behind the screenthe newsletter of the department of anesthesia

Volume 1 • Number 2

FellowshipGraduating residents and fellows highlighted

& Much more...prominent research...global outreach...new oRs...

2 3behind the screen behind the screen

I was honored when Enrique Pantin asked me to write an article for the newsletter about Valerie’s re-tirement. However, I’m not sure if he wanted my input or he couldn’t find another person brave enough to write a story about Valerie.

Well, either way, here it is:

I worked alongside Valerie in the Clinical Anesthesia Office for seven years. This was back in the day when Dr. Klein was our chairman and Drs. Kortis and Wugmeister were the clini-cal directors and there were about fif-teen anesthesia faculty members and ten residents. We used MultiMate® and WordPerfect® on our desktops and e-mail was unheard of.

The clinical office has always been a hectic and chaotic place to work with people constantly com-ing and going, the copier running, phones ringing off the hook and a million personalities all at once. At that time Valerie already had worked for the University for thirteen years and had a streamlined system in place for running the office.

As far as I was concerned, she knew everything there was to know about working for the University and running that office. I quickly learned that Valerie belongs to that rare group of very special people that commit to their job on a daily basis, even when the going gets tough. Valerie is an amazing teacher and her work ethic is second to none. She is one of the first staff in every day, never comes back late from lunch and never leaves early. She is someone you can count on to keep the office routine going day in and day out. And most impor-tantly, there is never any doubt; you always know exactly where you stand with her.

I’m sure that after working for the University for almost 36 years, re-tirement is a big deal and a big step. I’m sure Valerie is very happy and a little melancholy about retirement

Letters

On January 15, 2014, we launched the first issue of behind the screen, the newsletter of Department of Anesthesiology at Rutgers Robert Wood Johnson Medical School. Too often we hear from others, “What does an anesthesiologist do?” We hope that with this newsletter we can spread the word on issues related to anesthesia within our institution but in general as well.

This periodical will be available in printed format at our office and various patient care units throughout the hospital, and electronically in our Anesthesia Department webpage at:

http://rwjms.rutgers.edu/departments_institutes/anesthesiology/about/newsletter.html

We are happy to hear any comments from you!

Regards,

The behind the screen Editorial Teambehind_the_screen@hotmail.com

behind the screen

Farewell: Valerie Lisotto Retires

Enrique PantinQuiana Fraizer

Ashley GlorNeethu Kumar

Sagar S. MungekarDiane Ridley

Editor-in-ChiefAssociate EditorAssociate EditorAssociate EditorAssociate EditorAssociate Editor

Department of AnesthesiaRutgers Robert Wood Johnson Medical School

Clinical Academic Building 3100125 Paterson Street

New Brunswick, New Jersey 08901-1962United States of America

Unless otherwise noted, all content is copyright by and the intellectual property of behind the screen and may not be copied, reproduced, distributed, or displayed without express permission. The information contained herein is neither intended nor implied to be a substitute for professional medical advice; rather, it is provided for educational purposes only. The views expressed are not necessarily those of the Medical School or Rutgers, the State University of New Jersey. Informed consent was ob-tained as required. Correspondence may be directed to the address above or electronically to the address at the left. ©2013–2014

by Nancy Szkodny

Newsletter layout and design by Sagar S. MungekarCover photos by Enrique Pantin

and beginning of the next chapter of her life. I know you will all miss her morning greeting to you as you pass by her desk, the go-to person when we have questions, her dry sense of humor, her willingness to listen to you—especially when facing some real obstacles, and most of all her “off like a prom dress” remark every afternoon at 4:00 p.m. sharp.

I think I speak for everyone when I say this is a bittersweet moment…saying goodbye to a good friend and coworker who I believe has made the Anesthesia office a better, hap-pier and more productive place to work. I know her dedication to the department will be sorely missed and I know she will not easily be forgot-ten or replaced.

Happy retirement Miss Valerie, from Miss Nancy and everybody at the Department!

Here is something I will always remember:

When I first started my residency, I did not drive. I did not even

have a driver’s license.

On quite a few occasions, Valerie drove me home, and on other occasions, to the mall after work.

For a foreign graduate at my first job, it meant a lot.

Just a reminder of some of the really nice things she has done over the

years…under the radar.

—Rose Alloteh

Photo: Sagar S. Mungekar

Photo: Enrique Pantin

Valerie Lisotto, program assistant, poses for a picture at her desk in the Clinical Anesthesia Office during her last month before retirement.

Cover: Former fellows Darrick Chyu and Phat Trihn (cardiothoracic anesthesia) and Branson Collins and Sloane Yeh (pain medicine).

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Besides the many day-or-two– visits we have had from other institu-tions and countries, our department, with hospital support—specifically the Division of Cardiac Anesthesia, has hosted an anesthesia resident from Colombia who stayed with us for a total of three months, and with-

News: The anesthesia department...

Over the years our Department has been involved in several ventures beyond the limits of our hospital

building, New Jersey, and the United States of America.

by Enrique Pantin

...spans the globe

in this past year one from Spain and one from Venezuela. All these inter-national visitors sought us thanks to information disseminated by others and some by our publications.

