A retrospective analysis of the need for on-site emergency physician presence and mission characteristics of a rural ground-based emergency medical service.

BACKGROUND: This study aimed to address the challenges faced by rural emergency medical services in Europe, due to an increasing number of missions and limited human resources. The primary objective was to determine the necessity of having an on-site emergency physician (EP), while the secondary objectives included analyzing the characteristics of rural EP missions. METHODS: A retrospective study was conducted, examining rural EP missions carried out between January 1st, 2017, and December 2nd, 2021 in Burgenland, Austria. The need for physical presence of an EP was classified based on the National Advisory Committee for Aeronautics (NACA) score into three categories; category A: no need for an EP (NACA 1-3); category B: need for an EP (NACA 1-3 along with additional medical interventions beyond the capabilities of emergency medical technicians); and category C: definite need for an EP (NACA 4-7). Descriptive statistics were used for analysis. RESULTS: Out of 16,971 recorded missions, 15,591 were included in the study. Approximately 32.3% of missions fell into category A, indicating that an EP's physical presence was unnecessary. The diagnoses made by telecommunicators matched those of the EPs in only 52.8% of cases. CONCLUSION: The study suggests that about a third of EP missions carried out in rural areas might not have a solid medical rationale. This underscores the importance of developing an alternative care approach for these missions. Failing to address this could put additional pressure on already stretched EMS systems, risking their collapse.

Do Program Directors of Anesthesiology Residency Programs Interpret Narrative Letters of Recommendation as Intended?

Background Letters of recommendation (LORs) are an important part of the application process for medical residency programs with most specialties preferring a narrative format. Given the inherent subjectivity of narrative LORs, the current study sought to determine whether the intended messages of narrative LORs written for applicants to anesthesiology residency programs are accurately interpreted by readers. Methodology Anonymous online surveys were sent via the Qualtrics platform to program directors (PDs) of the Accreditation Council for Graduate Medical Education-accredited anesthesiology residency programs in the Mid-Atlantic region as designated by the Electronic Residency Application Service, which consists of the states of New York, Pennsylvania, and New Jersey. Each PD participant received five surveys, each of which was attached to a de-identified LOR that was written by another PD located at an institution in the same region. Both the letter writer and study participants were asked to score LORs on a Likert-like scale. Participants were additionally asked whether the LORs, if received, would influence their decision to either offer an interview to the applicant or to rank the applicant. Finally, participants were asked to note any specific words or phrases within the LORs that they found to be particularly impactful. Results Overall, 10 of 34, 29.41%, PDs responded to the survey. There was a high correlation between the LOR intent and the respondents' assigned rating (Spearman's rho = 0.7973, p < 0.001). Responses were more accurate for "outstanding and excellent" LORs compared to the lower three categories. Results were unaffected after adjusting for respondents' years of experience as PDs. Additionally, 71.6% indicated that the LORs would influence the decision about offering an interview, and 56.5% stated that the LORs would influence a ranking decision. Conclusions Our results indicate that respondents' perception of LORs correlated strongly with the intent of the writer. Additionally, respondents seemed to value LORs for interview and ranking decisions.

Lessons learned from the war in Ukraine for the anesthesiologist and intensivist: A scoping review.

BACKGROUND: The war in Ukraine provides purposefully anesthesiologists and intensivists with important data for improving the management of trauma patients. This scoping review aims to investigate the specific management of war-related trauma patients, during the war in Ukraine, through an objective and comprehensive analysis. METHODS: A comprehensive search of the Embase, Medline, and Open Grey databases from 2014 to February 2024 yielded studies focusing on anesthesia and surgery. These studies were assessed by PRISMA and STROBE criteria and needed to discuss anesthesiology and surgical procedures. RESULTS: Of the 519 studies identified, 21 were included, with a low overall level of evidence. The studies covered 11622 patients and 2470 surgical procedures. Most patients were Ukrainian men, 25 to 63 years old, who had sustained severe injuries from high-energy weapons, such as multiple rocket systems and combat drones. These injuries included major abdominal, facial, and extremity traumas. The surgical procedures varied from initial debridement to complex reconstructions. Anesthesia management faced significant challenges, including resource scarcity and the need for quick adaptability.Evacuations of casualties were lengthy, complex, and often involved rail transportation. Hemorrhage control with tourniquets was critical but associated with many complications. The very frequent presence of multi-resistant organisms required dedicated preventive measures and appropriated treatments. The need for qualified human resources underscored the importance of civilian-military cooperation. CONCLUSION: This scoping review provides original and relevant insights on the lessons learned from the ongoing war in Ukraine, which could be useful for anesthesiologists and intensivists.

