgery, but also critically ill patients in the ICU and patients undergoing non cardiac surgery. Subsequently, physicians in the field of anesthesiology and critical care feel the need to develop the skills to perform a full TEE exam, interpret the findings accurately, use the resulting information to make a differential diagnosis, assess their management strategy and help guide their treatment plan. Since many of these physicians are already in practice and do not want to do a full fellowship in cardiac anesthesia, the idea of developing a program in order to fulfill this need was born. Since we not only perform TEE studies in the operating room, but also in the Cardiac Surgery ICU and the Electrophysiology Lab, the trainees are exposed to a wide variety of cases. Electrophysiology lab constitutes all the following procedures: The Advanced TEE a-fib/flutter, SVT, VT training program at ablations, UCLA was started by Dr. cardioversion, Aman Mahajan and Dr. pacer/defibrillator Ali Salehi in response to placement. We increased requests from perform TEE for any practicing physicians for procedure where it is a TEE training program. indicated - mostly aThis advanced TEE fib/flutter ablations training program offers Drs. Scott Swenson and Damon Dertina, Cardiac Fellows, and and cardioversions. the trainees an Dr. Talin Evazyan (CA-1), doing TEE in Cath Lab Additionally, UCLA opportunity to perform has a large adult and hands on TEE studies pediatric congenital cardiac population and trainees under the supervision of division of cardiac can get experience in congenital cardiac patients if anesthesia faculty and to also attend the didactic they show interest. For more information and conferences conducted by the division of cardiac program application, please visit our web site at: anesthesia. http://www.anes.ucla.edu/TEEProgram.pdf. ² The program has a flexible structure to accommodate practicing physicians. Trainees are 10 UCLA ANESTHESIOLOGY THOMAS GROVE, M.D.; A NOTE OF APPRECIATION Dr. Thomas Grove By Michael Sopher, M.D. At least 60 anesthetizing locations, more than 70 anesthesiologists, 66 residents, 15 CRNAs, in two separate hospitals with over 50,000 cases per year, interacting with numerous surgeons and nurses, and sorting out one of the most complex call systems and incentive time reimbursements plans imaginable, and one person makes the whole process hum like an Aston Martin DB9. Anyone associated with UCLA Anesthesiology knows who this person is……..Dr. Thomas Grove. How many times a day have you heard “I don’t know, go ask Tom”, “what does Tom have to say about that”, or “If you don’t ….., I am going to have to talk to Tom”? Tom Grove came to UCLA in 1983. He received his BS/MS in electrical engineering at MIT in 1969; he received his MS in biomedical Drs. Grove and Sopher engineering from USC in 1974 and his PhD from USC in electrical engineering in 1977. He then entered medical school receiving his MD in 1980 from the University of Miami. He completed his anesthesiology residency training at the University of California, San Francisco in 1983. Since the time he arrived at UCLA, he has been involved in formulating the daily and monthly anesthesiology schedules. However, during that time our coverage has grown from 15 main ORs, 4 Jules Stein Eye Institute ORs and no off site anesthesia to its current massive size of 51 ORs and 10 “off-sites” daily in two separate hospitals and four different operating room suites, Ronald Reagan UCLA Medical Center, Jules Stein Eye Institute, the Surgery Center and Santa Monica -UCLA Medical Center/Orthopaedic Hospital. Our number of clinicians has grown accordingly. Throughout this expansion, Tom has taken on more and more responsibility, and yet has never (or at least very rarely) raised his voice, screamed, or shown any indication of frustration. Quite the contrary, he has always been the ultimate model on how to survive with humor, impartiality, soft-spoken calm, common sense and decency in an environment that is relentless at creating exasperation and frustration. Many people are not aware of how much time Tom spends on minute issues like making sure that all the first year residents rotate through all of