The first of our two latest visi-tors, Dra. Gabriela Agámez Medina, was a fourth-year anesthesia resident from the Hospital Uni ver si ta rio Fun da­ción Alcorcón in Madrid, Spain, who stayed with us for two months. The other, Dr. Ricardo Pumar, a recently graduated anesthesiologist from Ven-ezuela, spent a total of three months.

During their stay they were fully integrated in all of the academic ac-tivities in which our Cardiac Anes-

My rotation in echocardiog-raphy has been an enriching, extraordinary experience that motivated me and injected energy and additional drive to become better every day.

[It was] a significant academic challenge and time commit-ment, but every hour spent…even the late nights studying

and working on improving my English was very worthwhile.

It is a very competitive en-vironment that forces you

to give the best of you.

Thanks to the efforts of the whole cardiac anesthesia

team, cardiac anesthesia fel-lows, anesthesia residents,

nurses, perfusionists, techni-cians, and anesthesia secretar-ies that received me as in my house and made my stay to be as pleasant as possible.

—Gabriela Agámez Medina

thesia Fellows engage. They observed what is done in cardiac anesthesia and other anesthesia areas and each presented two cardiac anesthesia–re-lated topics. Their educational com-ponent emphasized learning echo-cardiography. Dra. Medina published the case report, “Anestesia para correc­

ción de escoliosis en paciente pediátrico con ataxia de Friedreich” in Revista Es­pañola de Anestesiología y Reanimación.

These interactions not only ben-efit the visitors, but their professional community. After her rotation here, Dr. Agámez remarked, “in my hos-pital I am promoting the interest in echocardiography for the periopera-tive management of patients, teach-ing my colleagues what I have learned with the tools you provided me”.

We also learned from our visitors how a similar case is managed else-where, and what differences in the practice of medicine there are.

One of the things we asked of our

visitors is to provide us feedback of what could help us improve—what-ever that may be. We have learned that most differences are related to limited resources and technology, and that unfortunately we do waste many more resources than actual sci-entific data would be able to support we have to—mostly related to regula-tory issues.

We know we still have room for improvement, and becoming waste conscious and add a “green” men-tality to health care is one of the challenges ahead of us. We hope to continue to foster curiosity in our Department and welcome colleagues interested in being a part of us.

Photo: Enrique Pantin

Dr. Gabriela Agámez Medina of Spain and Dr. Ricardo Pumar of Venezuela pause in the cardiac “pump room” between cases in November 2013 during their international rotation at Rutgers Robert Wood Johnson Medical School.

In 2007, a Robert Wood Johnson University Hospital (RWJUH)–Uni-versity of Medicine and Dentistry of New Jersey (UMDNJ) team lead by Dr. Peter Scholz, and Dr. Alann So-lina traveled to Saint Petersburg to teach cardiac surgery techniques. The recent mission to Egypt was borne from that initial educational endeav-or.

Those who engage in scien-tific research and development continually strive for safer, quicker, and more cost effec-tive improvements to existing surgical approaches. The birth of minimally invasive surgical techniques has done just that. With its reach to cardiac sur-gery, patients are having a less painful and quicker recovery time.

Minimally invasive cardiac procedures require a smaller incision between the patient’s ribs or the breastbone or ster-num, replacing the classical complete incision through the sternum. This approach is not only a game-changer for the pa-tient, but also presents a differ-ent set of skills for all who par-ticipate in these patients’ care.

While presenting on Mini-mally Invasive Cardiac Surgery (MICS) at an international conference in Cairo, Dr. Mark Anderson, caught the eye of the Egyptian Ministry of Defense. The Egyptian authorities asked for assis-tance in developing their own MICS program. Dr. Anderson met with us and teamed with Dr. Pantin to work on setting up a training program for the Egyptian team.

In January 2011 with the support of Amy Smith, former Vice-President of Perioperative Services and Dr. Christine Hunter, Chairman of An-esthesia, Drs. Anderson and Pantin formed a team that embarked on

what would become a multi-year mission including nurses and perfu-sionists from RWJUH.

These individuals collaborated on this training mission directly with the Egyptian government in a mili-tary medical facility that had an ex-isting cardiac surgery fellowship at El Galaa Family Hospital in Cairo.

This endeavor encompassed more than just teaching new cardiac surgery and anesthesia techniques. MICS changes many aspects of the perioperative period: pre-operative patient selection, intraoperative nurs-ing and perfusion services, cardiac anesthesia, and post-operative care given by cardiac nurses and the criti-cal care team. The training program extended not only to operative train-ing of existing cardiac surgeons and fellows, but also to operative organi-

zation, supplies, equipment training.“For the initial visits we had a

great amount of support on special-ized medical supplies donated by Edwards Lifesciences, LLC, and for all the trips RWJUH supported us with not only with personnel but supplies as well,” Dr. Pantin explained.

