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2012 Stanford Anesthesia Faculty Teaching Scholars

We are very pleased to announce the Stanford Anesthesia Faculty Teaching Scholars for 2012: Drs. Naiyi Sun, Brendan Carvalho, Jennifer Lee, Calvin Kuan, Sam Lahidji, Carlos Brun, and Rosario Garcia.

The proposals below are innovative and working with the Resident Teaching Scholars on the projects will help take the training program to the next level.

Dr. Pedro Tanaka has agreed to serve as Co-Director of the Teaching Scholar program.

Naiyi Sun (assisted by Resident Teaching Scholars Megan Olejniczak & Jared Pearson)
Project: Web based Curriculum for Pediatric Neuroanesthesia

Brendan Carvalho (assisted by Resident Teaching Scholars Javier Lorenzo & Luis Verduzco)
Project: Transthoracic Echo Curriculum for Obstetric Anesthesia

Jennifer Lee (assisted by Resident Teaching Scholar Morgan Dooley)
Project: Wellness Curriculum for Residents Not Attending CA1 retreat

Calvin Kuan (assisted by Resident Teaching Scholars Christine Jette & Ethan McKenzie)
Project: Multimodal Curriculum for Pediatric Cardiac Anesthesia

Sam Lahidji (assisted by Resident Teaching Scholar Kingsuk Ganguly)
Project: New Pain Management Resident Lecture Series

Carlos Brun (assisted by Resident Teaching Scholars Alex Quick & Lindsay Raleigh)
Project: Transthoracic Ultrasound Curriculum

Rosario Garcia (assisted by Resident Teaching Scholar Eric Mehlberg)
Project: CA1 Resident TEE Rotation Curriculum

Thank you,

Stanford Anesthesia Intern reports on research month

I asked Jan Sliwa currently an intern to write about his research month at Stanford so that others that might be interested in this elective can learn more about what is available.

From Jan: When choosing elective rotations at the start of my internship, I thought it might be valuable to do a research month in the Department of Anesthesiology at Stanford. I wouldn’t be rotating there at all until the beginning of CA-1 year, so I figured it might be a good way to get involved in a project or two and meet some of my future attendings, co-residents, and other members of the department. I wasn’t sure whether any of this was possible, but it was an idea and I went with it.

After emailing our program director, Dr. Macario, I got several emails back from him indicating that there were plenty of research opportunities to get involved with, and that I could tailor these experiences towards my own interests. I got in touch with Dr. Brock-Utne and one of this year’s chief residents (Dr. Laura Downey), who had begun a study looking at the effect of PEEP on increasing internal jugular vein cross-sectional area & circumference in obese patients (BMI >30) under general anesthesia.

On the first day, Laura explained the study methods and helped me determine what types of cases on the OR schedule would likely have patients that would be suitable candidates to consent for the study. I arrived at Stanford around 6:30AM each day, met with the resident and attending whose patient I was interested in consenting for the first case to make sure they were on board, and with their blessing, I would meet the patient, describe the study, and obtain written informed consent. There are 2 Sonosite machines in the main Stanford OR suite capable of manually measuring cross-sectional area and circumference of structures being viewed under ultrasound, one of which is generally used by the regional anesthesia team for the 8-12 peripheral nerve blocks done per day. Therefore, every morning I tracked down an ultrasound machine to make sure I could use it.

After patients were brought to the OR, anesthetized, and intubated, I would take 3 ultrasound measurements of the RIJ at 0 PEEP (each patient acted as their own control). Then we cranked the PEEP up to 5, and I took 3 measurements at that setting. Finally, if the patients were hemodynamically stable on 10 of PEEP (most were), I took 3 final measurements.

Over the month’s time, I was able to recruit 16 more patients, run the preliminary statistical analyses, and began drafting a manuscript. Dr. Brock-Utne is confident that we can present this study at WARC (Western Anesthesia Resident’s Conference), the ASA annual meeting, and will eventually even have a publication out of this research.

In the downtime between recruiting patients and taking measurements in the OR, I followed the CA-2 resident on the new echocardiography rotation as they performed exams in the OR’s or had lectures from the Cardiac Anesthesia faculty about various aspects of TEE, including cardiac physiology, hemodynamics, and congenital heart disease. At the end of the month, I feel pretty confident with identifying the anatomy present on all 20 of the standard TEE views. I was also able to spend time manipulating the probe in the TEE simulator at the Stanford sim center, and actually got a chance to find the 20 views on my own.

