Anesthesiology Critical Care Medicine Research Articles

Emergency Medicine/Critical Care Medicine (EM/CCM) Trainees' Performance on Standardized Critical Care Medicine Examinations: A Ten-Year Review.

Emergency Medicine/Critical Care Medicine (EM/CCM) trainees may obtain board certification through Internal Medicine (American Board of Internal Medicine [ABIM]), Surgery (American Board of Surgery [ABS]), and Anesthesiology (American Board of Anesthesiology [ABA]). However, EM/CCM trainees experience challenges, including: 1) additional training requirements and 2) an unwillingness to accept EM graduates by many programs. We sought to: 1) compare EM/CCM knowledge acquisition to medicine (Internal Medicine [IM]/CCM), surgery (surgical critical care [SCC]), and anesthesiology (anesthesiology critical care medicine [ACCM]) Fellows at the local and national level using the Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP) in-service examination as an objective measure; and 2) compare American Board of Medical Specialties (ABMS) pass rates for EM/CCM. Single-center retrospective analysis comparing scores obtained by EM/CCM on the MCCKAP examination with SCC and ACCM over a 10-year period. Scores are presented as means with standard deviations. We performed similar analysis on ABMS examination pass rates. There were 117 MCCKAP scores (37 EM/CCM; 80 SCC and ACCM) evaluated. EM/CCM mean score 562.4 (SD 67.4); SCC and ACCM mean score 505.3, (SD 87.5) at the institutional level (p<0.001). Similarly, EM/CCM scored higher than the national mean (562.4, SD 67.4 vs. 500 SD 100, p<0.001). Nationally, ABIM-CCM board certification rate was 91.2% for 137 EM/CCM, compared with 93.2% for IM/CCM (p=0.22); 28 EM/CCM have obtained ABA-CCM board certification with rates similar to ACCM (90.4 vs. 89.3%; p=0.85). EM/CCM Fellows demonstrate successful knowledge acquisition both locally and at a national level. EM/CCM achieve ABMS pass rates similar to other CCM trainees. The current arbitrary additional training requirements placed on EM/CCM should be removed.

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Introduction: Emergency Medicine (EM) trainees have been pursuing critical care medicine (CCM) training for numerous years. During her 2011 national conference remarks, former president of SCCM, Dr. Lipsett, specifically addressed the need to provide EM physicians fellowship “training equivalent to that of our internal medicine, anesthesiology, and surgery colleagues”. There has been an increased interest in formalizing approved CCM fellowship training for EM graduates (grads) within existing ACGME Anesthesiology Critical Care Medicine (ACCM) Fellowship Programs (FP). Hypothesis: EM grads are trained in the triage/resuscitation of undifferentiated critically ill pts and frequently manage multiple sick pts simultaneously. They also, by virtue of their training, are competent in a wide variety of CCM procedural skills (airway techniques, central venous access, bedside ultrasound, cardioversion, etc). We propose that existing ACCM programs could incorporate EM grads for formal training and certification. Methods: Currently, 51 ACCM FP exist in the United States. A survey was circulated amongst the ACCM program directors (PD) to assess attitudes and perceptions regarding the training of EM grads. We also requested information regarding ACCM FP that have previously or are currently training EM grads. Results: 46/51 (90%) ACCM FP replied. 20 (43%) programs are currently or have trained EM grads. 38 of 46 respondents (83%) either “strongly agree” or “agree” that EM trainees have the potential to be good intensivists. 35/46 (76%) “strongly agree” or “agree” that a pathway for training and board eligibility in CCM should be available for EM trainees in ACCM. 56% felt that the training should be 2yrs in length, while 28% felt it should be 1yr. Based on these results, a formal letter (endorsed by SCCM) of recommendation supporting the creation of a specialty track within ACCM FP was submitted to the Anesthesiology Residency Review Committee and the American Board of Anesthesiology. Conclusions: EM trainees are currently being trained in ACCM FP. The majority of ACCM FP would accept a formalized training tract leading to board certification. Further steps need to be taken to delineate a formal curriculum for EM/CCM fellows.

Anesthesiology critical care medicine: a fellowship and faculty recruitment program