“The pace of the program devel-opment has been slower than expected,” explains Pantin, “but is understandable as the local resources are very differ-ent and the country is under-going large transformation.” Adding to this, El Galaa Family Hospital rotates their surgeons with each yearly visit. While our team has encountered new physicians eager to learn, this rotation also generating a slow-er knowledge and skill learning curve, as would be expected

To date, Drs. Anderson and Pantin have participated in fifty-four MICS procedures in Cairo, that first case in January 2011 being the first MICS on the continent, as reported by the Egyptian government.

The collaborative support for the MICS training program has continued even after the departure of Anderson in 2013. Joint efforts from RWJUH pro-viding perfusion and nurs-ing personnel, Rutgers Robert Wood Johnson Medical School

providing anesthesia support, and Albert Einstein Medical Center in Philadelphia, make the program a reality. The effort to train, teach, and improve patient’s lives will continue with the leadership of Drs. Anderson and Pantin.

Pantin concludes, “Our Egyp-tian colleagues are able to success-fully face cases with a new set of tech-niques and tools like never before, and for that we are very proud of be-ing able to take some credit for it.”

Reaching as far as Egyptby Ashley Glor

Members of the MICS mission-to-Egypt team.Back row, left to right: Dr. Enrique Pantin (Anesthesiologist, RWJUH, New Brunswick, NJ), Dr. Osama Galal (Anesthesiologist, El Galaa Family Hospital, Cairo, Egypt), Angela Kutchera (Perfusionist, Einstein Hospital, Philadelphia, PA), Dr. Tamer Ayed (Cardiac Surgeon, El Galaa Family Hospital, Cairo, Egypt), Dr. Mark Anderson (Cardiac Surgeon, formerly RWJUH, now Einstein Hospital), Dr. Walee (Cardiac Surgery Fellow, El Galaa Family Hospital), Dr. Sami (Cardiac Surgeon, El Galaa Family Hospital), unnamed ICU nurses, El Galaa Family HospitalFront row: Dr. Sherif and Dr. Wael (Cardiac Surgery Fellows, El Galaa Family Hospital) and Dr. Mamdoh (Cardiac ICU Intensivist, El Galaa Family Hospital)Not pictured: Andrew Israel (Perfusioninst, RWJUH); Anna De Bari (RN), Maria “Malu” Asunción (RN), Kala Varughese, (RN), and Mary O’Brien (RNFA) (Cardiac nursing team, RWJUH; Gwen Staffiera (Perfusioninst, Einstein Hospital.

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Graduating Residents

Dr. Candy Anim will remain with us as a fellow in pain medicine.

Dr. Andy Burr, former chief resident, will work as an at-tending anesthesiologist at the University of Rochester, Rochester, NY.

Dr. Mohammad Chau dhry will stay with us as a fellow in cardiothoracic anesthesia. Take advantage of five matters before five other matters: your youth, before you become old; and your health, before you fall sick; and your richness, before you become poor; and your free time before you become busy; and your life, before your death.—Prophet Muhammad SAWS

Dr. David Delatte will stay with us as a fellow in pain medicine.

Dr. Ali Dinani will be joining the staff at Kingsbrook Jewish Hospital in Brooklyn, NY.

Never regret anything, because at one time, it was exactly what you wanted.

—Unknown

Dr. Sabrina Haque will work as an attending anesthesiolo-gist at the Albany Stratton VA Medical Center in Albany, NY.

Each of us has much more hid­den inside us than we have had a chance to explore.Unless we create an environ­ment that enables us to discover the limits of our potential, we will never know what we have inside of us.

—Muhammad Yunus

Dr. Aysha Hasan will join a fellowship program in pedi-atric anesthesia at the Chil-dren’s National Medical Cen-ter in Washington, DC.

You only live once, but if you do it right, once is enough. —Mae West

Dr. Ankit Kapadia will work as an attending anesthesiolo-gist with the Advanced Anes-thesia Group in Christ Hospi-tal in Jersey City, NJ.

Dr. Jane Kim will work as an attending anesthesiologist with the Advanced Anesthe-sia Group in Christ Hospital in Jersey City, NJ.

Dr. Sana Shaikh will join a fellowship program in pe-diatric anesthesia at Case Western Rainbow Babies and Children’s Hospital in Cleve-land, OH.

Wherever you go, no matter what the weather, always bring your own sunshine.

—Anthony J. D’Angelo

Dr. Tatyana Shkolnikova will join a fellowship program in cardiothoracic anesthesia at the University of Washing-ton, Seattle, WA.

Dr. Heather Skiff, former chief resident, will join a fel-lowship program in pediatric anesthesia at the Children’s Hospital of Philadelphia in Philadelphia, PA.

Love is state of perpetual anes­thesia.—paraphrased from a quote

of Henry Louis Mencken

Dr. Darrick Chyu will stay as an attending cardiotho-racic anesthesiologist at Rob-ert Wood Johnson Medical School in New Brunswick, NJ.

Dr. Phat Trinh will work as an attending cardiothoracic an-esthesiologist at Lawnwood Regional Medical Center in Fort Pierce, FL.

Dr. Branson Collins will work as Director of Pain Medicine at Saint Alphonsus Medical Group, Boise, ID.

It is the journey not the destina­tion that matters—paraphrased from a quote

of Greg Anderson

Dr. Sloane Yeh will work as an attending anesthesiologist and pain management physi-cian with Advanced Anesthe-sia and Pain in Hoboken, NJ.

