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.

Postpartum spinal cord, root, plexus and peripheral nerve injuries involving the lower extremities: a practical approach.

Neurological complications after labor and delivery are most often caused by compressive trauma related to childbirth and rarely related to neuraxial anesthesia/analgesia. However, it is important for anesthesiologists to be able to recognize the common manifestations of these neuropathies in order to distinguish them from more ominous causes of neurologic disease. In this article, we review the anatomy and etiology of postpartum thoracolumbar spinal cord, lumbar nerve roots, plexus, and lower extremity peripheral nerve injuries. We will focus on a practical approach to their diagnosis, management, and treatment. Cases will be used to illustrate diagnosis and management.

The development and historical context of the Datta short laryngoscope handle.

The hormonal, physiologic, and anatomic changes of pregnancy have a number of significant anesthetic implications, including the potential for difficulties and failures in tracheal intubation. The American Society of Anesthesiology closed claims database in the 1970s observed that maternal deaths were involved in 30% of all obstetrics claims, most stemming from difficulty with intubation or ventilation. In the late 1970s, Dr. Sanjay Datta, MBBS, an obstetric anesthesiologist at Brigham and Women's Hospital (Boston, MA), observed a number of differences in the practice of obstetric anesthesia in the United States when compared with his prior experiences in the United Kingdom and Canada. Dr. Datta perceived that parturients within North America had a higher body mass index. In addition, he observed an increased rate of cesarean delivery and general anesthesia use. These differences led him to evaluate ways in which the laryngoscope itself could be altered to improve the ease of intubation of parturients; this led to the development of the short laryngoscope handle. The genesis of the Datta short laryngoscope handle, and the accompanying historical context, will be explored.

Neurologic issues and obstetric anesthesia.

The rising popularity of regional anesthesia in the last several decades has greatly changed the experience of labor. Although the use of regional anesthesia has aided in decreasing maternal morbidity and mortality, a new dimension of neurologic issues, particularly headache and peripheral neuropathy, is apparent. Obstetric anesthesiologists frequently encounter patients with preexisting neurologic disease. Although very few of these disorders contraindicate the use of neuraxial technique, there are limited published data on specific neurologic and neuromuscular disorders in pregnancy. Neurologists are often consulted by anesthesiologists and obstetricians to evaluate pregnant patients for the feasibility of labor analgesia and when postpartum neurologic complications arise. Early consultation with an obstetric anesthesiologist, discussion with a neurologist, and communication with the obstetrician allows for the education and discussion of the risks and benefits of both the mode of delivery and anesthetic options. This multidisciplinary approach is crucial in forming reasonable expectations for the patient. The aim of this discussion is to provide an obstetric anesthesiologist's perspective on regional anesthesia and its implications in obstetrics, and to enhance communication between our specialties.