the MOR sub-specialty areas, or that all the medical students of different levels are placed in appropriate anesthetizing locations, or keeping track of which anesthesiologists prefer to work in certain areas or work with certain surgeons. These are only very small examples of the incredible detail that he takes care of every day, all of which enhance the education of our residents and medical students and creates a smooth functioning system in our OR environments. Over the years, Tom has developed a very sophisticated computer system that enables the department to keep track of who is working where and when, while at the same time keeping track of who is not available due to vacation, meeting time, jury duty, maternity/paternity leave or other issues. The “system” also keeps track of hours worked, extra hours worked and extra shifts worked. One would venture that there is not one person who has been associated with UCLA Anesthesiology in the past three decades who doesn’t have grateful memories of working with Tom Grove. He has been an inspiration, a dedicated leader, and a fairminded colleague to us all.² 11 UCLA ANESTHESIOLOGY Dr. Vivian Lee (CA-1) charting in the OR RONALD REAGAN UCLA MEDICAL CENTER IN PHOTOS Dr. Susan Chan running the new anesthesia board Drs. William Thompson, Chief Resident, and Swati Patel preparing to transport NICU baby Drs. Keren Ziv, Valerie Walker and Ihab Ayad checking the OR schedule for tomorrow Dr. Talin Evazyan (CA-1) and Dr. Philip Morway, securing the airway 12 UCLA ANESTHESIOLOGY Dr. Jacques Neelankavil (CA-2) searching for anesthesia supplies in the new OR Drs. Michael Trimming (CA-3), Barbara Van de Wiele, Komal Patel and Michael Sopher discussing patient care Dr. Oren Bernstein (CA-1) and Dr. Kianusch Kiai, perfecting emergence Dr. Siamak Rahman, unlocking PYXIS system with his fingerprint Drs. Anthony Nyerges, Hamid Nourmand, Nir Hoftman, Carsten Nadjat-Haiem and Thomas Grove at scheduling board 13 UCLA ANESTHESIOLOGY Chuck Griffis, CRNA, Ph.D. and Deborah Dach, CRNA, MS OUR FLOURISHING CRNA PROGRAM By Debbie Dach, CRNA, MS Each CRNA team member rotates to a variety of The Certified Registered Nurse Anesthetists (CRNAs) operating room areas within the medical center, function as an integral part of the anesthesia care including the team in the main Department of operating Anesthesiology room, Jules at UCLA Stein Eye Medical Institute, Center. The Ambulatory CRNA group Surgery has expanded Center, in number Santa over the past Monicafew years with Hospital and the ongoing many off-site construction anesthetizing of more locations. operating Everyone in suites and the group increased enjoys the volume of variety of cases at all assignments, the clinical CRNA team - back row, L to R: Debbie Paris-Teho, Erica Zima, Gena Dix, work hours sites. There Deborah Dach, Sarah Giron, David Higgins; front row: Jennifer Burak, Tao and daily are now fifteen Huong, Helen Timajchi, Pamela Shade, Robert Briel challenges at anesthetists each location. on staff as well as several per diem members. The CRNA staff share the daily workload and improve our department staffing when assigned in either a 2:1 or 3:1 ratio with their MD anesthesiologist colleagues. The CRNA assignment also allows the faculty anesthesiologist to spend more of their time with resident teaching, such as the administration of blocks or preoperative evaluation. Now that many operating rooms are functioning until later in the evening, the CRNA staff work longer shifts to ensure continuity of care for the longer running cases. CRNA’s also relieve residents, in the late afternoon, in order for them to attend important lectures by faculty and visiting professors. Several years ago affiliations were formed with both the USC and Kaiser Permanente graduate nurse anesthesia programs. We have three of these students rotating at UCLA Medical Center each month. The focus of their clinical experience is outpatient anesthesia. This is one of the few places, in their clinical education, that students learn in a fast-track, rapid turn-over, clinical setting such as the Ambulatory Surgery Center at 200 Medical Plaza and the operating rooms of the Jules Stein Eye Institute. Students