Dr. Daryl Oakes, CV Anesthesia faculty and the coordinator of the TEE course at Stanford, also had me prepare a set of questions to be used as part of a Pre & Post-test for the residents on the TEE rotation to evaluate their progress. All in all it was a busy and very educational month, and a good way for me to meet many future anesthesia colleagues at Stanford.

I would absolutely recommend this type of experience for any of the future Stanford Anesthesia interns as a way to get plugged into the anesthesia department early on. Dr. Macario is extremely supportive of this and very helpful with finding research projects and activities tailored to our interests. Thanks again for letting me make this happen! It’s been one of the definite highlights of my intern year so far.
-Jan

Santa Clara Valley Medical Center Transitional PGY1 Year

Sarah M. Clark, M.D. is an Intern at Santa Clara Valley Medical Center this year and will start Stanford Anesthesia in July 2012. She was kind enough to write a description of her PGY1 year at the Valley up to this point. I hope it is useful information to applicants interested in learning more about the transitional year there.

Internship at the Valley combines the flexibility and variety in schedule that you expect from a transitional year with all of the perks and disadvantages associated with working at a county hospital. The year is divided into 13 four week blocks that include obstetrics, pediatrics, surgery, ED, ICU, medicine wards, and elective time.

The program director, Melissa Chin, works with each intern individually to create electives that are interesting and relevant to that intern. I was able to spend 2 weeks on cardiology, 1 week on echocardiography, 1 week in the coroner’s office (a unique experience that I’d recommend to anyone who doesn’t get queasy around dead bodies!), and 4 weeks up at Stanford doing research and spending time in the anesthesia department. After all that, I still have 2 more weeks of elective later in the year that I can spend how ever I choose.

That being said, wards at the Valley can be pretty draining. Being a county hospital, the patients can be very sick and often have many social issues that can translate into difficult dispositions. In addition, the systems are not always the most efficient or logical and you can spend a significant portion of your day tracking down charts, looking for vitals binders, or filling out paperwork. However, working at a county hospital will also give you the opportunity to take care of patients with advanced medical conditions, and you will be able to do so from the perspective of the numerous different specialty services that you will work on throughout the year.

Another big advantage of being an intern at the Valley is the relationship with Stanford. Not only do you have the opportunity to spend time up at Stanford for electives and some ward months, but many of the residents, fellows, and attendings at Valley are affiliated with Stanford. This has allowed me to work with surgery and anesthesia residents, as well as residents and attendings in many other specialties. I have also had the opportunity to get to know my four co-interns who will also be heading up to Stanford for anesthesia in July 2012.

Overall, SCVMC is not the easiest or least stressful of transitional years, but it has numerous advantages that make it a great place to spend your intern year. Throughout the year I will work in a variety of departments and specialities that are all relevant to anesthesia. Furthermore, I was able to do exactly what I wanted during my elective time and the balance between difficult and easy months has been pretty reasonable thus far. At the end of the year I will be able to say that I worked hard and learned some medicine, but still had time to enjoy all that the bay area has to offer!

If you have any questions regarding SCVMC or intern year in general, please feel free to email me at sarahmclark11@gmail.com!

Essay by visiting medical student

Louise Wen is a fourth year medical student at Stony Brook University Medical School and is from New York City. She conducted research this past summer with Dr. Brendan Carvalho in the obstetric anesthesiology division of Stanford Anesthesia through the Foundation for Anesthesiology Education and Research Medical Student Anesthesia Research Fellowship (FAER MSARF) . She was kind enough to write an essay about her time here.

As I made my preparations for my summer at Stanford, I was filled with excitement and curiosity for my very first visit to California. My introduction to California was a weeklong visit to Yosemite Park with my partner of seven years and his parents. After creating a wealth of memories on this family vacation, we drove a few short hours to downtown Palo Alto. We found the area vibrant with innovative businesses that catered to the uniquely artistic, technological, and health and environmentally conscientious culture of Palo Alto.

At Stanford, I was struck by the universal friendliness of the hospital staff. Even though Stanford is a major academic medical center, I was surprised by the warmth and intimacy more commonly found at a community hospital. The nurses offered suggestions on ways to improve our study, which examined the role of oxytocin on pain in breastfeeding patients. By my second week, they would approach me to offer valuable information on potential study subjects. Through our daily interactions, we became friends.

