by MICHAEL AKERMAN, M.D.
“To succeed, jump as quickly at opportunities as you do at conclusions.”
– Benjamin Franklin
Many Americans have a preconceived notion about Serbia. The events of the 1990s left an impression and influenced opinions about the country. My recent experience in Serbia differed greatly from my own expectations, and I feel extremely fortunate to have spent time there.
My journey began at a get-together in New York with some of my colleagues and friends. As the night was winding down, I mentioned to my Serbian friend that I would be very interested in visiting her home country and doing some anesthesia work there. Within two weeks, I was put in touch with Serbian native Dr. Ivan Velickovic, director of OB anesthesia at SUNY Downstate Medical Center, and I was booked for travel a few months later to Serbia.
The details of my trip started to come together. The first few days after my arrival, I would attend the “Eighth Annual Scientific Symposium in Anesthesiology and Intensive Care” conference in Niš, Serbia. The meeting organizer, Dr. Radmilo Jankovic, was kind enough to invite me to give a lecture and to co-lead an ultrasound workshop. During the remainder of the week I would then travel to the Serbian city of Leskovac to teach regional anesthesia at the local hospital.
Offering Patients a Better Hospital Experience
I arrived late on a Thursday night in Niš; within a few hours of my arrival I presented a workshop on regional anesthesia with Dr. Jinlei Li from Yale University. With the help of Dr. Nada Pejcic (our host and local expert), everything went smoothly. The workshop was divided into two sessions — morning and afternoon. We focused on upper extremity nerve blocks in the morning and lower extremity nerve blocks in the afternoon. The success of the workshop was evident from the enthusiasm of the participants. The level of interest was so high that we gladly stayed to answer questions. After the workshop I was free to enjoy the many lectures and parties that were organized as part of the conference. The last day of the conference I presented my lecture — “An Update on the TAP Block.” Overall, the conference was an exciting and very educational event, and I am honored to have been a part of it.
In the early morning on Monday, I met up with Dr. Pejcic and we drove to Leskovac Hospital, a beautiful drive south of Niš through fields, farmland and beautiful scenery. We spent the next four days together offering patients our services. In that short time, we performed 27 quadratus lumborum blocks (mostly post-cesarean section under general anesthesia), one combined spinal epidural for labor pain, and one peripheral nerve block for an orthopedic procedure on the lower extremity. Twenty-six of the 27 patients who received the QL block reported adequate post-operative pain control. The patient who received the CSE reported an excellent birthing experience and the patient having the orthopedic procedure reported no pain. It was an amazing feeling to be able to offer these patients a better hospital experience. The patients and the medical staff were very appreciative. The level of interest in and excitement about regional anesthesia was palpable.
I wanted to leave my colleagues in Serbia with something they could continue to do even in my absence. I met Dr. Pejcic at the PGA before I went to Serbia and we talked about my plans to visit for a few weeks prior to my arrival. We discussed regional anesthesia extensively and she was well prepared by the time I arrived. During those four days in Leskovac, I spent a lot of time teaching her the use of ultrasound technique and regional anesthesia concepts. By the fourth day, Dr. Pejcic was not only performing QL blocks independently, she was teaching her colleagues how to perform them as well. Since I returned to New York, we remain in contact and Dr. Pejcic has been continuing to offer regional anesthesia to her patients. She has performed more than 70 blocks (and has expanded her repertoire to include popliteal and adductor blocks) and has presented her work at a local conference. Dr. Pejcic’s love of regional anesthesia, patient care and constant learning is something that I hope to emulate in my own practice.
My week in Serbia went as fast as it came. I met wonderful and hospitable people, people with warm hearts who have a strong connection to their history. They often take the time to sit and “have a drink” (normally coffee or tea) and enjoy each other’s company. Dr. Pejcic and her husband made me feel welcome in a foreign country. Every night they had another trip planned. We drove on roads rarely traveled to get to the top of a mountain for unforgettable views, visited monasteries, tasted fresh spring water, and of course ate a lot. I also learned about the history of this region from the people themselves and visited places of historical significance such as Skull Tower and Crveni Krst, a Holocaust concentration camp in Niš. This was a week I will cherish, and one that gave me much more than I gave in return. I appreciate my hosts inviting me into their home and treating me like family. I hope to plan more trips where I can work with my Serbian colleagues to provide exceptional patient care.
While people in the U.S. may be familiar with medical mission projects in Latin America or Sub-Saharan Africa, very few people know about the opportunities that exist to participate in these projects in Eastern Europe. I decided to go to Serbia because an opportunity presented itself. Ultimately, it was a decision that led to expanding my world view, meeting new people, and sharing what I know about anesthesia and acute pain with a dedicated group of professionals who hope to better serve their patients.
Michael Akerman, M.D., is an assistant professor in the Department of Anesthesiology at Weill Cornell Medicine in New York. He specializes in regional and thoracic anesthesia.
by SAMIR KENDALE, M.D.
There has been a lot going on behind the scenes at the NYSSA in support of our state’s anesthesiologists. One particularly the Ad Hoc Committee on Women Physicians. In the Fall 2017 issue of Sphere, there is a brief description of the committee’s origins and the benefits that this group hopes to provide to the women physicians in the state. Women in our profession have unique needs; hopefully the NYSSA’s women members, especially
those beginning their careers, will benefit from the mentorship opportunities and PGA sessions that will address these needs.