Study Objective To review national data on anesthesiology critical care medicine (ACCM) fellowship program enrollment and to describe a program that successfully recruited ACCM fellows and faculty at a single academic medical center. Design An incentive program known as the Mayo Clinic Scholar program, designed to recruit ACCM fellows and faculty, was reviewed. Interviews were conducted to assess the impact of the Mayo Clinic Scholar program. Setting Academic health center. Measurements ACCM fellowship program enrollment data were compared with similar data for critical care medicine fellowship programs in internal medicine, pulmonary medicine, pediatrics, and surgery.The results of a program to recruit ACCM fellows and faculty were reviewed. Main Results Only 89 of 147 (60.5%) ACCM fellowship positions available nationally were filled during the 2010-2011 academic year, and only 89 of the 896 (9.9%) critical care medicine fellows anticipated to graduate in 2011 were in ACCM programs. The Mayo Clinic ACCM fellowship enrolled 28 fellows from January 1, 2000 through July 1, 2010 (range 0-6 per yr). Ten of the 28 (35.7%) were United States medical graduates (USMGs) and 6 of the 10 (60.0%) USMGs who were graduates of the Mayo Clinic residency were appointed as Mayo Clinic Scholars. All 6 Mayo Clinic Scholars were retained as ACCM faculty. Only two of the 6 (33.3%) Mayo Clinic Scholars would have completed ACCM training without a Mayo Clinic Scholar appointment. All recommend ACCM training to others and plan to continue to practice ACCM. Conclusions The Mayo Clinic Scholar program effectively recruited ACCM fellows and faculty in a single institution. Incentive-based programs should be considered to support the involvement of anesthesiologists in perioperative medicine.

Romergryko Geocadin and Matthew Koenig

The Guest Editors of this issue of Seminars in Neurology on the Neurological Consultation in the Intensive Care Unit are Romer Geocadin, M.D. and Matt Koenig, M.D. Dr. Geocadin is Associate Professor of Neurology, Neurological Surgery and Anesthesiology-Critical Care Medicine in the Johns Hopkins University School of Medicine. He is the Director of the Neurosciences Critical Care Unit at the Johns Hopkins Bayview Medical Center and Associate Director of the Neurosciences Critical Care Division, Johns Hopkins Medical Institutions. Dr. Koenig is Assistant Professor of Neurology, Neurosurgery, and Anesthesiology-Critical Care Medicine in the Johns Hopkins University School of Medicine.

Eryrthropoietin and the promise of ischemic multiorgan protection*

Departments of Anesthesiology Critical Care Medicine, Neurology and Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Stevens) Departments of Neurology, Neurological Surgery and Anesthesiology, Peri-Operative Medicine, Oregon Health & Science University, Portland, OR (Bhardwaj) Dr. Bhardwaj has received grants from the National Institute of Neurological Disorders and Stroke. Dr. Stevens has not disclosed any potential conflicts of interest.

Rescuing the brain in acute liver failure*

Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, Surgery, Johns Hopkins University School of Medicine, Baltimore, MD Dr. Stevens is supported in part by NIH 9RO1 EB004130-05A1. For information regarding this article, E-mail: [email protected]

Romergryko G. Geocadin

Romergryko G. Geocadin, M.D., is the Guest Editor of this issue of Seminars in Neurology on Hypoxic-Ischemic Encephalopathy. Dr. Geocadin is Assistant Professor of Neurology, Neurosurgery, and Anesthesiology-Critical Care Medicine at the Johns Hopkins University School of Medicine. He is the Director of the Neurosciences Critical Care Unit at the Johns Hopkins Bayview Medical Center and Associate Director of the Neurosciences Critical Care Division, Johns Hopkins Medical Institutions.

Precise Use of Medical Terminology

Department of Anesthesiology Critical Care Medicine, Childrens Hospital Los Angeles, and Department of Pediatrics and Anesthesiology, USC Keck School of Medicine, Los Angeles, CA

CHARACTERISTICS OF CHILDREN ADMITTED FROM THE EMERGENCY DEPARTMENT TO THE PEDIATRIC INTENSIVE CARE UNIT

Anesthesiology Critical Care Medicine (AMS, CJT), Emergency Medicine (AMS), Statistics (MW), Childrens Hospital Los Angeles, Los Angeles, CA