On weekends and evenings, we exercised at a walking trail just south of campus called the Dish, enjoyed meals at delicious yet affordable dining options, and shopped at the weekend farmers’ markets that are open year-round.

Friendships also developed with the residents, who provided excellent guidance and mentorship for my goals of pursuing a career in anesthesiology as a researcher and educator. They introduced me to Stanford’s unique FARM track, which integrates an additional 9 mths of protected research time in the residency training. Additionally, FARM residents enjoy a university-wide network of support through the Stanford Society of Physician Scholars, which hosts a monthly seminar series on topics ranging from research funding to academic appointments.

Every afternoon, the ob anesthesia attendings give intimate seminar-style lecture in one of the hospital’s outdoor flowering alcoves. Occasionally, I would even spot a hummingbird as it zipped between blossoms. I especially enjoyed these lectures, as they were engaging and intellectually challenging, yet informal and fun. I marveled at the expertise of the attendings who shared their experiences of managing complex and high-risk cases, cited details from landmark studies to support their management strategies, and described medical-legal lessons from their experiences as expert witnesses.

During my last few weekends at Stanford, I explored the greater Bay Area. In the bustling streets of San Francisco’s Chinatown, friends and I enjoyed an authentically prepared Szechuan dinner. Another weekend, we visited the Santa Cruz beach boardwalk and the deafening rumbles of roller coasters and watched the golden sunset from the cool beach sand. My favorite weekend excursion however was a camping trip at Castle Rock State Park. The majestic Santa Cruz mountains are a perfect backdrop to conversations shared with fellow backpackers.

My summer was incredible and I am grateful to have had such a positive experience. Amidst Stanford’s warm and supportive environment, I further developed research skills that I will use in my future career as an academic anesthesiologist.

I would highly recommend the FAER MSARF program to any medical student interested in pursuing a career in anesthesia research, as it has both solidified my commitment to and clarified my personal goals in research.

thanks Louise for the nice letter!

Thank you,

Is step 2 score required to complete the residency application?

On Wed, Aug 31, 2011 at 8:47 AM the following question arrived:
There is a growing trend of programs in CA and across the country requiring applicants to have taken the USMLE Step 2 and have their scores reported before they will be considered for ranking. Does Stanford currently (for the 2012 PGY1 or 2013 Advanced Anesthesiology residency) require Step 2 scores prior to ranking an applicant?

Answer
Thanks for your question and I am pleased you are aware of the new 2012 pgy1 categorical positions now available at Stanford Anesthesia. We do not require the step 2 score prior to submitting our rank list. When we review applications in october, we do find that applicants that scored poorly on step 1 are more likely to have taken step 2, probably to get their score up and strengthen their overall application. On the other hand, we often see applicants that have high step 1 scores wait on taking step 2 so that result is not available to us during the interview season.

We know there is a lot more to being a good doctor than high test scores so during the review of applications we emphasize the applicant's overall medical school performance as well as recommendation letters and the interview.

BTW there isn’t a requirement for the timing of step 3 with the exception of needing to pass it prior to starting the PGY2 anesthesia residency year. The earlier you take it will mean the earlier you can get the paperwork going for your CA medical license. We generally recommend you start the licensing process around Oct. of your internship.

Thank you,

Combined residency training in anesthesia and critical care

Question: I am interested in a career in ICU and anesthesia. I know there are a couple of residencies that have a combined anesthesia/critical care medicine track. Does Stanford offer one?

Answer: Great question. Thank you. Critical care medicine has a long (36 years) and strong (157 fellows trained) tradition at Stanford. And, I have been impressed by how many medical students consider anesthesiology for a career because of their interest in critical care.

Stanford Anesthesia has applied this year for approval from ACGME for a combined anesthesia/critical care medicine training track within the residency. We expect to hear back from the ACGME in November 2011. Should the combined program be approved it will be an option for applicants graduating medical school in 2012. We have requested to make available two slots for CA1 through CA4 training (i.e. it does not include the PGY1 year) so that after 5 years the trainee would be eligible for board certification in both specialties.

The intent of a combined track in anesthesiology and critical care is to facilitate the training of the dual anesthesiologist-intensivist. During the CA1 and CA2 years, there would be increased critical care exposure (2 months/year instead of 1), so that by the CA3 year, additional ICU months are performed in a fellow's role with more supervision of junior residents.