The awareness of enhanced recovery after surgery (ERAS) cesarean delivery guidelines among anesthesiology and reanimation assistants in Turkey; a questionnaire study.

BACKGROUND: To reduce maternal-fetal morbidity and mortality, it is becoming increasingly important for anesthetists to understand and implement enhanced recovery after surgery (ERAS) cesarean delivery guidelines. Our aim was to reveal the knowledge of anesthesia assistants in Turkey about ERAS during cesarean delivery and to increase their awareness of ERAS. METHODS: This descriptive study was conducted in the city of Isparta, Turkey in 2023. The survey, which was approved by the ethics committee, was distributed to participants across Turkey via e-mail and online messages. The survey comprises of a total of 42 questions evaluating perioperative ERAS recommendations. RESULTS: Of the 404 participants in our survey, 59.9% were associated with university hospitals and 65.8% had completed three or more years of education. A total of 87.9% of the participants were familiar with ERAS; however, only 42.8% had received ERAS training. Although 93.8% of the participants' institutions performed a cesarean delivery, ERAS recommendations were only implemented at a rate of 48%. This may be due to the absence of an ERAS team, which was identified in our survey at a high rate of 66.6%. CONCLUSION: Awareness about ERAS was high among the participants, but the implementation rates of some recommendations were low. The reason for this may be the inability to form a multidisciplinary team and inadequate training of participants. For this purpose, we recommend the formation of a multidisciplinary team for ERAS protocol implementation and increased participant training opportunities.

Awe Inducing Elements in Virtual Reality Applications: A Prospective Study of Hospitalized Children and Caregivers.

Background: Hospitalized pediatric patients and their caregivers often experience anxiety and fear, resulting in withdrawal and aggression. Despite virtual reality (VR) being a safe and effective anxiolytic, it is unknown what software design aspects contribute to its effectiveness. This prospective observational study evaluated which VR application elements increased awe, which is correlated with improved behavior and satisfaction. Methods: Patients aged 6 to 25 years and their caregivers at an academic pediatric hospital interacted with a custom VR application that compared design aspects, including environment, graphics fidelity, and presence of a motivational character. Outcomes investigated self-reported awe, vastness, accommodation, and engagement. Data were analyzed using repeated measure ANOVA tests and correlation analyses. Results: A total of 202 participants were enrolled, and 179 (88 pediatric patients, 91 adult caregivers) were included in the final analysis. A fictional environment was more effective at increasing awe in pediatric patients (P = 0.030) compared with a realistic environment. However, increased graphics fidelity was more effective at increasing awe in caregiver adults (P = 0.023) compared with low resolution graphics. Presence of a motivational character did not influence awe in either patients or caregivers (P = 0.432, P = 0.904, respectively). All measures of awe were positively correlated with application engagement (P < 0.005). Conclusion: In conclusion, when software developers design VR software for pediatric patients and their caregivers, fictional settings and increased graphic fidelity should be considered for pediatric patients and adults, respectively. Future studies will explore other VR elements in gameplay settings.

The Landscape of Pain Medicine for Women Physicians: A Perspective.