Graduating Fellows

Photos: Enrique Pantin

Dr. Shruti Shah led a large randomized prospective trial designed to test whether reinserting the plastic obtura-tor or stylet into the epidural needle after the needle had pierced the skin and upon reaching the ligamentum flavum could reduce the incidence of accidental dural puncture. The investigators noted that this action could unmask a sub-dural puncture or an unnoticed epidural needle placement and postulated that a blood clot and/or a flap of pierced ligament may occlude the lumen of the needle used for epidural analgesia, preventing loss-of-resistance to air despite having reached the epidural space. They evaluated 1000 patients and noted that reinserting the epidural needle ob-turator upon reaching the ligament flavum decreased the risk of epidural perforation from 2.4 per cent, when this technique was not used, to 0.4 per cent, thus demonstrating that a simple technique can reduce the relative risk of this complication by over 83 per cent. This work was presented as a poster entitled “Does stylet reinsertion upon piercing the ligamentum flavum with an epidural needle reduce the incidence of accidental dural puncture?” at the sixty-sixth annual PostGraduate Assembly of The New York State Society of Anesthesiologists in December 2012.

Anesthesia, as a field, has pioneered patient safety for several decades. Complication rates continue to drop largely through research and education. Members of our department con-tinue to contribute original work to this global field. In the past academic year, we have authored 20 manuscripts in peer-reviewed journals, presented over 100 posters at national and

international conferences, gave 12 invited lectures around the globe, and wrote 33 book chapters. Here, we highlight a few of the noteworthy contributions. A full listing is available online.

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Dr. Steven Ginsberg, in collaboration with the anesthesia departments of Stony Brook University and the University of Miami, has coedited, the 2nd edi-tion of Board Stiff TEE: Transesophageal Echocardiography, published in April 2013.

Members of the Robert Wood Johnson Medical School Department of An-esthesia wrote six of the twenty-four chapters. This endeavor was a great op-portunity for our department to be involved in scholarly activity showcasing the works of residents, fellows and attending physicians.

This book is a fun and effortless way to learn everything about TEE. It is a complete introduction from the physics of ultrasound, recognition of structures from images, to the hemodynamic calculations derivable from TEE. It reviews all of the knowledge covered in the new competence examination for periopera-tive transesophageal echocardiography (PTEeXAM). It is a highly effective and enjoyable medical reference book not only ideal for those taking the boards, but it is also a great overview for anyone looking to stay up-to-date on this in-creasingly important monitoring modality. It is a launching pad for the medical student, the anesthesiologist, the surgeon, or the intensivist, who asks, “Where do I start?”

Similar to the writing style of a previous departmental collaboration, Anes­thesia Unplugged, Board Stiff TEE is jam-packed with simplified drawings illustrat-ing salient points coupled with a humorous approach that will keep the reader’s eyes open and airway from obstructing.

Epidural anesthesia is the standard modality of pain control for laboring patients. To place the epidural block, the anesthesiologist inserts a specialized needle under local anesthesia into the woman’s back. Often the anesthesiologist uses a loss-of-resistance to attempts to pump small amounts of air or saline through the needle while slowly advancing it. Whereas subcutaneous tissue and the ligaments around the spine do not easily expand, once the needle enters the epidural space, air or saline can easily be pushed through with little resistance. This is a blind technique: the anesthesi-ologist cannot actually see where the tip of the needle is but rather relies on the tactile sensation of the plunger of the syringe to detect entering the space just outside the dural sac that surrounds the spinal cord bathed in cerebral spinal fluid (CSF). After the epidural catheter is inserted, a test dose of medication is injected to confirm the placement.

The epidural space is often very small, and fractions of millimeters may determine whether the tip of the epidural needle is in the right space or has gone too far. That complication—the accidental dural puncture—results in the return of CSF through the needle. Though neither life-threatening nor severe, the accidental dural puncture plagues approximately 3 of 500 attempts at epidural anesthesia using the aforementioned technique and causes morbidity. Approximately 86 per cent of women with a dural puncture suffer from positional headache (ones that worsen when sitting up), which are often accompanied by nausea, blurry vision, ringing ears, and dizziness, sometimes persisting for days to weeks.

The standard treatment of this complication is the epidural blood patch, wherein a small amount of the patients own blood drawn from a peripheral vein is injected into the epidural space.

Traditionally, this technique is performed after the headache and other symptoms arise and after conservative techniques such as taking caffeine, fluids, and acetaminophen have proven ineffective. Only then is another epidural injection performed injecting the patient’s blood.

Drs. Mark Stein and Shaul Cohen of our department sought to test an alternative solution. What if instead of waiting for these symptoms to arise and then subjecting the patient to another injection in the back, the patient’s own blood was prophylactically injected through the catheter that was already there. This technique was previously considered controversial since its efficacy and safety was not known. Their study addressed this very question. After obtaining approval from the institutional review board, over several years, the two investigators took over a hundred women who suffered accidental dural punctures and randomized them to two groups: one would receive the tradi-tional regimen of conservative treatments eventuating in a therapeutic blood patch if symptoms occurred and per-sisted, the other group would receive blood through the epidural catheter after the complication occurred but before the symptoms set in. The results showed a significant difference between the two groups. In the first group, almost 80 per cent of women went on to developing a headache and needed the therapeutic blood patch. In the second group, only about 18 per cent had the symptoms, and they were less severe.

