Available Subspecialty Rotations…
Cardiothoracic Anesthesiology
The Cardiothoracic Anesthesiology Section provides anesthesia for cardiac, thoracic, and other types of vascular procedures performed by a group of five cardiothoracic surgeons, including more than 350 coronary revascularizations, 200 valve replacements/repairs, and 100 pediatric procedures requiring cardiopulmonary bypass. We also provide anesthesia for cardiac transplantation. Palliative procedures for congenital heart disease (including closure of patent ductus arteriosus) account for approximately 100 additional cases per year. We anesthetize approximately 200 patients requiring thoracotomy or thoracoscopy, usually involving one lung anesthesia and thoracic epidural catheters. We cover the cardiac catheterization laboratory in selected situations such as elective high-risk coronary angioplasty or valvuloplasty with cardiopulmonary bypass. The clinical experience includes invasive monitoring, transesophageal echocardiography, and extensive experience with the use of inotropes, vasopressors, vasodilators, and antiarrhythmics. Residents spend a total of two months on cardiothoracic anesthesia during their CA-I and CA-II years. During the CA-III year, we offer experiences varying in duration from 2-12 months. Any CA-III resident can arrange for a research project in collaboration with one or more of our faculty. Additional echocardiographic experience is often sought. A one-year fellowship in cardiothoracic anesthesiology is also offered.
Five members of the faculty of the Department of Anesthesiology participate in adult cardiothoracic anesthesia. Four of these faculty devote their clinical commitment to the operating room. The other one attending divides his clinical time among operating room anesthesia and intensive care activities. All participate in either laboratory or clinical research.
Much of the teaching in cardiothoracic anesthesia is performed preoperatively and intraoperatively while caring for patients. In addition to teaching in the operating rooms and critical care units, our service conducts a Wednesday morning didactic conference. This includes clinical case presentations, lectures, resident presentations, research presentations, journal clubs, and guest speakers from other departments. In addition, members of the cardiothoracic group provide 6-10 lectures per year as part of the Department's Monday afternoon didactic lecture series.
The cardiothoracic group has been highly active in research over the past five years, with multiple scientific presentations and publications. The areas of greatest activity have been intraoperative cerebral protection and mechanisms of brain injury, myocardial function and ischemia, inotropes and vasopressors, transesophageal echocardiography, coagulation and anticoagulation during cardiac surgery, blood pressure measurement and blood pressure wave form analysis during cardiac surgery, pharmacokinetics and pharmacodynamics, animal research on organ blood flow, and cardiovascular pharmacology.
Any questions about the cardiothoracic anesthesia service can be addressed to David Zvara, M.D., Associate Professor and Head, Section on Cardiothoracic Anesthesiology, at (336) 716-3118.
Critical Care
The Department of Anesthesiology is responsible for the co-management of cardiothoracic and neurosurgical patients, resident and student education, and administration of the 75-bed multidisciplinary Adult Intensive Care Unit. A total of 8 Anesthesiology and Internal Medicine faculty, representing various backgrounds (i.e., cardiac anesthesiology, pulmonary, cardiology, nutrition, and pediatrics) participate as attending physicians.
The Critical Care Services are composed of the Critical Care Attending Physicians, Critical Care Fellows, Anesthesiology and other Residents, and Senior Medical Students. Critically ill patients are separated into various groups according to disease. The major groupings are Cardiothoracic, Neurosurgery, Trauma, Burn, Vascular Surgery, General Surgery, Internal Medicine, and Pediatrics. Elective rotations are available to residents, fellows, and students in each of these areas.
The Critical Care Section sponsors an ACGME-approved fellowship program (one or two year). A maximum of two fellows are selected each year. Completion of the fellowship will make an individual eligible for Critical Care Board certification in Anesthesiology or Internal Medicine. Anesthesiology requires one year of critical care experience beyond the CA-3 year. General Internal Medicine requires two years of critical care training. Subspecialty certified internists must complete one year of critical care training.
A comprehensive teaching program includes daily formal teaching rounds, daily radiology rounds, and daily didactic conferences. These conferences cover basic topics in Critical Care Medicine. Each Friday there is a conjoint conference attended by Medical and Surgical Intensivists, residents, and students. This conference covers research topics in critical care, journal review, case presentations (morbidity and mortality), and other pertinent topics related to critical care. Critical care fellows are required to present at various conferences. A series of lectures related to emergency care of patients and respiratory physiology are presented each year. In addition, there is the opportunity to attend weekly grand rounds in Anesthesiology, Internal Medicine, and Surgery.