BACKGROUND: The gender bias in academic anesthesiology is well known. Women are not only a minority in the field but also underrepresented in leadership positions. Reported reasons for this underrepresentation include barriers to career advancement, lack of mentorship, and differences in compensation, among others. Interventional pain, a competitive procedural subspecialty of anesthesiology, sees the trickle-down effects of this disparity. According to a report from the ACGME that sorted medical subspecialties by number of female trainees, pain medicine ranked in the bottom quartile across all disciplines from 2008-2016. OBJECTIVES: To better understand the landscape for women physicians in the field of pain medicine, we undertook this investigation to review the knowledge about the topic and what questions remain unanswered. STUDY DESIGN: This study is a review of the current literature and aims to summarize and describe the landscape of pain medicine for women physicians. SETTING: All literature review and manuscript preparation took place at the Yale University School of Medicine. METHODS: We performed a comprehensive search using the PubMed, Scopus, and Cochrane databases for the combined terms "gender disparity," "pain medicine," and "anesthesiology," limiting our search to the year 2000 onward for the most recent literature on the topic. Our initial search retrieved 38 articles. All relevant articles pertaining to this perspective piece were collated. The available literature is discussed below. RESULTS: Women are underrepresented in interventional pain. The grim scarcity of female pain physicians is unlikely to improve soon, since while the number of Accreditation Council for Graduate Medical Education pain fellowship programs continues to grow, women trainees comprise only between 22-25% of all pain medicine fellows. Additionally, although studies have compared the numbers of male interventional pain faculty to their female counterparts in academic hospitals and shown the ratio to range from 71.84-82% to 18-28.52%, respectively, no studies have truly explored the landscape for women physicians in private practice. Patients prefer and have better experiences with physicians who are racially and ethnically like themselves. In fact, the preference for and the lack of female clinicians have been associated with delayed pursuit of care and adverse health outcomes. The consequences of the burnout and attrition caused by the gender disparity, especially in a field like pain medicine, cannot be understate. LIMITATIONS: The review might not have been comprehensive, and relevant studies might not have been included. CONCLUSION: While the gender disparity in academia is well documented for both anesthesiology and pain medicine, the reasons for this disparity have not been fully explored. Moreover, it is also unknown whether the minority of female physicians who select pain medicine as a subspecialty gravitate toward an academic or a private-practice path. To address the existing gender disparity, it is necessary to explore the landscape of interventional pain medicine in both academic and private practices and understand pain physicians' beliefs and sentiments regarding their subspecialty.

SimuVet: a preliminary study of the innovative development of a simulator for epidural anesthesia training in dogs.

Epidural anesthesia in dogs is a locoregional anesthesia technique used in veterinary medicine, becoming an important integrated application in the anesthetic protocol to provide safer and more effective analgesia to patients. For this, professionals must adhere to rigorous guidelines and possess technical skills. In this context, in veterinary education, the development of practical clinical skills represents a crucial aspect in the training of these professionals. However, traditional teaching methods have proven insufficient to ensure a consistent level of competence among recent graduates. The introduction of non-animal alternatives for educational purposes has contributed to the development of simulation-based teaching, an innovative and accessible field capable of enhancing pre-clinical proficiency in students and reducing the use of live animals and cadavers. Despite its application in various areas of veterinary education, there are no conclusive results regarding the development of accessible simulators capable of effectively enhancing training in epidural anesthesia in dogs. Therefore, this article represents a pioneering study aimed at sharing a method for creating SimuVet, a realistic simulator for training epidural anesthesia in dogs. The simulator was fully developed by veterinary researchers with limited experience in 3D printing and, after preliminary analysis, demonstrated excellent performance and ultrasonographic anatomy. Future work will focus on the formal validation of this simulator with the aim of improving the teaching and learning process for students and experts in performing epidural anesthesia in companion animals.

Educational perspectives in cardiothoracic anesthesia in the United States using a survey of educators and learners.

Background: Cardiothoracic anesthesiology training presents learners with unique challenges, procedural skills, and the management of high-intensity critical scenarios. An effective relationship between educator and learner can serve as the backbone for effective learning, which is crucial for the development of budding anesthesiologists. Strengthening this educational alliance between teachers and trainees involves understanding the educational values educators and learners find most important to their learning experiences. This study aimed to identify the key educational values related to cardiothoracic anesthesia for both learners and educators. By identifying these values in separate cohorts (learners and educators), the importance of various educational values can be examined and compared between the trainees and teachers. Methods: Two separate surveys (one for learners and one for teachers) were adapted from the Pratt and Collins Teaching Perspectives Inventory to establish the importance of various educational values related to cardiothoracic anesthesia. Surveys were sent to 165 ACGME-accredited anesthesiology residency training programs in the United States to trainees (residents and cardiothoracic anesthesiology fellows) and educators (board-certified cardiothoracic anesthesiologists). Results: Analysis of survey results from 19 educators and 57 learners revealed no statistical differences across the two groups, except Q15: "Let trainee perform critical technical steps" (P value = 0.02). Conclusions: While learners and educators in cardiothoracic anesthesia hold similar values regarding cardiac anesthesia education, they differ in the degree to which critical technical steps should be performed by learners.

