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Obstetric Anesthesiology Division
Introduction IntroductionObstetric health care is an important clinical, educational, and research component of the Department of Anesthesiology and Strong Memorial Hospital (SMH) at the University of Rochester Medical Center (URMC). The patients and obstetricians expect prompt and safe OB anesthesia care. The faculty in OB Anesthesiology provide leadership in all areas of this mission including effective and compassionate patient care, education initiatives for all constituencies, and research to develop innovative clinical care and understand its scientific basis.FacultyThe current OB Anesthesiology faculty team members are:Division director: Richard N. Wissler, M.D., Ph.D. "Core" faculty (n=3): Carol Ann Diachun, M.D., Suzanne B. Karan, M.D., Richard N. Wissler, M.D., Ph.D. "On-call" faculty (n=29): Drs. Bigeleisen, Borovcanin, Cheng, Clark, Cytryn, Davila-Perez, Diachun, Dooley, Dupanovic, Dziak, Finkelstein, Glance, Hadian, Iannoli, Isaacson, Jain, Karan, Kolano, Lucas, Norton, Papadakos, Sabnis, Stone, Thakur, Ward, Wissler, Wojtczak, Zimmerman, Zollo. The "core" faculty (Drs. Diachun, Karan and Wissler) are dedicated members of the OB Anesthesiology Division. One of the most exciting aspects of Drs. Diachun and Karan joining the core faculty in OB anesthesia is the re-establishment of a critical faculty mass for collaborative clinical trials in this field. The clinical team in OB at SMH consists of many members including OB attendings, anesthesiology attendings, anesthesiology residents, OB residents, OB nurse practitioners, OB staff nurses, OR technicians and administrative staff. The NICU staff interact with the OB clinical team as well, particularly at the time of delivery. The OB Anesthesia Division has an excellent working relationship with the other members of the OB clinical team, and this collaboration is reinforced by frequent communication at the leadership level. Patient CareIn keeping with the nature of obstetrics, the OB anesthesia service is designed to provide excellent OB anesthesia clinical care, 24 hours per day, 7 days per week. At all times, there is an anesthesiology attending in SMH with responsibility for the OB anesthesiology service. From 0700 to 1700 on non-holiday weekdays, the department assigns a "core" faculty member solely to the OB anesthesia service to facilitate the resident education mission, in addition to clinical care. During on-call hours (weekends, holidays and 1700 to 0700 on non-holiday weekdays), the anesthesiology attending in SMH has overall responsibility for all anesthesia services including OB and the main OR.The on-call anesthesiology attending in SMH may contact additional on-call anesthesiology attendings or residents to come in to SMH immediately, as necessary for prompt and safe anesthesia care in any location (i.e. workload or case acuity). Anesthesiology residents or occasionally CRNAs are routinely assigned to the OB anesthesia service for educational and clinical experience (under the supervision of the anesthesiology attending). With few exceptions, OB anesthesia care occurs on the third floor of SMH with the following distribution:
Table 1 shows the distribution of vaginal deliveries among these units. Together, 3-1600 and 3-3600 are known as the "Birth Center". Table 1Vaginal Delivery Locations at SMH
Labor neuraxial analgesia is available to patients on 3-1400, 3-1600 and 3-3600. There are two operating rooms for OB on the third floor of SMH (OR-A = 3-2535 and OR-B = 3-2530) plus a third backup OR for OB in the basement (OR#22). Labor epidural carts are stored in the OR corridor that connects 3-1400 with the 3-1600 stem. This corridor is restricted to authorized personnel, except for patients and visitors with an authorized escort. The majority of anesthetics administered by the OB anesthesia service are: 1. Neuraxial labor analgesia a. Lumbar continuous epidural b. Lumbar CSE c. Lumbar continuous spinal d. Saddle block or 2. Anesthesia for cesarean section a. General - usually reserved for emergency cesarean section b. Spinal - most common method - has similar complication profile to epidural, but better quality of block. c. Epidural - may be converted from labor analgesic to cesarean section anesthetic, if functioning well as an analgesic. The workloads for these procedures are shown in Tables 2 and 3. Table 2: OB Clinical Workload at SMH
Table 3: OB Anesthesiology Workload by Billing Codes, SMH, 2002-2004
