Invasive Pressure Monitors: Leveling the Playing Field.

Invasive pressure monitors are ubiquitous in cardiothoracic and vascular anesthesia. This technology allows beat-to-beat assessment of central venous, pulmonary, and arterial blood pressures during surgery, procedural interventions, and critical care. Education is commonly focused on the procedural aspects and the complications associated with the initial placement of these monitors without instruction on the technical concepts required for obtaining accurate data. Anesthesiologists must understand the fundamental concepts on which measurements are made to effectively use invasive pressure monitors, including pulmonary artery catheters, central venous catheters, intra-arterial catheters, external ventricular drains, and spinal or lumbar drains. This review will address important gaps in knowledge surrounding leveling and zeroing of invasive pressure monitors, emphasizing the impact of varied practice patterns on patient care.

Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes.

BACKGROUND: Obtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment. METHODS: Seven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail. RESULTS: Interrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room. CONCLUSIONS: Sensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

Random drug testing to reduce the incidence of addiction in anesthesia residents: preliminary results from one program.

Substance abuse occurs in approximately 1%-2% of anesthesia residents and nearly 80% of programs have had one or more resident (s) with such a problem. Education and control efforts have failed to reduce the frequency of substance abuse. Anesthesia providers have a professional obligation to be drug-free for the well being of their patients. We have instituted a program of preplacement and random urine testing of residents in anesthesiology in an attempt to decrease the incidence of substance abuse. We demonstrate that such a program is feasible, despite logistic and cultural obstacles. Larger multi-institutional studies will be required to determine whether instituting a program of random urine testing decreases the incidence of substance abuse in anesthesiology residents.

Changing Physician Behavior With Implementation Intentions: Closing the Gap Between Intentions and Actions.

In medical education, even well-intentioned learners struggle to change their practice. This intention-action gap is a well-described phenomenon. Strong commitment to changing behaviors is important, but by itself it is only a modest predictor of goal attainment.Implementation intentions are an extensively studied strategy from cognitive psychology that have been shown to close the intention-action gap and increase goal attainment across myriad domains. Implementation intentions are "if-then" plans that specify an anticipated future situation and a planned response-"If I encounter situation X, then I will respond with action Y." They differ from simple goals, which specify only a desired behavior or outcome-"I intend to perform action Z." Despite this subtle difference, they have shown substantial effectiveness over goals alone in increasing goal attainment.In this article, the authors first describe implementation intentions, review the substantial body of evidence demonstrating their effectiveness, and explain the underlying psychological mechanisms. They then illustrate the connections between implementation intentions and established learning theory. The final section focuses on forming effective implementation intentions in medical education. The authors provide concrete examples across the continuum of learners (from medical students to attending physicians) and competencies, and make recommendations for when and how to employ implementation intentions.

Anesthetic implications of traumatic pulmonary hernia repair.

Traumatic pulmonary herniation involves the protrusion of lung parenchyma beyond the normal borders of the thoracic cage through a defect in the musculoskeletal wall. Anesthetic management involves airway protection, lung isolation, and avoidance of distension of the herniated segment. We report the successful anesthetic management during surgical management of pulmonary herniation.

Drug testing physicians for substances of abuse: case report of a false-positive result.

The risk of a false-positive urine drug screen is one of the major impediments to widespread implementation of drug testing programs in anesthesiology. A case of a false-positive urine screen for ketamine in an anesthesia provider is presented, with recommendations for methods of managing such an event.