Blood pressure monitoring gaps in patients with left ventricular assist devices presenting for non-cardiac surgeries.

STUDY OBJECTIVE: The hemodynamic assessment of patients with left ventricular assist devices (LVAD) using noninvasive blood pressure (NIBP) monitoring may be unreliable without pulsatile blood flow. The primary goal of this study is to examine the association between intraoperative blood pressure monitoring gaps of 10 min or greater and LVAD type in patients undergoing noncardiac surgeries with NIBP monitors at induction. DESIGN: Retrospective cohort. SETTING: Single institution, academic university hospital. PARTICIPANTS: One-hundred fifteen patients undergoing 187 noncardiac surgeries without arterial lines at induction. INTERVENTIONS: Noncardiac surgery. MEASUREMENTS: The primary outcome was the association of blood pressure monitoring gaps, which were defined as ten minutes or greater, and LVAD type including the HeartMate 2 (HM2; Abbott, Chicago, IL) and the HeartMate 3 (HM3; Abbott, Chicago, IL), as evaluated by multivariable logistic regression analysis. MAIN RESULTS: After adjusting for patient characteristics, HM3 was associated with lower odds of monitoring gaps (p = 0.02). Additionally, the odds of a monitoring gap were higher in patients with morbid obesity (p = 0.04) and in surgical duration longer than 180 min (p = 0.001). In the post-hoc analysis, morbid obesity, general anesthesia, and prolonged surgeries were found to be associated with increased odds of arterial line placement after induction (p = 0.05, p = 0.007, p < 0.001). CONCLUSIONS: Patients with a HM2 undergoing noncardiac surgery had nearly three-fold higher odds of blood pressure monitoring gaps of 10 min or greater compared to patients with a HM3. Morbid obesity and prolonged surgical duration were also associated with a significant increase in monitoring gaps. Morbid obesity, general anesthesia, and longer surgical duration were found to have a greater odds of arterial line placement after induction. These results may help anesthesiologists determine the appropriateness of NIBP in patients with LVADs undergoing noncardiac surgeries.

Prevalence of faculty mentoring programs in anesthesiology and medical schools in the US and their association with federal research funding.

BACKGROUND: While mentoring programs have demonstrated success for faculty development, reported rates of formal mentoring programs vary for specific programs as well as academic medical institutions overall. The aim of this paper was to evaluate the overall prevalence of faculty mentoring programs and faculty development offices in anesthesiology departments and at academic medical schools and assess the association between those with mentoring programs and faculty development support and NIH funding. METHODS: This study used publicly available data from program and institutional websites to record the presence of faculty mentoring programs and faculty development offices in anesthesiology departments as well as both formal and informal mentoring activities and whether there were offices and deans specifically related to faculty development at the institutional level. Data on NIH funding of anesthesiology departments were recorded from the Blue Ridge Institute for Medical Research rankings of medical schools and their departments. Cramer's V was used to evaluate the association between NIH funding and the presence of mentoring programs offered by the department and/or institution. Logistic regression was used to evaluate the association between total NIH funding of ranked programs (categorized as above or below median of funding) and presence of mentoring programs. RESULTS: The study included 164 US anesthesiology programs, of which 33% had NIH funding. Only 10% of anesthesiology programs had faculty mentoring programs and 29% had offices or leadership positions related to faculty development. At the institutional level, 59% had formal mentoring programs, 73% offered informal mentoring activities, and 77% had offices or deans related to faculty development. Seventy-four percent (74%) of anesthesiology departments offering mentoring resources had NIH funding, compared to only 26% of departments without such resources. For anesthesiology departments with NIH funding, departments in the upper median of funded programs were much more likely to have departmental mentoring resources (OR = 1.429.08; 95% CI: 1.721.03-1.9748.99). Departmental NIH funding was not significantly associated with institutional level presence of formal mentoring programs (OR = 0.91; 95% CI: 0.0.23-3.65). CONCLUSIONS: Our findings suggest an association between the presence of faculty mentoring programs and faculty development support with departmental NIH funding, with the amount of funding associated primarily with department-specific mentoring and faculty development initiatives. Our findings support efforts to create formal mentoring programs and establish offices and other support systems for faculty development and suggest, at least in terms of academic productivity, that efforts should be more focused on department-specific initiatives.