In addition to these anesthetics, the OB Anesthesiology Division provides care for patients undergoing other OB procedures including: removal of a retained placenta, cerclage placement or removal, postpartum BTL, pregnancy termination (D&E), oocyte retrieval, or fluid resuscitation for peripartum hemorrhage. The OB service periodically requests OB anesthesia "standby" in the OR during a vaginal delivery of twins or a singleton breech, due to the substantial risk of fetal distress requiring an immediate cesarean section. The OB Anesthesiology Division participates in the QI program of the Department of Anesthesiology. This includes the blue sheet on the back of each anesthesiology record. The division director personally reviews approximately 70% of the division anesthetic records, and provides the appropriate feedback to attendings and trainees. Post-anesthetic problems and complications are usually addressed by the anesthesia attending who is assigned to the OB anesthesia service, with appropriate communication to the patient's anesthesia providers and the department QI coordinator. OB anesthesia cases are regularly presented and discussed at a monthly department-wide QI conference. The OB Anesthesiology Division maintains a daily written log book permitting us to track post-anesthesia visits and OB anesthesiology patients with problems or complications even after their discharge. Educational ProgramsThe OB Anesthesiology Division participates in several formal medical student educational programs, as well as clinical teaching of medical students on other OB and anesthesiology assignments. The School of Medicine and Dentistry (SMD) has a formal elective in "Obstetric Anesthesiology", ANS-603. Dr. Wissler designed and implemented this medical student elective in 1994, and has directed it since. The annual enrollment for ANS 603 has varied from 9 to 14 medical students in recent years.In the "Double Helix Curriculum" of the SMD, the third year-medical students have a two week period of "advanced basic science" following each ten-week clinical core clerkship. The basic science course that follows the Women's and Children's Health Clerkship is entitled "Genes to Generations". In 2001, Dr. Wissler designed a one-day course on "Obstetrical Anesthesia" for the "Genes to Generations" course, and he has taught it four times per year since then. This course uses the student's recent clinical observations of labor pain and cesarean sections as a springboard to discussions of the underlying anatomy, physiology and pharmacology. The format includes multi-station demonstrations, case discussions and student presentations. In addition, the medical students enrolled in the Department of Anesthesiology summer fellowship program rotate on several subspecialty services, including OB anesthesia. Anesthesiology resident education is a major emphasis of the OB Anesthesiology Division. The introductory (CA-1 & CA-2) rotation, also known as the Core Curriculum in OB Anesthesiology, is designed for the introductory four week rotation in OB anesthesiology. It is based primarily on the content outline of the Joint Council on In-Training Exams, and has been reorganized in 2005 to include twenty daily topics based on four themes; basic safety principles, labor pain and analgesia, OB-specific clinical issues, and outcomes in OB anesthesia. The recent reorganization of the curriculum incorporated OB anesthesiology keywords/topics based on University of Rochester anesthesiology resident performance on recent ABA In-Training and AKT-18 exams. The current text for the Core Curriculum is "Obstetric Anesthesia: Principles and Practice", ed. David H. Chestnut, 3rd edition, 2004, with supplemental peer-reviewed publications assigned by Dr. Wissler each month. The department has purchased several copies of the Chestnut text for the residents and medical students to borrow during rotations on OB anesthesiology. In the Advanced Elective in OB Anesthesiology (CA-3), the residents are given more responsibility in the daily management of the clinical service and more choices for educational activities. Examples include the Core Curriculum, directed readings on specific advanced topics, and participation in research or administrative projects. In addition to educational activities within the subspecialty curriculum, the core faculty provides a regularly scheduled series of lectures in OB anesthesia for the anesthesiology resident general curriculum. The Division of Obstetric Anesthesiology offers a 12-month clinical fellowship in OB Anesthesiology at the CA-4 level. The emphasis of the fellowship is on individual educational programs based on the career goals of each fellow. Components of a fellow's educational program may include patient care, supervision of residents and medical students, didactic teaching in our daily OB Anesthesiology conferences, clinical research, and administration. Fellows with an interest in laboratory research are encouraged to apply, provided they are willing to invest a minimum of 24 months in academic development in this area. The goal of the fellowship is to provide the best possible educational experience for the next generation of leaders in OB anesthesiology. The OB Anesthesiology Division continues to be an active participant in interdisciplinary OB patient safety initiatives at SMH. Dr. Wissler is a faculty member in the OB Team Training Program initiated in 2004 by MCIC. Also, Dr. Wissler is a member of the task force that is designing an interdisciplinary education program in OB Hemorrhage Management that will utilize human patient simulation (implementation in late 2005). |
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