In a continuation of the wellness theme that we highlighted in the winter 2017 issue of Sphere, Drs. Melinda Aquino and Sergey Pisklakov address the topic of bullying. As anesthesiologists we have all been in tense situations: the unanticipated difficult airway, the sudden surgical bleeding, and the obstetric hemorrhage, to name just a few. Everyone
handles these circumstances differently. And everyone likely has had a disagreement with a colleague, sometimes even in the midst of these tense situations. There is an appropriate time to be demanding for the sake of patient safety, but there really is no excuse for bullying or threatening behavior. While aggressive behavior in the healthcare field may seem like a remnant of days past, we newer physicians have heard our share of stories about hurled instruments, berated nurses, and medical students whose hands were slapped. It seems like a natural byproduct of high-risk situations and type A personalities, and of long hours coupled with short fuses; ultimately, however, the hostile
environment that results from disruptive behavior is likely to make things worse for the patient.
There will always be challenging people with whom we are forced to interact. We all need to feel empowered enough to speak up when something around us is amiss, and to take the high road when placed in a compromising situation. Having open communication with our
work colleagues goes a long way toward maintaining a positive work environment.
Finally, speaking of communication, we are very happy to announce the launch of this Sphere website. The site is viewable via both desktop and mobile devices. We will be publishing some of our more popular articles on here, and encourage all of our readers to link to your favorite articles on social media by using the links at the bottom of each
article. For example, if you want to share with family members and friends the amazing things that New York’s anesthesiologists are doing around the world, tweet the recent feature article about the medical mission in Nigeria. If you are concerned about the
well-being of your colleagues in the medical field, share a link on Facebook to one of the wellness articles. Sphere authors devote a great amount of time and energy to writing these excellent articles; it would be terrific to increase the readership of their work!
by MELINDA AQUINO, M.D., & SERGEY PISKLAKOV, M.D.
The American Psychological Association defines bullying as “a form of aggressive behavior” intended to cause distress or harm. Bullying involves an imbalance of power between the aggressor and the victim. It can be identified when someone persistently perceives him or herself to be on the receiving end of negative actions from one or several persons over a period of time. The individual at the receiving end has difficulty defending against these actions. Bullying can be physical as well as relational. It is a way to gain power.1
Physical bullying is obvious; in our society this form of bullying tends to be the province of children. Adults are more subtle and devious in their approach; their bullying can take a variety of forms, many of which may not be obvious to a third party. This allows bullies to continue their activities unchecked, enabling them to do what they want at the expense of others.
Aggressive and disruptive behavior in the workplace is fueling a nationwide grassroots legislative effort to force companies to draft and enforce policies aimed at stopping it. Bullying has been linked to higher costs in terms of turnover and insurance claims, and to decreased productivity.2 In January 2009, a new standard issued by The Joint Commission (formerly JCAHO) went into effect. It requires hospitals to have “a code of conduct that defines acceptable, disruptive, and inappropriate staff behaviors” and for its “leaders [to] create and implement a process for managing disruptive and inappropriate staff behaviors.” The rationale for the standard states: “Leaders must address disruptive behavior of individuals working at
all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members.” A Joint Commission sentinel alert includes “uncooperative attitudes” and “condescending language or voice
intonation and impatience with questions” as disruptive behaviors.
The Joint Commission’s first-ever alert about the problem is the latest industry effort to address an issue that has challenged the medical community for years. Suggested actions include better systems to detect and deter unprofessional behavior; more civil responses to
patients and families who witness bad acts; and overall training in “basic business etiquette,” including phone skills and people skills for all employees.3 The lack of action against disruptive and aggressive behavior can lead to serious liabilities since these incidents sometimes constitute not only bullying, but also sexual harassment and discrimination.4
Disruptive behavior has been observed in almost all healthcare specialties. Physician behavior, however, may have the greatest impact because of the position of authority that doctors hold as members of the healthcare team.5 Out of fear of being intimidated or patronized, a team member may withhold valuable or even critical input, such as a medication error or a breakdown in adherence to safety protocols.2
Ensuring good patient care and respect among all healthcare professionals is at the very foundation of the ethics advocated by the American Medical Association.6 Intimidating, condescending, off-putting, or discouraging behavior by the physician inhibits positive teamwork. If an OR staff works suboptimally because of disruptive behavior by the physician or another team member, overall care quality is compromised and patient safety is threatened. To mitigate these risks, healthcare organizations may need to re-examine their hospital harassment policies to ensure those policies include specific prohibitions. Hospitals need to create workplace conduct policies that forbid disruptive and aggressive behavior, bullying or harassment. Once policies are in place, comprehensive training courses should be given to all supervisors and physicians. If policies are violated, appropriate action should be taken against violators to ensure proper enforcement.4
There is evidence that the prevalence of disruptive behavior in the medical world is high.7 The outburst by a physician in the OR is not uncommon. Bullying and mistreatment during training are also part of the experience for many early career doctors, medical students and residents.5 A 2004 study reported that 37 percent of doctors in 10 NYSSA — The New York State Society of Anesthesiologists, Inc. training had witnessed disruptive and aggressive behavior in the past
year.8 One of the major reasons for disruptive behavior is the lack of training in management and communication skills. Why do victims often not speak out against perpetrators? Victims often believe that a complaint would blight their professional progress; with an intentional
bully, this might be the case.9 The consequences of disruptive and aggressive behavior are far-reaching. There is evidence that this behavior is responsible for victims becoming stressed and depressed, leading to job turnover.