Perioperative Care of the Patient with Directives Limiting Life-Sustaining Treatments.

Like most complex aspects of procedural care, sound perioperative management of limits to life-sustaining medical therapy requires a multidisciplinary team-based approach bolstered by appropriate care management strategies. This article discusses the implications of care for the patient for whom limitations of life-sustaining care are in place and the roles and responsibilities of each provider in supporting quality procedural care compatible with patients' right to self-determination. The authors focus on the roles of the surgeon, preoperative clinic provider, anesthesiologist, and postoperative care consultants and discuss how the health care system and care pathways can support and improve adherence to best practices.

Managing the Labyrinth of Complex Ethical Issues in Anesthesia Practice: The Anesthesiologist's Ariadne's Thread.

Facing ethical dilemmas is challenging and sometimes becomes a real burden for anesthesiologists, particularly because they rarely have previous or long-standing patient relationships that help inform clinical decision-making. Although there is no ideal algorithm that can fit all clinical situations, some basic moral and ethical principles, which should be part of every clinician's armamentarium, can guide the decision-making process. Dealing with conflicting views among providers and/or patients can be distressing but can lead to meaningful professional and personal growth for each clinician.

Ethics Consultation in Anesthesia Practice.

Because modern surgical and medical care have advanced, patients increasingly present for procedural and surgical intervention with life-limiting diagnoses and/or advanced care goals such as "do not resuscitate." Anesthesiologists now care for these patients across the complete perioperative setting and frequently find themselves at the crossroads of these mounting pressures. As the boundaries and capabilities of anesthetic care and critical care anesthesiology expand so too do the specialty's needs for support in ethical decision-making. Herein, we review the role of the ethics consultation in anesthesia practice and special ethic issues encountered by the anesthesiologist.

Public Good versus Private "Goods": Ethical Implications of Drug Shortages on Anesthesiology Practice.

Drug shortages remain a serious and widespread problem affecting all health systems and patients. Anesthesiology practice is strongly impacted by shortages of sterile injectable drugs, resulting in a negative impact on the quality of care. Understanding the root causes of drug shortages guides the anesthesiologist toward an ethical response. While rationing is a common consideration in secular ethics, and indeed rationing strategies are utilized, the use of rationing alone risks normalizing and perpetuating the drug shortage problem. Drug shortages are the direct result of a market failure brought on by lack of oversight of drug production standards in some cases as well as by the impact of intermediary purchasing groups on costs and availability of drugs. Legislation needs to reestablish a responsible, competitive, and robust manufacturing drug market.

Predicting Intraoperative Hypotension: An Intraoperative Case Report.

Intraoperative hypotension (IOH) is a common issue associated with acute kidney injury, myocardial injury, stroke, and death. IOH may be avoided with the incorporation of newer advanced hemodynamic monitoring technologies. This case study examines the use of advanced hemodynamic monitoring with an early warning system for the intraoperative hemodynamic management of a patient presenting for pancreaticoduodenectomy. Incorporating the hypotension prediction index and other hemodynamic parameters to anticipate impending hypotension and treat potential causative factors is an emerging technological advancement. Understanding and embracing the potential for new advanced hemodynamic technology to reduce intraoperative hypotension's severity, duration, and occurrence is key to reducing negative patient outcomes.

Anesthetic Management of a Patient With Wolff-Parkinson-White Syndrome Undergoing Gynecological Robotic Surgery.

Robotic surgery provides precision and safety for minimally invasive gynecological operations but introduces unique anesthetic challenges, especially for individuals with pre-existing conditions like Wolff-Parkinson-White (WPW) syndrome. This case report addresses the anesthetic management of a 32-year-old female with WPW syndrome undergoing a myomectomy. A thorough pre-operative evaluation, including an ECG, echocardiogram, and Holter monitoring, was performed to assess the anesthetic and cardiac risks. The patient was administered a combination of loco-regional and general anesthesia, with an emphasis on neuromuscular monitoring, antiarrhythmic preparedness, and pain management to effectively manage the complexities introduced by WPW syndrome and robotic surgery. The anesthetic protocol comprised premedication with midazolam, induction using sufentanil, propofol, and rocuronium, and maintenance with desflurane, along with techniques to mitigate the effects of pneumoperitoneum and Trendelenburg positioning. Employing these strategies, the surgery concluded successfully without any anesthetic or surgical complications. The patient experienced a rapid and complete awakening, achieved optimal pain control, and was able to mobilize early, leading to her discharge 24 hours post-surgery. This case demonstrates the essential nature of customized anesthetic management for patients with WPW syndrome undergoing robotic surgery. It underscores the necessity of an exhaustive pre-operative assessment, diligent intraoperative monitoring, and active postoperative care to ensure patient safety and promote swift recovery.