attend our department weekly educational conferences and learn new anesthetic techniques from our faculty. Student performance is reviewed by both clinical coordinators, Erica Zima and Pamela Shade who 14 UCLA ANESTHESIOLOGY “The Principal Anesthetists have developed mentoring situations for senior staff members…” Robert Briel, CRNA and Dr. Harvey Rosenbaum provide for individualized care plan review and case assignments. The teaching experience has been very gratifying for senior staff anesthetists as well. As clinical instructors, they teach the students anesthesia case management, pharmacology, fluid therapy and pain management. Each clinical instructor participates in the student evaluation as well as selection of the most Chuck Griffis, CRNA, Ph.D. accomplished student of the year, from each program, for an award given by the UCLA Department of Anesthesiology. Teaching in the operating room has been an incentive to many of the senior staff anesthetists to participate in lectures, oral boards and faculty development courses to broaden their own skills in adult education. Another benefit of our nurse anesthesia program affiliations has been the ability to work with and recruit potential new hires. Two of our senior students will be joining our department in the fall. The Principal Anesthetists have developed mentoring situations for senior staff members interested in a sub-specialty of anesthesia. Chuck Griffis, PhD, has involved our senior staff member Sarah Giron in data collection for his post-doctoral research on pain and the immune system. He assisted her in preparing for a speaking engagement for a Kaiser Permanente educational conference this past January as well. His enthusiasm for continued learning has drawn other CRNA staff to participate in his lectures or in-service programs for nurses at the medical center. Classes have been given on sedation, recovery from muscle relaxants and the “Code Red” role of the RN. Debbie Dach has provided for a developmental award for senior staff member Erica Zima. Ms. Zima will pursue courses in supervision through the Staff and Faculty Counseling Center at UCLA. These courses will provide a foundation for future leadership opportunities in the department. Together they will outline CRNA leadership roles, responsibilities and patterns of communication at our clinical sites, including the new hospital. I would like to take this opportunity to thank Dr. Kapur and all the members of our Anesthesia Department for their ongoing support of the professional activities undertaken by the CRNA staff members. Please take a look at our webpage www.anes.ucla.edu/CRNAwebsite/index.html for information about other staff and faculty activities.² Clinical Coordinators Pam Shade and Erica Zima with Cal State/Fullerton and USC Student Nurse Anesthetists 15 UCLA ANESTHESIOLOGY Drs. Rusheen, Messerlian, and Matevosian CA-1 ROTATION AT OLIVE VIEW At the completion of this rotation, the resident is able to provide the safe and efficient administration of regional anesthesia. This includes the preoperative evaluation, intraoperative management and postoperative care utilizing the most Dr. Matthew LeDuc (CA-2) [right] current medical receiving instruction from Drs. knowledge Cheng and Messerlian pertinent to each case; using on-line medical information, communicating with patients and working effectively with the patient care team. Residents learn the importance of proper documentation and the value of medication management. The residents have become part of the cohesive team that provides excellent anesthetic care for the patient population here at Olive View. With regards to the Regional Anesthesia Program here at Olive View, a study was conducted which looked at the efficacy of axillary brachial plexus blocks performed by the UCLA Residents for patients undergoing repair of a distal radius fracture. The study found that patients receiving a brachial plexus block had a lower postoperative narcotic requirement, lower pain scores, less nausea and vomiting and shorter recovery room stays compared to the general anesthesia only group. The UCLA anesthesiology residents at Olive View have been a great addition to clinical care here and have received numerous accolades from patients and staff.