Although there would appear to be a difference between intentional and unintentional disruptive and aggressive behavior, the initially unintentional perpetrator may well come to gain satisfaction from this form of behavior, which will then, of course, be reinforced. Intentional bullying is a behavior that needs both decisive intervention and help.9
Approaches to unintentional bullying should be both educational and organizational. Work with the individual accused of bullying may need to include psychotherapy to explore the reasons for bullying or aggressive behavior. It should also include improving interpersonal and
self-awareness skills so that the bully can explore and adopt alternative ways of behaving.10 The organizational culture also needs to change. Hospitals, departments and individual personnel need to develop a higher level of awareness. Anti-bullying policies should be given a
higher profile. This should encourage victims to come forward so that individual bullies can be identified.
Unintentional bullies will usually, although not always, respond to the strategies outlined above and modify their behavior. They may well respond to personal approaches on the part of the victim. Victims should also approach their professional associations for advice and support. Primary preventive methods may include providing educational materials and communication skills training for residents, staff, and educators. Education on abuse, discrimination, and harassment in the workplace, and how these can be addressed and averted, can also be
presented in formal and informal curricula. Such initiatives should promote inclusive language and a culture of collegiality and respect for all faculty, staff, and trainees. Secondary preventive measures should rely in part on clear reporting mechanisms so that any occasion of abusive
or discriminatory language or behavior can be addressed as soon as it arises. In the meantime, and until further data confirm or deny the concerns identified here, we should be duly vigilant.
Melinda Aquino, M.D., is an assistant professor in the Albert Einstein College of Medicine and the Department of Anesthesiology at Montefiore Medical Center.
Sergey Pisklakov, M.D., is an associate professor and director of the neuroanesthesia fellowship in the Albert Einstein College of Medicine and the Department of Anesthesiology at Montefiore Medical Center.
1. Einarsen S, Raknes B, Matthiesen S. Bullying and harassment at work and their relationships to work environment quality: An exploratory study. European Work and Organizational Psychologist 1994; 4:381-401.
2. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. Am J Nurs 2005; 105:54-64.
3. Joint Commission - Sentinel Event Alert - Behaviors that undermine a culture of safety. Issue 40, July 9, 2008.
4. Institute for Safe Medication Practices (ISMP): Survey on workplace intimidation 2003. http://ismp.org/Survey/surveyresults/Survey0311.asp. Accessed on July 5, 2017.
5. Quine L. Workplace bullying in junior doctors: questionnaire survey. BMJ 2002; 324:878-9.
6. Physicians and Disruptive Behavior July 2004.
Behavior-Policy.pdf. Accessed on July 23, 2017.
7. Paice E, Aitken M, Houghton A, Firth-Cozens J. Bullying among doctors in training: cross sectional questionnaire survey. BMJ 2004; 329:658-9.
8. Margittai KJ, Moscarello R, Rossi MF. Forensic aspects of medical student abuse: a Canadian perspective. Bull Am Acad Psychiatry Law 1996; 24:377-85.
9. Cohen JS, Leung Y, Fahey M, et al. The happy docs study: a Canadian Association of Interns and Residents well-being survey examining resident physician health and satisfaction within and outside of residency training in Canada. BMC Res Notes 2008; 1:105.
10. Huntoon LR. Abuse of the “disruptive physician” clause. J Am Phys Surg 2004; 9:68.
by KIRI MACKERSEY, M.D.
All photos courtesy of Kiri Mackersey, M.D.
“How about Nigeria?” The job was at a large, long-standing maternity hospital in northern Nigeria with Doctors Without Borders/Médecins Sans Frontières (MSF), an independent, medical humanitarian organization. It was my first assignment. My role would be head of the obstetric ICU and supervisor of the local nurse anesthetists in the operating rooms. MSF’s emergency obstetrics program at the Ministry of Health hospital in Jahun, Jigawa State, Nigeria, provides obstetric care and offers surgery for women with vesicovaginal fistulas. Although other areas in the north had been devastated by the ongoing conflict between Boko Haram and the Nigerian military, the security situation in Jahun was stable. The expat compound was colloquially known as Jahun Paradise and was rumored to have the best cook in MSF. I signed up.
New York — Paris — Abuja — Jahun
I had been warned that Abuja Airport would be a goat-filled market of chaos and danger — don’t talk to anyone after the security gate and don’t walk out with anyone, even if they say that they are a policeman. In place of livestock, however, are businessmen, tourists, families coming home and a Nigerian movie star whose entourage rivals that of the Kardashians. I spend a couple of nights in Abuja receiving security and medical briefings before heading to Jahun.
The drive is about five to six hours to Jahun, depending on traffic.
The drive takes seven hours on a good day … without military roadblocks.
You’ll be driving for eight hours, depending on weather.
Are you ready for a nine to ten hour drive, more or less?
At this point, I stop asking how long the drive to Jahun will take.
ICU: India Charlie
We arrive in Jahun in the late afternoon. Finally I see the promised goats surrounded by a distinct lack of chaos or danger. My Australian predecessor wastes no time showing me around the hospital. I put down my bags and 10 minutes later I’m on an ICU round. The ICU has eight beds run by a local staff of two nurses and a charge nurse, Helene. At the start and conclusion of the round I am greeted with “The new med anesthetist! You are welcome.” At the door to the ICU we wash our hands and change from outside shoes into rubber clogs and white coats. The room is simple and functional, each bed separated by a nylon curtain. The head of the bed can be raised mechanically and every component can be wiped clean. There are several fans and two air conditioning units that provide welcome relief from the heat outside. We start the round immediately at bed one.