The proposed Stanford combined tract would also involve moving some of the CA3 rotations to the CA4 year. This allows residents in the combined track to do OR anesthesia rotations during their last year of training.

The proposed program also offers space in the CA3 year for electives (up to six months). These elective months can be spent doing either critical care relevant rotations (such as infectious disease, transthoracic and transesophageal echo, nephrology, pulmonary medicine) or as research months so that the trainee can design and finish research that facilitates their move toward grant awards and a successful launch to an academic career.

The way it was proposed to ACGME the combined training track would be a separate entity from the standard anesthesia residency with its own match.

This program is expected to attract someone who knows early in medical school that they want to be an anesthesiologist-intensivist. We believe trainees will benefit from the overlapping of the residency and fellowship training that is not allowed by the traditional sequential training (3 yr Anesthesia Residency followed by 1 yr critical care fellowship). Patients in the OR and in the ICU will benefit from physicians cross-trained in both areas.

As soon as there is more to update you with I will,
Thank you,

6 Categorical Stanford Anesthesia Positions

We are delighted to report that we are well underway in being able to offer a Clinical Base Year as part of our Anesthesia Residency.

This means that we would have 6 Categorical Stanford Anesthesia positions, and 18 Advanced (3 year) positions available in the 2012 Match.

The Clinical Base Year is divided into thirteen 4 week rotations and is structured similarly to the Stanford Medicine preliminary medicine year.

A sample schedule would include one each of the following Emergency Medicine, ICU, Anesthesiology, as well as 7 Medicine Inpatient rotations (e.g., General Medicine or specialty inpatient rotations such as Cardiology), and 2-3 consult service (e.g., pulmonary) rotations. One of these rotations could instead be a research elective if discussed with Program Director.

Interns would work alongside the Stanford Medicine Categorical Interns, and participate in Medicine education sessions. Stanford Anesthesia Interns would also spend approximately 2-3 half-days per month half day in the Stanford Anesthesia Preoperative Evaluation Clinic.

Other
4 wks vacation. There is 1 week off between the end of internship June 25 and Stanford Anesthesia Orientation June 30.

PGYIs will be reimbursed $590 towards the cost of USMLE Part III exam. Stanford interns may receive california medical licence reimbursement of partial fees (the $505 application fee) if the application is given to the GME Office to March 1st of internship year. Each resident commencing training in a Stanford house staff program for the first time is eligible for up to $3,000 in housing allowance.
http://gme.stanford.edu/ has details

Thank you,

Best Allergies

Normally I write about residency issues but today it is about our bulletin board which has a sheet of white paper with best allergies written on top and people have been writing in funny Allergies they see in patients medical records.

The list is below with medication followed by side-effect as reported by patients.
Atracurium ---> temporary paralysis
Epinephrine ---> racing heart
Cold chicken ---> nausea
Benadryl ---> anaphylaxis
Morphine (only Dilaudid works)
Epi ---> “I died so they gave Epi”
Dilaudid (only Demerol works)
Sodium ---> leg swelling (in a CHF patient)
Beta Blocker ---> bradycardia
Sterile water ---> rash
Prednisone ---> throat tightness
Amoxicillin ---> UTI
Hay Fever ---> rhinorrhea
All narcotics ---> sleepiness
Epinephrine ---> tachycardia
Ativan ---> drowsiness
Fentanyl ---> stopped breathing
Pain ---> agitated

Resident Research Presentations at the Western Anesthesia Resident Conference

The ACGME and Residency Review Committee for Anesthesiology expects resident involvement in research. This scholarship is necessary because anesthesiologists now and in the future need to be problem solvers for the institution (e.g., need to use QA data to improve clinical care). As a result, we believe experience and understanding of the scientific method, intervention, data collection, and analysis are needed.

Part of the Stanford Anesthesia curriculum is to advance resident knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. We also expect that that the outcomes of resident investigations will be suitable for presentation at local, regional, or national scientific meetings and that many will result in peer-reviewed abstracts or manuscripts. Next academic year every month there are two residents on research rotations.

Dr. John Brock-Utne, former Program Director, wrote the following summary of the Western Anesthesia Resident Conference (WARC) conference held from April 29 - May 1, 2011 hosted by the Dept of Anesthesiology, University of Arizona. John has been a long standing supporter of resident research.
The venue was the West La Paloma Resort, in Tucson. Travel expenses for Stanford housestaff are funded by the Department of Anesthesia.