“Prophylactic vs therapeutic blood patch for obstetric patients with accidental dural puncture – a randomised controlled trial” was published in the journal Anaesthesia (2014, 69, 320–326). Drs. Stein and Cohen believe that the results from this study will change how anesthesiologists will address the accidental dural puncture, potentially saving scores of women from the debilitating symptoms that arise at a time when she should be enjoying the birth of her child.

Background photo: Bookshelf in the Clinical Academic Building Anesthesia Library by Sagar S. Mungekar; Anesthesia and Analgesia is the copyrighted title of a scholarly journal of Wolters Kluwer Health, Inc. Unless otherwise stated, no reference is made to this journal.

Mastisol® is a registered trademark of Ferndale IP, Inc, Ferndale, Michigan.

Dr. Shaul Cohen led a prospective clinical trial investigating whether suturing the epidural catheter to the skin can reduce the incidence of a properly function-ing epidural block that subsequently failed often due to catheter dislodgments. The study included 1,324 parturients requesting an epidural block for labor and vaginal delivery or cesarean section. The patients were randomized to one of two groups. In one, 660 parturients had their epidural catheters sutured with 3-0 silk suture at the insertion site and then looped downward 5 cm. In the other group, 664 parturients had their epidural catheters looped downward 5 cm in the same manner without being sutured. In both groups, after catheter was looped, Masti-sol® liquid adhesive and transparent dressing were then applied. Results showed a significant reduction in catheter movement and need for reinsertion, one-sided anesthesia, catheter puncture of epidural vessels, and increase in overall success of the epidural block. These results were presented as a poster entitled “Suturing the epidural catheter reduces the incidence of failed epidural block in obstetric pa-tients” at the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th annual Pain Medicine meeting in Miami, FL in November 2012.

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One typical example, which I have remembered fondly for nearly thirty years follows.

I was supervising two nurse anes-thetists in two operating rooms when I was approached by the head nurse. She pointed out to me a surgeon in the lounge whom I had not seen before. She said he was an urologist who used to do over 150 cases per year at our hospital, but as a protest against the presence of the medical school, had moved nearly all of his surgical cases to St. Peter’s Hospital.

Maybe I could go talk to him and see if I could use my vast supply of charm to get him to reconsider?

I eagerly approached him with a welcoming smile, introduced myself as the new chief of anesthesia and asked if there was anything I could do for him that would make his life easier, getting him to reconsider his move to St. Peters.

“Yes, he said, [pregnant pause]you and all the members of the Uni-versity staff can drop dead!”

Me: “What’s your second request, you aren’t getting your first.”

Another flash point: Because the private practice used its full comple-ment of personnel every day in the

operating room (OR), and because I insisted that they also do night call in proportion to the percentage of the ORs that they staffed, they used cer-tain short cuts.

A large proportion of the patients whom they attended at night arrived in the recovery room intubated. The anesthesia staff then left for home (preferred) or the call room, leaving orders for the recovery room nurses to extubate when they thought the patient was ready.

When I found out about this practice, I met with the head nurse of the recovery room and asked what training her people had on reintuba-tion. The answer was “none”, but it did not matter (she said) as no pa-tient had ever gone into respiratory distress to the point where reintuba-tion was necessary.

I asked for the records proving this belief, and to my barely hidden surprise there were none. I ordered the practice to stop, telling people that if they could not be sure they could get a tube back in, they were not allowed to take it out. This meant that the private practitioners had to either extubate patients in the OR or wait around in the recovery room to

manage any late airway problems. This increased my popularity enor-mously.

But it was not all fun and frivol-ity: Within two years we established the first full service pain clinic in New Jersey, which was one of the earlier in the country. We actually were written up in, I believe, the Ladies Home Jour­nal for this accomplishment.

People standing in line in super-markets everywhere, who grabbed a copy of this magazine, heard of us.

The private practice people flat out refused, and had it written into their contract with the hospital, that they would not cover the obstetri-cal floor past four o’clock every day. This made our staffing and on call schemes complicated, but built our reputation, as we provided a level of service the hospital had not seen be-fore.

This may or may not have con-tributed to the suicide death of our first chief of OB. Anesthesia, who, according to the coroner’s report, died of a self-injected intravenous dose of the now ancient drug Brevital (methohexital). Since this drug was by no means a favorite of addicts, the death was ruled intentional.

* * *Next time: We start the residency

and our money disappears.

History of our Department, Chapter Two by Sanford Klein

Watch for the continuation of this story in the following issue of behind the screen.

I mentioned in the first installment of this history, the animosity that flavored every interaction be-

tween the University faculty and the private practi-tioners both anesthesia and surgical, who felt threat-ened by our presence and potential for growth.