Bed one: an 18-year-old G3P0 with eclampsia. She was seizing at home for about nine hours before she was brought in and delivered a deceased term baby last night. BP 185/101. No hyperreflexia, no headache. Magnesium treatment is halfway complete and she’s on labetalol. The labetalol is increased. Bed two: a 20-year-old G4P1, eclampsia. Seized again last night despite magnesium. There’s a low-grade fever and she’s drowsy and incoherent. We start a discussion: is it a postictal state, a stroke in progress, magnesium or the benzodiazepines used to break the seizure? Blood pressure is controlled, pupils equal and reactive, limbs are symmetrically hypotonic. Continue magnesium, check mag levels and electrolytes, rapid malaria screen. In my head I imagine the work-up she would receive in New York: a CT head, cultures from every orifice, anesthesia team on standby to intubate. Bed three: 25-year-old G6P3, eclampsia. She has finished magnesium treatment and is on oral antihypertensives.
Northern Nigeria has one of the highest rates of preeclampsia in the world. No one knows exactly why. It could be nutritional deficiency in magnesium or a genetic predisposition, but more universal reasons, such as second marriages with multiple gestations, cannot be ruled out. The American obstetrician on our team shakes his head. He’s never seen three recently eclamptic women in the same room before. “Sahnu?” The patient in bed three nods. “Sahnu” is Hausa, the predominant language in this area. It is one of those indispensable, Swiss Army pocketknife words: how are you?/I’m fine/hello/thank you/OK/I’m sorry. By the end of my mission it forms the backbone of my vocabulary.
We move on. Bed four: a 17-year-old G1P1, jaundice, abdominal distension, renal failure, lethargy, normotensive, no seizures. Her baby is in a crib beside the bed. We stand around scratching our medical heads. One of the local doctors suggests herbal toxicity. The woman has been taking a local herbal concoction of potash and plants to speed labor — her tongue is still dark from the ash. These mixtures are usually made by traditional healers and come with a high risk of liver failure. Will the lab do liver enzymes? Our new French lab technician has recently catalogued the reagents — she is hopeful. The obstetric ultrasound confirms ascites. I move up onto her chest. The curvilinear ultrasound probe just about fits between her ribs and I see a hyperdynamic, empty heart. We start IV fluids and discuss transfer to a larger state hospital.
The women in beds five and six have recovered from postpartum bleeds and are ready to move to the step-down beds in the adjacent room. Helene calls their names out the window. The central courtyard is full of waiting aunts and grandmothers who feed, wash and transfer our patients. “Fatima … Family of Fatima! Come to the ICU.” A few minutes later, Family of Fatima is cloaking her in a long hijab and bright cloth “wrappa,” the traditional dress in this area. They scoop up her brightly bundled baby and walk across the doorway into the general ward. Here she will have her own bed for a couple of nights, then she will share her bed with another postpartum patient before returning to her own village. As they pass me, the women raise their hands and bow their heads: “Sahnu! Sahnu! Sahnu!”
Bed seven: a 16-year-old G1P1 with anemia. Her presenting hemoglobin was 2, presenting complaint: dizziness while walking. She had delivered at home two days previously and her baby is beside her. After 4 units, the hemoglobin on our bedside fingerstick is now 6. She feels good. We debate transfusing another unit. She is nutritionally deprived and is about to spend the next few months breastfeeding. I grab the obstetric ultrasound probe (my echo). Her left ventricle is hyperdynamic and relatively empty. We take a vote and the transfusers win. We also add some high-calorie nutritional supplements.
We turn to our last bed. She’s 35, G5P2 with weakness. She was brought in by her family an hour ago, unresponsive. The story is that she delivered at home overnight. She then became confused and lost consciousness in the early hours of the morning. It’s now evening. The outgoing medical anesthetist educates me: only the men drive and they may be reluctant to travel at night or in poor weather. Our admissions come in mainly between 9 a.m. and 11 a.m., regardless of the onset of symptoms. Some women travel for days, from neighboring countries, for the free, highquality care that MSF delivers. The lucky ones come by car, the rest by oxcart. Our patient flails her left side but her right side is immobile. Blood pressure is uncontrolled, Babinski’s ... I have not checked for this sign since I was a medical student. I doubt myself and repeat the test. Up-going. Her prognosis is grim. Long-term treatment facilities and rehab units do not exist in Jahun and her ongoing care will place an enormous burden on her extended family. The team is silent for a moment, deeply aware of the repercussions if no recovery is made.
The static of a walkie-talkie breaks my reverie. India Charlie, this is Oscar Tango, do you copy? We copy. India Charlie, is the med anesthetist with you? We need help in Oscar Tango. Good copy, she’s coming.