WARC is specially designed for anesthesiology residents, medical students and fellows from the 19 anesthesiology residency programs in the Western US. Its objective is to promote and encourage academic pursuits by future leaders in anesthesiology.

This year’s WARC had 338 abstracts and oral presentations. This is just two abstract less than the biggest number ever.

Abstracts accepted for presentations by Stanford Anesthesia residents were:
1. Sarah Bain: Prolonged neuromuscular blockade following cardiac surgery in a patient with ESRD after administ4ratin of Clindamycin.
2. Ioana Brisc: A diagnostic dilemma in PACU.
3. Carlos Brun: Paralyzed by beauty or if chins could kill.
4. Michael Charles: Rocuronium induced tachycardia.
5. Jay Jay Desai: Clinical and Cultural perspective: Establishing an immersive international rotation for anesthesia residents.
6. Jay Jay Desai:Ultrasound Popliteal nerve block in a patient with malignant degeneration of neurofibromatosis.
7. Laura Downey: Anesthetic management for a patient with anterior horn disease undergoing serial electroconvulsive therapy.
8. Erin Hennessey: Improving resident education on the post-operative anesthesia care unit rotation.
9. Christine Jette: The sensitive button: Intraoperative diagnosis of a cardiac paraganglioma.
10. Matthew Jolley: Optimization of electrode configuration for subcutaneous ICD using Finte element modeling.
11. Shaun Kunnavatana: The severely agitated ECT patient- An alternative treatment option
12. Vanessa Moll: Three cases of failure to ventilate with the Drager Apollo Anesthesia Workstation.
14. Andy Neice: A case of serotonin syndrome after methylene blue administration.
15. Andy Neice: Design considerations for video bronchoscopes suitable for the developing world.
16. Cat Reid: No laughing matter: Inadvertent exposure to waste anesthetic gas due to machine failure. Is there a solution?
17. Vikas Shah: Pseudohyperkalema in the setting of chronic lympocytic leukemia.(Vikas was at last minute unable to attend)
18. Becky Wong: Thoracic irrigation can produce transient EKG changes that may not be consistent.

Anesthesia Faulty involved with the above abstracts were in no particular order: Vivek Kulkarni, Brendan Carvalho, Jenna Hansen, Jonay Hill, Pedro Tanaka, Jeremy Collins, Suma Ramzam, Vidya Rao, David Soran, Jay Brodsky, Alex Macario, Gillian Hilton, Richard Jaffe, Jon Bradley, Jennifer Lee and John Brock-Utne.

Matthew Jolley did very well and got a first Prize for his oral presentation.

At the same time as the WARC judges were judging, the CSA judges were hard at work to establish the winner for the best CSA Resident presentation. There were 3 awards and I am very pleased that Matthew Jolley got 2nd place. He will collect his price on Saturday May 14 at 11 am at the Annual meeting of CSA in the Fairmont Hotel in San Jose.

Next year WARC will be hosted by UCLA and will be held in Marina Del Rey. It promises to be a great venue and a lot of fun.

Thank you John!

Stanford Opportunities in Global Health

Anesthesia department
Please visit our new website
https://www.stanford.edu/group/globalanesthesia/cgi-bin/mediawiki/index.php/Main_Page
which summarizes a lot of the global health activity in the department.

Also, we have a new global anesthesia fellowship for physicians after residency who aim to spend a large part of their career in international work focused on education, service, volunteerism and the advancement of global health equality. Dr. Ana Crawford is the Program Director for this Fellowship.

Medical School
The Stanford Center for Global Health has a website
http://globalhealth.stanford.edu/
that lists opportunities for residents as well. For example, the center is debuting a new Fellowship, this one in Global Health Media in partnership with NBC News. This program provides practical training in global health reporting using a variety of media platforms including: radio, print, investigative journalism, photography, television and social networking.

Up to two fellows are selected to complete a 12-month fellowship with leading media companies, examples include: NBC News, ProPublica, NING, and the Journal for Health Affairs. Fellows complete training programs through the Stanford University Graduate Program in Journalism and the Kaiser Family Foundation. A documentary filmmaker and an award-winning photographer will train fellows in the impact that still photographs and short films can have on global health. The Fellow may intern with ProPublica learning how to report and work on stories with “moral force”. S/he will also be embedded with Dr. Nancy Snyderman, Chief Medical Editor for NBC News and her producer to research the ‘news of the day’ and learn how Nightly News stories are chosen to be highlighted in the US.