Clinical experience with remimazolam in pediatric anesthesiology: An educational focused review.

Remimazolam is a novel ultrashort-acting benzodiazepine, which like midazolam, results in sedation, anxiolysis, and amnesia through its agonistic effects on the gamma-amino butyric acid A receptor. As opposed to midazolam, its unique metabolism is via tissue esterases, which results in a rapid elimination with a limited context sensitive half-life and prompt dissipation of its effect when administration is discontinued. Remimazolam received FDA approval for use in adults in 2020. In preliminary and initial clinical trials, its efficacy and safety has been suggested in the adult population, both as a primary agent for procedural sedation or as an adjunct to general anesthesia. There are limited data regarding the use of remimazolam in infants and children and its use in this population remains off label as it does not hold FDA-approval in pediatric-aged patients. This narrative outlines the pharmacologic properties of this unique medication, reviews previous published reports of its role in pediatric-aged patients, and discusses dosing parameters and clinical use in this population.

Evaluation of burnout levels among healthcare staff in anesthesiology departments in Greece - Is there a connection with anxiety and depression?

Introduction: Healthcare workers in anesthesiology departments often experience burnout syndrome, which may be combined with anxiety and depression. Aim: The study aimed to assess the levels of burnout among nurses and physicians working in anesthesiology departments in public hospitals in Attica and to investigate a possible correlation between burnout, anxiety, and depression. Methodology: A cross-sectional study was conducted on physicians and nurses working in anesthesiology departments in public hospitals in Attica, Greece. A questionnaire was distributed electronically using the snowball sampling method, including questions about demographic characteristics, burnout, anxiety, and depression. Results: Physicians and nurses in anesthesiology departments were found to have moderate levels of burnout, and normal/low levels of anxiety and depression. More specifically, it was found that 2% of physicians and 14.4% of nurses had extremely elevated levels of burnout. On the other hand, 6.1% of physicians and 23.7% of nurses had high anxiety, while 6.1% of physicians and 15.5% of nurses had elevated levels of depression. Females (p = 0.008), staff aged 45-55 (p = 0.021), lower educational level (p = 0.025), nurses (p = 0.001), more than 21 years of service (p = 0.001), and having children (p = 0.008) were determinants of greater levels of personal burnout. Work-related burnout correlated with having children (p = 0.017), whereas client-related burnout was significantly higher for nurses (p = 0.002). In addition, a correlation was found between anxiety, depression, and increased levels of burnout (p = 0.000). Conclusions: As physicians and nurses working in anesthesiology departments have stressful jobs and work long hours, it is important to further study their physical, emotional, and mental exhaustion as well as psychological resilience levels.

The Use of Remimazolam During Awake Craniotomy for Seizure Foci Resection in Adolescents: A Case Series.

Remimazolam is a novel benzodiazepine with sedative, anxiolytic, and amnestic properties similar to midazolam. Metabolism by tissue esterases results in a short clinical half-life of 5 - 10 min and a limited context sensitive half-life. We present initial retrospective clinical experience with the use of remimazolam as an intraoperative adjunct to sedation during awake craniotomy in a cohort of three adolescent patients. A remimazolam infusion was added to a combination of dexmedetomidine and remifentanil to deepen the level of sedation during surgical incision, craniotomy, duraplasty, and surgical dissection for exposure of the seizure foci. The remimazolam infusion was discontinued 30 min prior to the planned awake assessments and electrophysiology testing. The patients emerged calmly and were able to follow commands for intraoperative testing. Our anecdotal experience supports the efficacy of remimazolam for awake craniotomy and tumor resection using a standard asleep-awake-asleep technique. We noted adequate sedation, maintenance of spontaneous respiration, rapid awakening, and no limitations to intraoperative neuromonitoring or awake assessment in our three patients.