Operating Theatre: Oscar Tango
The nurse anesthetist is struggling with an intubation. I take over and, after the tube is in, find out what is going on. Uterine rupture from a combination of eclampsia and protracted labor. Extra IV lines are secured and we cover her with a washable forced air warmer. Fresh blood is ordered from the blood bank. It arrives four minutes later, still warm from donation. In Jahun, the family of the patient “repays” by donating the number of units used by the patient. There is always a line of willing husbands and fathers on the bench outside the blood bank, waiting for a spot in the “bleeding room.” The type and screen is done on a large porcelain tablet. Blood is screened for hepatitis, HIV, syphilis and malaria. Malaria positive blood is still used — in an endemic area, too many units would be wasted otherwise — but the recipient is simultaneously treated. Packed cells are available for the neonates, everyone else gets whole blood.
Hysterectomy underway, I explore the drug cabinet. It’s fully stocked with a familiar family of emergency medications. Stacks of single-use syringes and needles are neatly organized. A separate, locked shelf contains controlled substances and there is a log book in the office nearby for periodic inspections by the Ministry of Health (MOH). All controlled substance containers are discarded separately. The MOH inspector will compare the log book with the collection of vials. While I understand how narcotics and benzodiazepines made the controlled list, the reason for locking up ephedrine, caffeine and methylergometrine is more of a mystery.
I turn to the anesthesia machine. I had read the orientation pack but the chrome box is quite different in practice. The nurse smiles. “Not like the one you are used to?” It reminds me of a gramophone from 1950.
I follow a standard mental algorithm: first find the “on” switch. There are six dials and two pressure gauges on the Monnal D2. My predecessor points out the pressure dial, rate setting and pressure alarms. There’s an oxygen blender and an isoflurane vaporizer. Monnal has continued manufacture of these simple models as a service to medical NGOs — they are easy to maintain, easy to transport and difficult to break. In terms of the circuit, everything except the endotracheal tube is reusable. The sterilization room has a counter window into the operating theatre — central supply gives us immediate service!
The next five weeks of my assignment pass quickly. I’m on call around the clock and every few days there is a soft nighttime knock at my door. Sometimes I’m called to help with mystery diagnoses (a thyroid storm, an acute non-obstetric abdomen, liver failure, psychosis mimicking a stroke) or to the operating room when a spinal won’t go in easily for an overnight C-section. I use the OB ultrasound for echo often, and rapidly discover that these young women have far from young hearts. Admissions for heart failure come in two or three times a week and some have concomitant valvular disease. I dredge up knowledge from medical school, consult my pocket pharmacopeia, and ask the local doctors if this is what a malaria spleen feels like. Every day I feel humble and grateful.
How to treat burnout? Talk to colleagues, get a massage? Rest on holiday? Quit your job? Become an administrator? Perhaps. For anyone who still has the embers of medicine alight, my advice is to drop the pressures of the Joint Commission, escape the clipboards and walk away from the man who didn’t like the “feel of the pillow” in PACU. Go and treat people who ask for nothing and give only gratitude in return. I hope I helped them. There is no doubt that they helped me. ■
Kiri Mackersey, M.D., is an attending cardiothoracic anesthesiologist at Montefiore Medical Center.
by MELINDA AQUINO, M.D., & SERGEY V. PISKLAKOV, M.D.
What is wellness? While many anesthesiology departments across the country have “wellness programs,” the term “wellness” has been applied in different ways. The National Wellness Institute shares the following interpretation of wellness:
explains the ability of each individual to contribute to his or her environment and community. It allows for the building of better social networks. Using this model we become able to learn the benefits of regular physical activity, healthy eating habits, strength and vitality, as well as personal responsibility, self-care and when to seek medical attention. The model encourages self-esteem, self-control, and determination as a sense of direction and helps to encourage creative and stimulating mental activities, and sharing your gifts and abilities with others.2
For years, employers have realized that on-the-job factors significantly affect workers’ ability to perform their duties appropriately and to be productive. Burnout is a known concern in terms of staff rotation and retention. Burnout is a state of emotional, mental, and physical exhaustion caused by excessive stress. It occurs when one feels unable to meet constant demands. The epidemic of burnout has spread around the world. This epidemic did not leave healthcare untouched. Significantly higher burnout rates have been found among anesthesia providers. The high incidence of burnout was reported among anesthesiology residents and academic chairpersons. Individual factors, stress, family issues and lack of a supportive community can lead to exhaustion, inefficacy, and poor clinical performance.3
Burnout can be easily mistaken for substance abuse, depression, or a personality disorder. However, in the case of burnout the symptoms are job-site related and more about dissatisfaction rather than hopelessness and withdrawal, as one finds in cases of substance abuse or depression. Those who experience burnout feel empty and devoid of motivation, and are beyond caring. Physicians experiencing burnout often don’t see any hope of positive change in their situations. If excessive stress is like drowning in responsibilities, burnout is like being all dried up. There is one additional difference between stress and burnout: while you are usually aware of being under a lot of stress, you don’t always notice burnout when it happens.4
The term “second victim” refers to the healthcare professional who experiences emotional distress following an adverse event. This distress has been shown to be similar to that of the patient — the “first victim.” It leads to burnout as well. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. Because of this broad impact, it is important to offer support for second victims. It is critical that support networks are in place to protect both the patient and the involved healthcare providers. “Second victims” may experience lack of respect. This may be responsible for lack of workplace motivation and employee satisfaction, increased turnover, and a lack of trust and team building among anesthesia providers. It can cause serious damage to self-esteem and the ability to contribute.5
It is the duty of the anesthesiology department’s leadership to listen, to mediate, and to be proactive in such cases. The second victims of errors often suffer in silence. Support must begin the moment an adverse event or outcome occurs. We need to facilitate the second victim’s receptiveness to receiving help and to understand the enormous emotional toll that second victims endure. Second victims have a right to participate in the process of learning from the error. The support of peers and organizational leaders is paramount. Certainly, patients and family members who are harmed come first; however, it is also important to take care of the practitioners involved in the errors, especially when they meant to do good and now find themselves in a situation where a patient has been harmed by their unintended actions. Staff needs to be aware of available resources.