Pain Relief in Labour

Associated Director; Division of Obstetric Anesthesiology; Department of Anesthesiology Critical Care Medicine; Johns Hopkins University; Baltimore, MarylandJames C. Eisenach, M.D., EditorPain Relief in Labour. Edited by Felicity Reynolds. London, BMJ Publishing Group, 1997. Pages: 256. Price: 27.00 [pound sign].Pain Relief in Labour is one of a growing number of textbooks in the area of management of labor pain. This textbook by Russell, Scrutton, and Porter has some influences characteristic of practice in the United Kingdom. The textbook is intended for the nonanesthesia care provider, such as midwives, obstetricians, and general practitioners. The emphasis is, not unexpectedly, on nonregional labor analgesic techniques, including “natural childbirth,” transcutaneous electrical nerve stimulation, acupuncture, hypnosis, herbal remedies (including aromatherapy), homeopathy, and inhalational analgesia for labor.This textbook begins with a description of US and UK surveys of labor analgesia practices. A Table depictsthat in the United States in 1990. 0% of cases were performed with inhalational analgesia for labor analgesia, and 33% of cases were performed with epidural analgesia for labor. In contrast, in the United Kingdom in 1992, 60% of cases were performed with inhalational analgesia for labor analgesia, and 20% of cases were performed with epidural analgesia for labor. The authors state that inhalational analgesia with nitrous oxide is an option despite their statement that “nausea and vomiting is very common with nitrous oxide.” The data presented may incorrectly convey to the reader a sense that inhalational analgesia is without complications or without loss of maternal protective airway reflexes and loss of maternal consciousness. The authors state that “failure to provide epidural analgesia was the single most frequent cause of anxiety and disappointment among laboring women. There are insufficient anaesthetists in the UK and many countries to provide an efficient epidural service universally.”Who should inform the mother about pain relief and methods of analgesia? The authors suggest “midwives not anaesthetists” provide information to the patient but recommend development of a liaison between midwives, obstetricians, general practitioners, and anesthetists. This comment raises concerns regarding which individual can effectively and accurately disseminate information regarding regional analgesic techniques for labor. Should the nonanesthesia care provider carry this responsibility?The psychological methods of pain relief, including “natural” childbirth, psychoprophylaxis, hypnosis, and biofeedback are discussed with emphasis on the benefits of antenatal training for these psychological methods and suggestion that these methods should be “strongly encouraged” by the midwives, obstetricians, and general practitioners. The physical methods of pain relief, including transcutaneous electrical nerve stimulation, massage, water bath, aromatherapy, homeopathy, and herbalism, suggest effective analgesia for the first stage of labor only. Reports on efficacy are anecdotal and without clear scientific evidence. The authors state, “Though many nonpharmacological approaches to pain relief have been put forward, few have been widely used and fewer still subjected to randomized trials.”The authors briefly review the anatomy and physiology of regional analgesia for labor with nice diagrams and illustrations of spinal-epidural anatomy. There is also a brief review of the indications and contraindications of regional analgesia for labor and reference to the effects and complications of regional analgesia for labor (i.e., potential association of epidural analgesia for labor with obstetric outcome).The final part of the textbook illustrates “practical procedures” for regional analgesia for labor with sample infusion regimens. A guide is also provided for the nonanesthesia care provider on how to administer an epidural top-up dose.Is this book worth buying? This textbook is more suited for the nonanesthesia care provider, such as the midwife, obstetrician, or general practitioner. For anesthesiology trainees and practitioners, this book is of peripheral interest only.Sumedha Panchal, M.D.Associate Director; Division of Obstetric Anesthesiology; Department of Anesthesiology Critical Care Medicine; Johns Hopkins University; Baltimore, Maryland(Accepted for publication September 23, 1998.)

Anesthesiology Critical Care Medicine Fellowship Training

Comment As this article summarizing a survey of program directors indicates, there is considerable variability in the actual programs for fellowship training in anesthesiology critical care medicine. This is both a strength and a weakness of the anesthesiology critical care medicine training process. There may be concern that some fellows are getting inadequate training in some programs because of a lack of rigidly defined curriculum. On the other hand, the variability may be due to the fact that there are only one or two fellows in most programs and the programs are being modified to meet the needs and proclivities of the fellows in training.

Anesthesiology Critical Care Medicine Fellowship Training

Anesthesiology critical care medicine (ACCM) fellowship training was accredited in 1989, and a small number of graduating anesthesiology residents pursue this additional training. Considering the flexible program guidelines of the American Board of Anesthesiology (ABA), we hypothesized that ACCM fellowship training programs varied significantly among the 42 institutions accredited to offer this program. This study of ACCM fellowship programs used a six-part, 57-item questionnaire completed by 36 program directors to describe six aspects of the program: institution size, program director, attending staff, fellowship applicants, curriculum, and the role of the American Society of Critical Care Anesthesiologists (ASCCA). Ninety-four percent of ACCM fellowships are in facilities with more than 400 beds; 81% of these institutions have more than 20 intensive care unit (ICU) beds as the basis for fellowship teaching. Eighty-three percent of ACCM program directors have practiced critical care for more than 5 yr. All programs had more than one attending physician, with the majority having a multidisciplinary attending staff. During two academic years (1990-1992), 12 (33%) of 36 programs did not have a fellow, resulting in an average of less than one fellow for each program. ACCM fellow involvement in patient care was characterized as "primary" in medical and pediatric ICUs and "cooperative" in surgical ICUs. Fellowship curricula had varied requirements for research, intraoperative anesthesia, and ICU procedures performed by the fellow. In general, program directors believe that salary and on-call responsibility are not important issues for applicants. Nineteen percent of program directors train ACCM fellows longer than the 12 mo required by the ABA and believe that ACCM training should be lengthened.

Anesthesiology Critical Care Medicine Fellowship Training

Anesthesiology Critical Care Medicine Fellowship Training

American Board of Anesthesiology critical care medicine examination

American Board of Anesthesiology critical care medicine examination

Fiberoptic Endoscopy in Anesthesia

Chicago, Yearbook Medical Publishers, 1983. Pages: 146. Price: $61,75.Associate Professor of Anesthesiology Critical Care Medicine University of North Carolina at Chapel Hill Chapel Hill, North Carolina 27514