Photo: Sagar S. Mungekar; Logo, seal, and marks are property of Rutgers, the State University of New Jersey

Traditionally viewed as the gate-keepers of drugs, pharmacists at Rob-ert Wood Johnson University Hos-pital are becoming more clinically involved with patient care. Along with compounding and distributing intravenous drugs, pharmacists pro-vide clinical services in the operating room, including educating the staff about drugs, making recommenda-tions on adjusting drug treatments, and participating in medical emer-gencies or “codes.”

In the operating room, pharma-cists draw on their wealth of drug knowledge and experience to provide information. Whether questions come from a physician, nurse, or pa-tient, pharmacists willingly devote

their time to inform them about ad-verse effects, compatibility of differ-ent intravenous drug solutions, and drug interactions.

After reviewing a patient’s demo-graphic information, allergies, and pertinent laboratory results, phar-macists may also recommend mak-ing changes to drug treatments such as adjusting the dosage to avoid the unwanted side-effects from interac-tion with another drug or changing the frequency of administration if a patient’s kidney function is compro-mised.

The pharmacist will then com-pound the drug. In the operating room, common drugs that are pre-pared include antibiotics, vasopres-

sors, and coagulation products. Along with distributing any important drug information to healthcare providers prior to drug treatment, pharmacists track patient outcomes by observing the results of the treatment.

Pharmacists also play a key role in monitoring the usage of narcotic drugs in the operating room. Daily, a pharmacist reconciles healthcare pro-viders’ narcotic records by review pa-tient anesthesia records for accuracy and completeness.

By providing information and recommendations, by compounding and dispensing, and by reconciling narcotic drugs, pharmacists play a pivotal role in caring for patients in the operating room.

The Role of the Pharmacistby Ken Hau and Rich Tyska

Ken Hau (left) and Rich Tyska (right), both doctors of pharmacy, compound, prepare, and distribute medications in the operating room (OR) satellite pharmacy, rapidly serving anesthesiologists and other staff members in the OR suite.

Photos: Sagar S. Mungekar

On September 1, 2006, when we were known as the UMDNJ-Department of Anesthesia, we be-gan providing anesthesia services at Southern Ocean Community Hos-pital (SOCH), a small, standalone community hospital along the Jersey Shore.

Today, more than seven years since the beginning of that relation-ship, our department, Rutgers Rob-

In anesthesia, two extremes de-fine a continuum, from general anes-thesia to monitored anesthesia care. In the former, the patient is uncon-scious, immobile, and does not feel pain--or at least pain that will be remembered--and the body’s auto-nomic responses are manipulated as necessary to keep the patient safe. In the latter, often abbreviated “MAC”, the patients’ vital signs are monitored while a procedure is performed. The anesthesiologist and assistants may

administer medications in case the patient does not tolerate the planned intervention.

During MAC, the level of seda-tion can vary, including “deep” (very close to general anesthesia), “mod-erate” (sleepy but can be aroused), “light sedation” also called “anxioly-sis”, and “just being there” to moni-tor vital signs while reassuring the patient verbally.

How Many Types of Anesthesia are There? Sister Department: SOCHby Enrique Pantin by Mordechai Bermann

continued on page 14 continued on page 14

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Pediatric Operating Room Suite

The Bristol-Myers Squibb Children’s Hospital at Rob-ert Wood Johnson University Hospital opened its

doors to the new pediatric operating room suite ear-lier this year. Staffed by pediatric anesthesiologists and

pediatric surgeons in the following specialties: general surgery, hema-tology and oncology, neurosurgery, ophthalmology, orthopedics, otolar-yngology, plastic surgery, and urol-ogy, this OR suite has seen an ever increasing volume of cases. Recently, the staff celebrated the completion of one hundred cases in less than a week, a number which has since been exceeded.

Dr. Valerie McRae, pediatric anes-thesiologist, and the lead consultant in the design of this suite explains, “Every detail was considered” when the operating rooms were developed, using state-of-the art equipment. Rooms like the one above provide the anesthesiologist with machines and equipment specifically sized for pediatric patients ranging from pre-mature infants to young adults.

A panoramic composition (top) of one pediatric operating room highlights the state-of-the art equipment available to anesthesiologists and surgeons. The modern design is carried over to the waiting room for patients’ families (right) where they experience a panoramic view of the surroundings behind an electronically controlled privacy glass wall.

Photo and composition: Sagar S. Mungekar

Photo: Sagar S. Mungekar

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Anesthesiologists can also just anesthetize a portion of the body by applying medications near nerves. Needles can be placed near the spi-nal cord and, depending on exactly where the anesthetic is placed, an epidural or spinal anesthetic can be performed, resulting in deep or total analgesia (no pain) from the upper chest down. Many people call these “epidural anesthesia” or “spinal anes-thesia” and over the years these terms have been accepted, but in reality un-less we give additional medications to make the patient unconscious these are really “spinal and epidural anal-gesia” techniques. Finally once the nerves come out of the spinal canal many of them can be anesthetized in their path through the body to create analgesia in a particular region, or lo-cal anesthetic can just be applied by infiltrating around the proposed op-erative area, most of the time this last one is done by the surgeon.

ert Wood Johnson Medical School Department of Anesthesia and the hospital, Southern Ocean Medical Center (SOMC), one of five Fortune 100 Meridian Health System hospi-tals, are continuing to strengthen the symbiotic relationship between an academic department and a commu-nity hospital.