Second victims deserve the presumption that their intentions were good. Nobody should be blamed or shamed for human fallibility. Second victims need compassionate help to grieve and heal, and department leaders must understand the psychological emergency that occurs when a patient is
Some healthcare facilities have established special programs to prevent burnout and second victimization. These types of programs are still missing in the field of anesthesiology, however. Recently we established a Wellness Committee within the Montefiore Medical Center Department of
Anesthesiology. We started by establishing a baseline for assessing staff burnout. We used the Maslach Burnout Inventory, a measurement tool that grades burnout, a three-dimensional syndrome made up of exhaustion and inefficacy.6 We also created the position of ombudsman, an individual who will advocate on behalf of the rotating students, residents, fellows and attending faculty. To ensure confidentiality and independence, the position will be held by an attending physician who is not part of the department leadership.
Simple things like exercise, engaging in a hobby, and interacting with significant others are the best preventers of burnout. The role of an anesthesiology department is to enforce a respectful workplace environment. Burned out physicians can be taught the essentials of stress management and
shown techniques that will enable them to deal with stress, making it manageable and thereby improving their performance and increasing their value to the department.3 The most obvious tangible benefit of supporting a colleague is an enhancement of that individual’s personal efficiency, since he or she can then focus attention on patient care and productivity. ■
Melinda Aquino, M.D., is an assistant professor of anesthesiology, pain medicine and regional anesthesiology in the Department of Anesthesiology at Montefiore Medical Center. She is co-chair of the Department of Anesthesiology’s Wellness Committee.
Sergey V. Pisklakov, M.D., is an associate professor of anesthesiology in the Department of Anesthesiology at Montefiore Medical Center. He is also a member of the Department of Anesthesiology’s Wellness Committee.
by PATRICK GARCIA, M.D.
Cost: Free, three-day trial;
Review: Pedi-Anesth is a companion app developed primarily for those practicing pediatric anesthesiology. The app was developed in part by Dr. Jerrold Lerman, one of the authors of the well-renowned pediatric anesthesiology textbook A Practice of Anesthesia for Infants and Children by Charles J. Coté, Jerrold Lerman and Brian Anderson. Originally released for the Android platform, the iOS version is a port of the Android version. Like many pediatric apps, there is a thorough list of medications for weight-based dosing, organized by medication class. In addition, the app has numerous other informative sections dealing with airway equipment sizing, diagrams for congenital heart defects, difficult airway algorithms, etc.
The app comes as a trialware; users have a three-day period to access the full version of the app. After the trial period, the app will prompt you to purchase either the Lite version or the Pro version. The Lite version comes with just the reference card, which provides the weight-based
dose and formulas. The Pro version includes the reference card and offers the convenience of calculating the actual dose by inputting the patient’s weight. The comprehensive content in this app, with its straightforward presentation, is unmatched compared to other pediatric anesthesia apps.
The sections and categories are also organized well with appropriate color schemes for better visual clarity and recognition. Other pediatric anesthesia apps are very bland in their presentation. The app has a license for use of the material from the actual textbook A Practice of Anesthesia for Infants and Children. Both the Lite and Pro versions are of great value at their price points. I did have a couple of gripes while using the app, mainly concerning the user experience. The weight selection is very unintuitive: a rotary phone layout for the numbers is confusing in this day and age — unfamiliar and unnecessary. Additionally, the transition from one section to another seemed a little more sluggish than most medical apps. The user
experience is not a deal breaker, however; rather, it’s something that can easily be improved by switching to a numeric keypad from the rotary setup as well as hastening the transition speed, which I hope could be implemented in the next update.
Bottom Line: Pedi-Anesth is a comprehensive app for pediatric anesthesiology providers and makes for an excellent reference. Pedi-Anesth can be downloaded from the iTunes App Store as well as the Android Google Play Store.
Patrick Garcia, M.D., is a CA2 resident at SUNY Downstate.
by MARK W. SAWERIS, M.D.
At a time when hospital administrators are often challenged to keep their medical systems afloat, SUNY Upstate Medical University in Syracuse, New York, is flourishing. In 2015, the hospital reported a $120 million profit (up $50 million from the previous year) on $1.02 billion in revenue, largely due to an additional 1,133 operating room cases performed. The increase in caseload requires a keen and attentive administrative effort to maintain diligence and patient safety. The Department of Anesthesiology, led by Chairman Dr. P. Sebastian Thomas, has played a significant institutional leadership role in the successful adjustment to this higher volume. Under his guidance, the department has made strides both at the institutional and state levels. As the premier institution in Central New York, there hasn’t been a more exciting time to practice anesthesia here. SUNY Upstate Medical University is a vital regional resource for an area that stretches from Pennsylvania to Albany and all the way to the northern Canadian border. The anesthesiology department serves a major leadership role in the provision of the highest level of care in the region’s only comprehensive Level I trauma center. The East Tower is the home of the newly constructed Golisano Children’s Hospital, which opened in September 2009 and has become the major referral center for a full range of pediatric services, including an acute post-operative pain service, under the leadership of Dr. Bettina Smallman.