We individualize the educational goals for residents and fellows. In general, we hope to see the trainee develop sound skills in the principles and practice of cardiopulmonary resuscitation, treatment of respiratory failure, cardiovascular support, arrhythmia management, nutrition/metabolic support, use of hemodialysis, intracranial pressure monitoring, and management of organ failure. Management of the high risk surgical patient is emphasized (i.e., blunt and penetrating trauma, burn injury, neurosurgery, vascular surgery, cardiac surgery). We also emphasize differential diagnosis, problem solving, strategies of patient intervention and management, an understanding of monitoring technology, and the ethical concerns inherent in the practice of critical care medicine (including withdrawal of life support, "Do not resuscitate" orders, and brain death determination). The trainee is expected to acquire the ability to approach numerous common problems in critical care medicine. The fellow trainee will acquire the needed procedural skills to qualify for certification in Critical Care Medicine. We recently added Critical Care modules in the Patient Simulation Laboratory for additional training and experience.
The critical care group has an active clinical research program. Current research centers upon clinical monitoring of patients, nutrition/metabolic support, and nosocomial pneumonia. Critical care fellows are required to spend time doing research. Although we do not require residents to participate in research, the resources of the group are available to assist selected residents in research projects.
Additional information about specific aspects of the program in Critical Care of the Department of Anesthesiology can be obtained from David L. Bowton, M.D., Professor and Head, Section on Critical Care Medicine at (336) 716-2593.
Neuroanesthesiology
Each resident has an introductory rotation in neuroanesthesia by the middle of their CA-2 year. A second, more advanced, rotation will follow this and many choose to add a third elective month in their CA-3 year. The rotation emphasizes certain basic tenets of neuroanesthesia: specifically, emergence-based case management and the mastery of the difficult airway. The neurosurgical service is quite busy and performs more than 1700 cases annually, to include 250 intracranial tumors, 70 intracranial aneurysm clippings, 60 carotid enarterectomies, and more than 400 spine procedures.
We take teaching very seriously. Members of our section have won more than half a dozen Golden Apple awards, and we continue to recruit enthusiastic new faculty. As such, our rotation has a strong academic slant with required reading, written study guides, and continuous in-room instruction and assessment. This is conducted in both didactic and question/answer formats. Key concepts are presented from various directions to facilitate retention. We strive to produce both a strong foundation in concept comprehension as well as excellence in the essential skills needed to perform our craft. As an organ-system based specialty, we care for a great variety of pathophysiology—at all stages of life.
Additional information about specific aspects of our program in neuroanesthesiology can be obtained from John E. Reynolds, Associate Professor and Head, Section on Neuroanesthesiology, at (336) 716-4285.
Obstetrical and Gynecological Anesthesiology
Forsyth Medical Center, an 822 bed modern general hospital and home for the new Forsyth Women's Center that opened in April 1992, is located approximately 10 minutes from the Medical Center. This ultra-modern unit contains 16 LDR rooms, two cesarean section rooms, three gynecologic operating rooms, as well as an obstetric intensive care unit, newborn intensive care unit, and all private rooms for postpartum patients.
The Department of Anesthesiology of Wake Forest University Medical Center provides the anesthesia services for the unit. The anesthesia staff consists of 11 board certified anesthesiologists with special interest and training in obstetrical anesthesiology, seven certified registered nurse anesthetists, one or more CA-4 residents in obstetrical anesthesiology, in addition to the usual complement of anesthesia residents and student nurse anesthetists. The Department provides a full range of obstetrical anesthetics including epidurals, spinals, and inhalation anesthetics. In addition, the Department provides all services 24-hours per day with in-house faculty supervision.
The workload consists of approximately 5,600 obstetric anesthetics and 3,000 gynecologic anesthetics. The cesarean section rate is approximately 25% and approximately one-third of the obstetric patients qualify as high risk. Ninety to 95% of cesarean section patients receive regional anesthesia, and 75-80% receive epidural anesthesia for labor and vaginal delivery.
The large number of deliveries offers an excellent opportunity to provide first class patient care, teaching, and clinical research. In addition to the large clinical load, the anesthesiologists conduct daily didactic sessions which address various aspects of obstetric anesthesiology. House staff are excused from clinical activities so they may attend them. The Section on Obstetric and Gynecologic Anesthesiology also participates in the didactic series at the University. Every 12th week obstetric anesthesia cases serve as the basis of the Wednesday Morning Case Presentation/Case Complication Conference.
The section offers one to two, 6-month to 1-year obstetric anesthesia fellowships each year.
Additional information may be obtained by contacting Robert D’Angelo, M.D., Associate Professor and Head, Section on Obstetrical and Gynecological Anesthesiology at (336) 718-8278.