² By Rima Matevosian, M.D. The Olive View-UCLA Medical Center located in the San Fernando Valley, provides high quality medical care to an underserved population. The surgical services offered at Olive View necessitate a diverse range of regional anesthetic techniques to improve outcomes and enhance patient care. Because of this, the Olive View UCLA Medical Center Department of Anesthesiology was selected as an important site for teaching regional anesthesia to the UCLA residents. UCLA anesthesiology residents started training at OVMC in October 2006 and, because of the excellence of the training, an additional resident was added to the rotation in May 2007. The regional anesthesia program at OliveView is dedicated to providing the residents with a comprehensive experience. The residents work one on one with the attending, allowing dedicated hands-on teaching, as well as allowing ample time for independence. Anesthesiology residents prepare for the rotation by reviewing the anatomy and physiology of blocks, and by reviewing the properties of local anesthetics. At the beginning of the rotation, the resident is provided with a handout of current and pertinent journal articles for discussion with an anesthesiology attending. In addition to significant teaching during each supervised case, a series of interactive lectures take place during the rotation. Additionally, there is a weekly teaching conference with the residents and faculty. A block room to place regional anesthesia blocks was established to facilitate the teaching experience and for greater efficiency/utilization of operating rooms. The latest ultrasound technology is in use, with a plan in place to continually upgrade as new technology becomes available. Regional anesthesia is often chosen to supplant or supplement general anesthesia. 16 UCLA ANESTHESIOLOGY ANESTHESIOLOGY UPDATE 2008 MORNING PROGRAM 7:15 8:00 Registration and Continental Breakfast Welcome Session 3: 1:15 Tom Bradley International Hall SATURDAY, NOVEMBER 15, 2008 TOM BRADLEY INTERNATIONAL HALL 417 CHARLES E. YOUNG DRIVE – UCLA CAMPUS AFTERNOON PROGRAM Pharmacology for the Future Moderator: Jordan D. Miller, MD Atypical Plasma Cholinesterase as a Model to Understanding Pharmacogenetics Mohamad Iravani, MD Sugammadex: An Update for Its Use in Anesthesia Wendy H. Ren, MD New Anesthesia Medications, Drugs You Will Want/Need Right Away: Alvimopam, Methylnaltrexone, Intravenous Acetaminophen and Clevidipine Jonathan S. Jahr, MD Questions and Answers Break Session 1: 8:15 8:45 9:15 9:45 Perioperative Medicine Moderator: Michael J. Sopher, MD Current Concepts in Perioperative Glucose Management and Diabetes Christopher L. Wray, MD Anesthesia for Interventional Neuroradiology Keren Ziv, MD Herbal Medications and Perioperative Implications Edward J. Park, MD Perioperative Use of Temporary Pacemakers Ryan A. Crowley, MD Questions and Answers Break 1:45 2:15 3:00 3:15 10:15 10:30 Session 4: Case-Specific Anesthetic Considerations Moderator: Ihab A. Ayad, MD Session 2: 10:45 11:30 Improving Patient Outcomes Moderator: Parisa Partownavid, MD 3:30 Anesthesia Patient Safety: It Is Not What You Think It Is Kenneth F. Kuchta, MD Post-operative Epidural Analgesia: How To Make It Work James M. Moore, MD Questions and Answers Lunch 4:00 They Want To Do What? Things the Anesthesiologist Should Know about Hepatic Surgery Michelle Y. Braunfeld, MD Anesthetic Management for Surgery Requiring Neurophysiologic Monitoring Victor F. Duval, MD Questions and Answers Adjourn 12:00 12:15 4:30 5:00 Please go to: www.anes.ucla.edu/2008CME.pdf for details on registering for this course 17 UCLA ANESTHESIOLOGY Dr. Randolph Steadman teaching AED functions to 3rd year medical students UPDATE ON THE UCLA SIMULATION CENTER masters program have been reinstated at UCLA to address the national nursing shortage, which has created a need to train critical thinking in a shorter amount of time. The School of Dentistry has also developed full-scale simulation for their students, illustrating physiology and integrating case scenarios using manikins. By Yue Ming Huang, EdD, MHS and Cecilia Canales, MPH