Across from the East Tower is a brand new, state-of-the-art Cancer Center, which was awarded the CEO Cancer Gold Standard accreditation. The cancer team’s mission is to promote healthy lifestyles, reduce cancer risk, and encourage early detection through advancements in cancer screening.
The institution also boasts Central New York’s first and biggest comprehensive Stroke Center, with the highest designation and level of care for stroke patients with the worst possible neurological sequelae. The new facility allows for the expansion of faculty research projects, including hyperbaric oxygen treatment of brain injury, amelioration of neurologic injury after cardiopulmonary bypass, chronic pain models, and immunosuppression after organ transplantation. Additionally, these modern facilities supplement a unique residency training experience by expanding the practice of anesthesiology to new “off-site” locations.
This training experience supplements many other components of the academic curriculum, including the department’s own simulation lab. The lab experience helps get trainees up to speed with common operating room emergencies, providing an instrumental transition to clinical practice. Dr. Jesus Robert Calimlim and Dr. Rahila Bilal simulate many virtual scenarios with trainees — including, for example, emergency endoscopies with uncontrolled gastrointestinal bleeding and blunt trauma requiring massive transfusion protocols — before they encounter real situations with real consequences. The program also maintains an annual dissection course in the cadaver lab with the pain fellows, a great way to master anatomical landmarks and skills needed for regional anesthesia. Dr. Bilal is one of many faculty members with IRB-approved research projects on the subject, including the study of long-term analgesia obtained from penile blocks in hypospadias repairs and circumcisions.
Dr. Carlos Lopez, our program director, strongly believes in a rigorous academic curriculum. He is a passionate educator who takes all first-year categorical residents under his wing. My first encounter with Dr. Lopez occurred late in my residency interview trail. Instead of the standard one-on-one applicant and prospective program director interview (one that the majority of programs follow), he utilizes a more inclusive approach. Sitting at the edge of the table while nervous applicants made their entrance, his skill at transforming an awkward group encounter into an open group discussion (among strangers, no less) stood out to me. He is truly a gifted teacher. In his spare time, aside from residency obligations, he serves as a member of both the NYSSA’s Problem-Based Learning Discussions (PBLD) and Academic Anesthesiology committees to encourage academic discussion on important anesthesia topics. Dr. Lopez works closely with Dr. Thomas, our chairman and the vice chair of the NYSSA’s PostGraduate Assembly in Anesthesiology (PGA) Mini-Workshops Committee. Our program had 20 presentations at both the American Society of Anesthesiologists (ASA) and PGA conferences this year, thanks in part to our faculty’s heavy involvement in academic research with the residents in our program.
Dr. Richard Beers, who is also a member of the NYSSA’s PBLD Committee and serves as PGA general chair, works with Dr. Lopez and Dr. Thomas to encourage academic achievements and advancements in clinical practice. As a member of the ASA’s Committee on Occupational Health, Dr. Beers helps provide guidance on the prevention of workplace illness and injuries. He recently published multidisciplinary infectious control recommendations for the operating room — in conjunction with surgeons, nurses, and pharmacists — in the May 2015 issue of the ASA MONITOR. This is a subject anesthesiologists are putting in the national spotlight while also taking a more prominent role in providing recommendations to help diminish the rampant progression of uncontrolled infectious diseases. As the fifth district delegate to the Medical Society of the State of New York and a former president of the Onondaga County Medical Society, Dr. Beers has also been active in legislative reform, specifically with regard to New York tort law and the effort to limit burdensome legal expenses in the region.
SUNY Upstate Medical University has been a huge stimulus for economic growth by providing employment opportunities in its unique subspecialty service areas. These include complex spinal procedures, robotic gynecological and urological procedures, and neurological interventions, including the region’s only Gamma Knife Center. Dr. Reza Gorji, professor of anesthesiology, and Dr. Fenghua Li, assistant professor of anesthesiology and associate program director, are heavily involved in complex neuroanesthetic services and are pioneers in the advancement of intraoperative neuromonitoring. Together they published a research article in the Neurodiagnostic Journal regarding multimodality of intraoperative neurophysiological monitoring during Onyx embolization of cerebrovascular malformations. They have also worked to advance the understanding of cerebral ischemic injury in relation to repercussion injury as well as intraoperative fluid management. I personally had the privilege of working with both of them on a poster presentation regarding postoperative neuroleptic malignant syndrome secondary to pharmacological interactions in an end-stage Parkinson’s patient, to be presented at the ASA 2016 Conference in Chicago.
We also have faculty and fellows from our outstanding pain management division who have written chapters in notable textbooks, including a chapter written by Dr. Vandana Sharma in Complex Regional Pain Syndrome: Past, Present and Future, published by Nova Science Publishers. Additionally, Dr. Brandon McGinn wrote a piece for the Essential Clinical Anesthesia Review regarding physiological changes in pregnancy and analgesia for labor. Drs. McGinn and Sharma, along with Dr. Parikshith Sumathi, work with residents in the block room and the Upstate Comprehensive Pain Clinic. They are instrumental in teaching the attentive skills necessary in regional and neuraxial anesthesia to provide regional blocks for operating room procedures as well as treatment for chronic low back pain syndromes, sympathetically mediated pain syndromes, CRPS, post-operative and diabetic neuralgias, deafferentation pain syndromes, phantom limb pain, cancer pain, and various myofascial pain syndromes. The pain fellowship here at SUNY Upstate is one of the largest and oldest in the state, established in 1977 and rapidly growing in size and patient load. Aside from these academic achievements and positions, our department members proudly host the NYSSA booth at the annual New York State Fair in Syracuse. For those unfamiliar with this event, it is without question upstate’s biggest attraction. Drawing nearly one million to the New York State Fairgrounds, it is conveniently located in the heart of Syracuse, the ideal location for such an event. The fairgrounds are currently undergoing a $50 million renovation to accommodate even larger crowds that are coming to watch mainstream artists like Jason Derulo and Nas, among others.