Our department includes seven physicians and two anesthesia ad-vance practice nurses who provide services in four operating rooms, the labor and delivery suite, the en-doscopy, and for interventional ra-diology procedures. Our most re-cent staff addition is Sherine Hanna, MD who joined us in January from Loyola University in Chicago. Medi-cal students from the School of Os-teopathic Medicine (SOM) in NJ, as well as students from other schools have the option to do their elective anesthesia rotation with us. We also provide a clinical training site for the

Anesthesia Technology Program at the Sanford-Brown Institute.

Last year, our surgical volume increased by about 7% compared to the previous year. Currently, we are in the process of adding electronic medical records (EMRs) to all of our locations and are busy populating all of the necessary pages. This system will improve our clinical and billing documentations, and provide data collection for research purposes. We look forward to implementing qual-ity matrices and participating in the American Society of Anesthesiolo-gists’s (ASA’s) Anesthesia Quality In-stitute Registry. The project allows our department to be compliant with Centers for Medicare & Medic-aid Services (CMS) requirements and prepares us to be an effective team in future payment models such as the ASA’s Perioperative Surgical Home (PSH) or any Accountable Care Or-ganization (ACO).

Types of Anesthesia SOCHcontinued from page 11 continued from page 11

At Rutgers Robert Wood Johnson Medical School Department of An-esthesia we believe that education is the foundational building block for

any solid career and. That is why we have partnered with the first accred-ited Anesthesia Technology program in the state of New Jersey, The San-ford Brown Institute. Sanford Brown opened its doors to their first anes-thesia technology class in April 2009 and to date, seventy-three persons have graduated. They offer an eigh-teen-month program that consists of thirteen months in class and a five-month externship at various hospi-tals in New York and New Jersey that have been approved by the American Society of Anesthesia Technologists and Technicians (ASATT).

Under the direct supervision of Quiana Frazier as the Anesthesia Manager at RWJUH and Dr. Enrique Pantin, in the summer of 2013 the anesthesia department received its first anesthesia technology externs.

The externs rotate through all areas that anesthesia is administered including but not limited to: adult and pediatric operating rooms, hold-ing areas, the labor and delivery suite, special procedures and radiology rooms, the endoscopy suite, and the cardiac catheterization laboratory. While rotating these areas, externs are placed with a preceptor, who is a member of the anesthesia techni-cal staff and it is here that they learn their anesthesia technical role. The educational environment that is pro-vided equips the externs with real- world clinical experience that will help them in assisting the anesthesia provider during unforeseen emer-gency situations in the preoperative, intraoperative and postoperative phases of anesthesia.

We are confident that all the ex-terns who have rotated through our facility will be ready to use their learned in clinical skills in their pro-fession. After the successful comple-tion of the entire program, the school offers career services support to as-sists the graduates in finding jobs.

We are very proud on being able to not only serve our patients but also to have an opportunity to be part of the education and training of the new generation of anesthesia technologists.

As the Program Director for the Adult Cardiothoracic Anesthesia Fel-lowship, I am delighted to be part of a dynamic and talented team of cardiothoracic anesthesiologists. Our fellowship program offers our two fellows a tremendous opportunity to experience and care for some of the sickest patients in the most challeng-ing of cases.

Procedures span the full gamut from a coronary artery bypass graft-ing case in a patient with a good heart function to a patient needing a heart transplant with a ventricular as-sist device in place.

The fellows take part in weekly lectures and give the department yearly lectures. They rotate through various disciplines including the

cardiac catheterization laboratory, intensive care unit, cardiology, the electrophysiology laboratory, thorac-ic surgery cases, and perfusion. They even scrub with a surgeon for certain cases and help to educate junior resi-dents in cardiothoracic anesthesia and echocardiography.

This year we have the talented Dr. Darrick Chyu who will be joining us on faculty. Recently graduating fellow Dr. Phat Trinh started a position in Fort Pierce Florida. We look forward to this academic year, in which Dr. Chaudhry, former resident remaining on as a fellow, and Dr. Marco DelCas-tillo joining us from Iowa where he was a member of the junior faculty, will continue the tradition of educa-tion and excellent patient care.

Quiana Frazier, anesthesiology technician and Anesthesia Manager at Robert Wood Johnson University Hospital and Medical School supervised the anesthesiology technology program of the Sanford Brown Institute, the first in the state to be accredited.

Anesthesia Technology Education

by Quiana FrazierPhoto: Sagar S. Mungekar

Adult Cardiothoracic Anesthesia Fellowshipby Steven Ginsberg

Dr. Alann Solina, professor, chief of cardiothoracic anesthesia, and vice-chair of the department jots notes in the anesthesia library while developing new ways to improve efficiency in the operating room.