Regional Anesthesia & Acute Pain Management
The section of Regional Anesthesia and Acute Pain Management (RAAPM) is made up of 5 board certified anesthesiologists with special interest or fellowship training in regional anesthesia and acute pain management who work with four CA-2 or CA-3 residents rotating on service each month. The RAAPM section is responsible for the provision of regional anesthetics and acute pain management throughout our 800 bed hospital and for select ambulatory patients. We perform about 2400 peripheral nerve blocks, 1800 neuraxial blocks, and 550 continuous peripheral nerve blocks yearly in our 40 bed OR suite. Our routine practices include the use of nerve stimulation catheter techniques, ultrasound guidance, sustained release epidural morphine, and ambulatory peripheral nerve block infusions. We currently deliver anesthesia for 8-20 total joint replacements every week using continuous peripheral nerve blockade or combined spinal-epidural sustained release morphine without general anesthesia. Approximately 5000 orthopedic procedures were performed at WFUBMC last year and regional anesthesia was used for most inpatient orthopedic procedures. Most patients undergoing major thoracic or abdominal general, plastic, urologic, gynecologic, and oncologic surgeries at WFUBMC also have their pain managed by RAAPM using thoracic epidural analgesia or sustained release epidural morphine. In addition to providing care for inpatients recovering from surgery, the RAAPM section also maintains an active census of outpatients managed with continuous peripheral nerve blockade at home and patients with chronic pain managed in the hospital. Daily opportunities to practice acute and chronic pain management abound. An active Visiting Clinical Preceptorship for practicing anesthesia providers provides continuing medical education credits for observational visits to our institution after training has been established.
All these types of regional anesthetics are initiated in a dedicated Regional Anesthesia Area staffed by specially trained nurses where medical direction is the responsibility of RAAPM faculty. These same faculty manage these same patients postoperatively using multimodal analgesia based on regional techniques while employing a handheld computer database for tracking patient care and for billing. In addition, members of the section are well versed in managing patients with chronic pain using the same regional analgesic techniques used for acute pain and by providing consultation to medical and surgical services in the medical management of in-patients with chronic pain.
Resident education and hands-on involvement is the cornerstone of patient care in our section. Every month, four residents rotate through RAAPM and each places 40-100 peripheral nerve blocks. RAAPM residents receive one-on-one instruction in the craft of regional anesthesia because they are scheduled to provide patient care in the Regional Anesthesia Area rather than a single operating room. Alternatively, these same RAAPM residents receive instruction in acute and chronic pain management when rounding on the Acute Pain Service and when scheduled to provide coverage through home call of the same patients cared for previously in the Regional Anesthesia Area. Regional anesthesia and acute pain management are a standard part of departmental conferences. Additionally the RAAPM section uses dedicated teaching time for a weekly resident-oriented subspecialty conference, hosts a fresh cadaver anatomy lab twice a year, and has monthly resident in-services for infusion pumps and equipment. Anesthesia residents at WFU have at their disposal the resources necessary to leave their residency capable of providing consultant level patient care in sophisticated techniques for acute pain management such as thoracic epidural analgesia, sustained release epidural morphine, and continuous peripheral nerve blockade.
Additional information can be obtained by calling J.C. Gerancher, MD, Associate Professor and Head, Section on Regional Anesthesia and Acute Pain Management at (336) 716-4497.
Pediatric Anesthesiology
Resident education in Pediatric Anesthesiology is accomplished by three months direct care of both healthy and critically ill children. During the second year of anesthesia training at North Carolina Baptist Hospital, residents work on a daily basis with one of nine Board Certified anesthesiologists, all with formal pediatric anesthesia fellowships, in the care of children for all forms of general, urologic, ophthalmologic, cardiac, plastic and reconstructive, orthopedic, otolaryngologic, cardiothoracic, and neurosurgical procedures. Care of premature infants and critically ill children is emphasized, and the experience is complemented by a diverse exposure to pediatric patients during a month in the ambulatory surgery unit. A pediatric anesthesia text is provided for all house officers which includes an extensive bibliography. Pediatric anesthesia lectures and journal clubs are held to complement the clinical experience.
In 2004, a new dedicated pediatric operating suite was opened with seven ORs, a separate pediatric PACU, holding area, and nursing/support staff. Over 90% of pediatric anesthetics are provided in this child and family friendly facility.
Additional pediatric experience is acquired with a one-month rotation in the Pediatric Intensive Care Unit. During this month, the resident is supervised by pediatric anesthesiologists and intensive care specialists providing full multidisciplinary management of infants and children with complex medical and surgical disease and experience with sedation for brief procedures in children. During the three required months of pediatric anesthesia experience, residents generally perform more than 100 individual anesthetics for children, newborn to 12 years of age. The combined outpatient OR, inpatient OR, out of OR anesthesia, and PICU experience provides extremely valuable resident education in the preoperative assessment, intraoperative care, and postoperative management of children.
Additional information can be obtained by calling Joseph R. Tobin, M.D., FAAP, FCCM, Professor and Head, Section on Pediatric Anesthesiology and Pediatric Critical Care at (336) 716-2596.