In the mix of the chaos, Dr. Srinivasa Thota, the NYSSA state fair vice chair and Communications Committee member, can be found at the NYSSA booth raising awareness about the role of anesthesiologists in medical practice. In addition to his work on behalf of the NYSSA, Dr. Thota has
written chapters on pituitary apoplexy for a textbook on neuroanesthesia by Elsevier publications as well as a chapter on neuroimaging and clinical monitoring for a standard reference book, Essentials of Neurointensive Care, to be published by Oxford University Press, U.K.
Dr. Thota is joined at the fair by SUNY Upstate residents who volunteer their time to answer questions about the specialty of anesthesiology. This includes showing enthusiastic members of the general public airway management techniques using mannequins. Volunteer physicians inevitably offer medical advice to those who haven’t seen a doctor in years. In one instance, an intrigued elderly man, who admitted the only reason he visited the booth was to learn more about the field for his grandson, was persuaded by our chief resident to go to the emergency room for chest pain that was later diagnosed as an NSTEMI. This likely saved his life, and he was very thankful after the fact. This fairgoer and others have commented on the traction and recognition the NYSSA booth has garnered at the jam-packed event. Our department excels in advancing the mission of the New York State Society of Anesthesiologists at this annual event, while occasionally also enjoying some roasted corn, a Daniella’s lobster roll, or a Gianelli’s sausage with peppers and onions.
The New York State Fair isn’t the only fun event in town. The hospital is located in close proximity to University Hill, and the faculty and staff members at Upstate Medical University are frequent visitors to the Syracuse University Carrier Dome. In the stadium that athletic icons and legends Jim Brown and Ernie Davis built, the incredible athletic program here never disappoints, including the basketball program’s improbable run from an at-large number 10 seed bid in the NCAA tournament to the Final Four. Jim Boeheim, assistant coach of the USA Olympic men’s basketball team and legendary coach of Syracuse basketball, is nearing retirement. He is a frequent visitor to the Golisano Children’s Hospital here at SUNY Upstate, to the excitement of patients and staff alike. A great role model and incredible icon, he embodies everything people love about Syracuse. He is a big supporter of and an advocate for the institution. Under his guidance, the hospital and private university often throw joint fundraisers for children with incurable malignancies.
In addition to serving the NYSSA at a regional level, members of the institution are invigorating their approach to treating uncontrolled diabetes, a national epidemic that affects 29 million people. SUNY Upstate has officially reinstated its pancreatic transplant program under the leadership of Dr. Rainer Gruessner, chief of the Transplant Surgery Program, and the results are promising. As an advocate of pancreatic transplant in the definitive treatment of diabetes, it was Dr. Gruessner’s goal to reinstitute this program after a prolonged dormant period. To that end, the institution recently (and successfully) performed its first pancreatic transplant since 2005. The reinstitution of pancreatic transplant surgery reaffirms SUNY Upstate’s reputation as the leader in the region for combating endocrine disease. The procedure offers a cost-effective alternative to the rampant medical costs accumulated secondary to diabetic end organ damage. This cost-effective approach has been made possible through advancements in population health management tools and partnerships with healthcare providers to share analytics on clinical interventions aimed at key patient groups, including those with diabetes.
Upstate University Hospital was recently listed as a 2016 “Most Wired” hospital by Hospitals & Health Networks (H&HN), a publication of the American Hospital Association. This has been a great breakthrough for our anesthesiology department, as advancements in IT continue to improve the infrastructure and quality performance necessary for the residency training program to achieve both value-based and educational healthcare. For example, it is through IT advancements that the institution can promote the immunosuppressive protocols in the operating room that are necessary for successful procedures. The transplant program not only adds to our training, it also offers a promising alternative to combat one of our nation’s biggest health epidemics.
It’s an exciting time to be a resident here at SUNY Upstate Medical University and a member of the Syracuse community. The cliché, “If you can make it here, you can make it anywhere” certainly applies for SUNY Upstate, an institution that is experiencing incredible growth and achievement. I am thankful for my time here and will continue to enjoy watching this program grow to new heights.
Mark W. Saweris, M.D., is a CA2 resident at SUNY Upstate Medical University from the Long Island and New York City region who loves all that Central New York has to offer.
Photographs courtesy of SUNY Upstate Medical University.
Sphere is published four times per year by the New York State Society of Anesthesiologists, Inc.
NYSSA Business Address:
110 East 40th Street, Ste 300
New York, NY 10016
Copyright © 2017 The New York State Society of Anesthesiologists, Inc. All rights reserved. No part of this
publication may be reproduced
in any form or by any electronic
or mechanical means without
permission in writing from the
publisher, the New York State
Society of Anesthesiologists, Inc.