Under the guidance of Dr. Randolph Steadman, the UCLA Simulation Center has grown tremendously since its establishment in 1996 by the Department of Anesthesiology. Despite space and resource constraints, twelve years later the program continues to provide state-of-the-art simulation training to medical students and residents from UCLA and its affiliated hospitals. In 2006, a generous $1M pledge from Maxine and Eugene Rosenfeld initiated plans to enlarge and While the initial emphasis was on anesthesia renovate the UCLA simulation program. Further resident and medical student training, the fueled by institutional simulation program efforts and a $3.1M has expanded to offer telemedicine grant from simulation training to the UC Office of the other departments. President, we are now One of the key efforts in the process of a was the large expansion of the establishment of a UCLA Simulation multidisciplinary Center. The goal is to team training course unite similar with anesthesia educational efforts residents, general occurring throughout surgery residents and the health science operating room campus and to conduct nurses. Piqued by team training between the growing interest the different disciplines in simulation at and departments. The society national new simulation center, conferences and by anticipated to open in positive feedback Spring 2009, will bring from participants, the Preparation for third year medical student introduction to together all the Internal Medicine airway management course simulation resources department has within a single location. initiated mock codes for their residents, and the OB/Gyn department has The multidisciplinary simulation center will be piloted in-situ simulation drills with anesthesia, located on the A-level of the Crump Building NICU and nursing teams. (directly across Westwood Boulevard from the Ronald Reagan UCLA Medical Center). This center Through grant support, the School of Nursing has will integrate all simulation activities throughout the taken advantage of this interactive and experiential UCLA health community, housing high fidelity educational modality. This is an opportune time as patient simulators, virtual reality trainers, the undergraduate nursing program and a new 18 UCLA ANESTHESIOLOGY “Each room is designed to be flexible, allowing interchangeability for any desired clinical environment to be simulated” procedural task trainers, computer-based simulations and telemedicine/ teleconferencing capabilities. Teleconferencing connectivity will provide real time patient care consulting and teaching opportunities between the UCLA Simulation Center, Reagan Hospital, Santa Monica Hospital, the UC campuses and other institutions throughout the world. The new simulation center floor plan includes five simulation suites with a central control room. Each room is designed to be flexible, allowing interchangeability for any desired clinical environment to be simulated, such as operating room, intensive care unit, emergency room, pediatrics and obstetrics room. The 8,700 square foot facility will include three debriefing/conference rooms, four standardized patient exam rooms, a task training room, a telemedicine conference room, a screen based simulation classroom, administrative offices and IT support. Currently, approximately 2,000 individuals participate in simulation training each year at UCLA. With the expansion of the facility in 2009, we will have the ability to conduct multiple simulation sessions concurrently in one location. We anticipate our utilization will double over the next few years as a result of participation from residents in surgery, pediatrics and emergency medicine, as well as hospital staff nurses, allied health professionals and faculty. Additionally, we envision serving the community by offering simulation-based continuing medical education (CME) for fully trained practitioners.