Ashley Glor grew up in Alabama as part of a large family of seven children. She completed her under-graduate education at Virginia Com-monwealth University, worked eight years as an intensive care unit nurse, and completed her Master of Science in Nursing Anesthesia at the Univer-sity of Pennsylvania. Her first job as

a nurse anesthetist was here, where she became the clinical coordinator for Rutgers nurse anesthesia students. During Ashley’s last three years here, she has enjoyed the challenge of working as a team with the attend-ing anesthesiologist and surgeons to create the best anesthetic plan for each patient. To describe her view of anesthesia, Ashley quotes one of her mentors, “Anesthesia providers are like ninjas: expertly vigilant, we go in, do our job ,and leave without a trace”

Our department of anesthesia has been fortunate to have Ashley Glor as a professional colleague and as a friend. She now looks forward to a new position in private practice at Memorial Regional Richmond, Vir-ginia that brings forth new challeng-es and allows her to be closer to her family. Ashley does not leave with-out a trace as her excellent teamwork skills, communication, diligence and passion for anesthesia will continue to be cherished by her coworkers in our department. We wish her success in all her future endeavors.

A Farewell to Glor

Photo: Enrique Pantin

Ashley Glor, CRNA, passes through the anesthesia office earlier this year.

by Viviana Freire

Department of Anesthesia Chairman

Christine Fratzola, MDVice-Chairman

Alann Solina, MD

Faculty MembersRose Alloteh, MD

Sylvania Barsoum, MDStefanie Berman, MDMordy Bermann, MDRenu Chhokra, MD

Oak Chi, MDAntonio Chiricolo, MD

Shaul Cohen, MDChristine Curcio, MD

Vincent DeAngelis, MDHoward Denenberg, MD

John Denny, MDGina George, DO

Steven Ginsberg, MDJeremy Grayson, MD

William Grubb, DDS, MDDennis Hall, MDPreeti Joshi, MDSamuel Kiel, MD

Geza Kiss, MDSanford L. Klein, DDS, MDChristian McDonough, MD

Valerie McRae, MDTejal Mehta, MD

Scott Mellender, MDLeigh Nelson-Lane, MD

Enrique Pantin, MDDenes Papp, MDJessica Perez, MDKang Hi Rah, MDDiane Ridley, MDAshraf Sakr, MDShruti Shah, MD

Edward Ryan Sison, MDLaurie Spina, MDMark Stein, MD

Jayeshkumar Thaker, MDJames Tse, MD, PhD

Boris Veksler, MDMonty Wang, MDMelissa Wu, MDDora Zuker, MD

Chief ResidentsSagar S. Mungekar, MD

Brian Raffel, DO

ResidentsOren Ambalu, MDGianna Casini, MD

Luis Chabla-Penafiel, MDJennifer Cowell, MD

Amanda Doucette, MDJude Escano, DO

Viviana Freire, MDStanislav Ganzman, MD

Thomas Jan, MDMatthew Johnson, MD

Robert Jongco, MDAlexander Kahan, MDIbraheem Khan, MD

Carolyn Kloepping, MDNeethu Kumar, MD

Benjamin Landgraf, MDOleksiy “Alex” Lelyanov, DO

Jacques Lorthé, MDChristian Mabry, MD

Quynh Mai, MDMohammed Adil Mohiuddin, MD

Neeraj Nanavati, MDAndres Ocampo-Salazar, MD

Arpit Patel, MDErica Patel, MD

Mengmeng Shen, MDTrishna Upadhyay, MD

Wayne Wang, MD

Certified Registered Nurse Anesthetists

Orlando Gopez (Chief)Temitope AjibadeDaphne AnudonYvelise Bargman

Bruno Beja-UmukoroKatherine Glass

Kristen KellyTanya Milask

Sharon MorganKatie Novak

Stacey PaulusAndrew PrusanAlex Rozhitsky

Elzbieta SamojlukAnthony Smith

Kenneth Truesdale

Anesthesia TechniciansQuiana Frazier (Anesthesia Manger)

Jade Barnes (Lead)Kenie Lebron (Lead)

Katrina Sinkfield (Lead)Salah Attia

Ahmed BanguraDoreen “Mama” Bell

Luz CamachoEbonee Clark

Gwendolyn LeeHanan Malek Jorge Mancera

Cecil “Chris” McFarlaneLinda OrtutayShevon ParksIgnacio Rivera

Andrea Sroczynski Deon TaylorKeith Taylor

Gwendelyen Wells

E-mail editors: behind_the_screen@hotmail.com

Support StaffBenjamin R. Schoen, MBA, MPS

Diane PlonaAlesia Clark

Virginia (Ginger) Freeman RecchiaElaine Iwachiw

Wendy KuziemskiJennifer Lim, RN

Helen LowryDoreen M. Stillwell

Cardiothoracic FellowsMohammad Chaudhry, MD

Marco DelCastillo, MD

Pain Medicine FellowsCandy Anim, MDDavid Delatte, MD

Southern Ocean Medical Center (SOMC), Manahawkin, NJMordechai Bermann, MD

Michelle Bouyea, MDIlya Manevich, MD

Jim Marco, MDKeith Barton, DO

Jianhua (Jay) Guo, MDRichard (Rich) Richlan, MD