² Ceci Canales monitoring simulator behind the scenes Dr. Victor Duval [back center] with 4th year medical students simulating mega code Dr. Jun Park (CA-3) [right] with a research resident from Stanford University participating in pediatric simulation scenario as part of the UCLA-Stanford pediatric airway study 19 UCLA ANESTHESIOLOGY Dr. Barbara Van de Wiele CATCHING UP WITH OUR SENIOR FACULTY Dr. Philip Larson and Dr. Philip Ostermann (CA-1) in the OR Dr. Judith Brill in front of the floor plan for the 2nd floor of the new hospital Dr. Joseph Rosa Dr. Anthony Nyerges 20 UCLA ANESTHESIOLOGY Dr. Jordan Miller Dr. Jill L’Armand in front of the Santa Monica OR scheduling board Dr. Johnny Harrison Dr. Michelle Braunfeld with Dr. Ronald Cheng, visiting fellow, liver transplantation anesthesiology Dr. Harvey Rosenbaum 21 UCLA ANESTHESIOLOGY Dr. Wald with Chief Residents, Drs. Strom and Duarte, and Dr. Steadman GRADUATION CEREMONIES CLASS OF 2008 Back row, l to r: Drs. Daniel Tongbai, Mariya Svilik, Julio Duarte, Scott Swenson, Suzanne Strom, Megan Thomas, Dedrick Kon, Brian Keefer, David Cho. Front row, l to r: Drs. Oji Oji, Valerie Walker, DeEtte Zahn, Cristianna Vallera, Sharon Lin, Scott Suetsugo, Angela Hsu, Richard Kim, Jeremy Wong, Lingzhong Meng Dr. Jordan Miller, Teacher of the Year with Chief Residents, Dr. Suzanne Strom and Dr. Julio Duarte Dr. Harvey Rosenbaum presenting the Dillon Award to Dr. Ali Sadoughi 2009 Chief Residents, Dr. William Thompson and Dr. Jason Chua honoring the 2008 Chief Residents, Dr. Suzanne Strom and Dr. Julio Duarte 22 UCLA ANESTHESIOLOGY CLASS OF 2009 2009 Chief Residents, Drs. Chua and Thompson with Coco Camargo Drs. Natalie Danino (CA-2) and Dorothea Hall with Chief Resident Dr. Jason Chua Pediatric Fellow Dr. Suzanne Strom Dr. Valerie Walker Cardiothoracic Fellow 23 UCLA ANESTHESIOLOGY Dr. Robert Kaufman By Harvey Rosenbaum, M.D. ROBERT KAUFMAN, M.D. RETIRES AFTER 34 YEARS on perfecting liver transplants in swine. This work was instrumental in enabling human liver transplantation at UCLA. Dr. Kaufman has greatly contributed to the department as Director of OR services (1996-1999), Vice Chairman since 1997 and Chair of the Appointments and Promotions Committee since 2002. Dr. Kaufman also played a key role in establishing the Department of Anesthesiology Professional Group (DAPG) in 1994, and served as its first president from 1994 - 1996. His actions demonstrated a sustained commitment to improving the welfare of his colleagues. We are fortunate that Dr. Kaufman will be returning to work part-time and continuing to teach residents the art and science of anesthesiology² Last year I learned that Robert Kaufman was going to retire at the end of June, 2008. If Robert were a star athlete, you would say he was retiring at the top of his game. Dr. Kaufman was one of my first attendings as a new resident. I remember learning how to care for patients having total hip replacements performed by a surgeon who always wanted the blood pressure a little lower. Dr. Kaufman taught me proper conduct of a deliberate hypotensive technique, and how to avoid an inadvertent hypotensive technique. As a clinical teacher, Robert has served as an excellent role model. He is very calm and confident in his clinical skills. Robert was one of the first attendings at UCLA to teach fiberoptic intubation. He has a remarkable knowledge of how things work. His lectures about electricity and equipment were always informative and wonderfully entertaining. In this age of PowerPoint, Dr. Kaufman can lead a superior discussion using his mind and a blackboard. Dr. Kaufman is an alumnus of our residency program. During his residency, Robert completed a research fellowship and authored a review article on mechanisms of anesthetic action that was published in Anesthesiology in 1977. In the late 1970’s 1980’s, Robert was part of an accomplished UCLA group investigating respiratory physiology. For those of you who talk about “West zones”, I highly recommend that you read Dr. Kaufman’s articles in the December 1987 issue of the British Journal of Anaesthesia. Another study demonstrated that accurate measurement of temperature with an esophageal stethoscope requires positioning the probe behind the heart. Dr. Kaufman has continued to encourage junior faculty to conduct and publish clinical research. You are familiar with the success of the UCLA Liver Transplant Program. Dr. Kaufman was the leader of the anesthesia team that worked with Dr. Busuttil Dr. Robert Kaufman 24