Observations: An Educational Metaphor

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December 1, 2013 Volume 77, Number 12
Observations: An Educational Metaphor N. Martin Giesecke, M.D.

Probably my first recollection of a teaching moment related to the concept we now call the Surgical Home occurred during my residency. The event took place in my CA-2 year and it centered on a neurosurgical case.


On Wednesday mornings back then at the University of Texas Medical Branch, residents (and occasionally faculty) gathered for two educational conferences. The first meeting was the Case Presentation conference. The second session was the Morbidity and Mortality (M&M) conference, a review of undesired or unexpected outcomes related to anesthesia.


The Case Presentation session was almost always run by our chairman, James F. Arens, M.D. On Tuesday afternoon, Dr. Arens would look over the Wednesday surgery schedule. For educational reasons (or sometimes retribution for some resident behavior or act – at least that is what we residents thought), Dr. Arens would pick out cases for discussion the following morning. The chosen cases would be indicated on the schedule with a “star.” Residents whose cases were indicated were thus “starred.”


The actual conference was run like a series of oral exam questions. Dr. Arens posed these questions to the starred resident, and if that person was unable to answer the question, he would then call on someone of his choice in the room. I can tell you that there was no use trying to hide in the back row; if Dr. Arens wanted to find a particular resident to answer a question, he would do so. Now the reason I mentioned that we residents sometimes felt being starred was retribution is that for one three-week stretch, for instance, I was starred every Tuesday. But luck must have been with me, because I don’t recall actually having to present, or answer questions about my starred case, any of those three weeks. That is not to say that I was never starred and not called upon. Maybe Dr. Arens just wanted me to spend a bit more time reading about my cases. Being starred was a pretty good incentive to do so.


The second conference was attended by both residents and faculty, or at least by the faculty whose cases would be presented by a resident that day. Like many M&M sessions, the resident presented the case and the outcome. Then Dr. Arens, or other faculty, would ask pointed questions directed at making the presenting resident and responsible faculty consider ways the anesthetic care might be improved. For me, this was an important lesson. Not just that we should all continually strive to improve our game, especially in light of an unexpected outcome, but also that the faculty were held, at least in the confines of the conference, at least as responsible as the resident.


Now, let’s return to the story of my educational moment for the Surgical Home. All the residents had gathered in the classroom for the Case Conference. I had not been starred, so I was feeling about as calm as one could at the start of the session. Then Dr. Arens called on me and told me to meet with Dr. Gibson, one of the faculty. He told me my assignment had changed and that Dr. Gibson and I would be taking care of a patient who needed to have a craniotomy.


It seemed that my new patient, who showed up on Wednesday’s surgical schedule, had also been on Tuesday’s schedule. And believe it or not, he was on Monday’s schedule, as well. The patient’s surgery had been cancelled, both times due to hyponatremia, by the anesthesiologists assigned to take care of him on Monday and Tuesday. If merely seeing the same name and procedure on the schedule three days in a row had not attracted Dr. Arens’ attention, I’m sure he received an admonition from the chair of the neurosurgery department about this. Therefore, the team (which was the same resident and faculty pair who had cancelled the case on Sunday and Monday nights) that was scheduled to take care of the patient on Wednesday was reassigned, and Dr. Gibson and I were tasked with taking the patient to the O.R.


The anesthesiologists who were scheduled to care for the patient on Monday and Tuesday had informed the neurosurgical service each day that the case would be cancelled, as the patient was hyponatremic. The etiology of the patient’s hyponatremia was the syndrome of inappropriate antidiuretic hormone (SIADH) secretion resulting from his brain tumor. At the time, I guess these anesthesiologists expected the surgeons to fix the problem (i.e., further restrict free water or appropriately administer sodium). Somehow, this plan of therapy was not carried out by the surgeons, or their approach on the floor was inadequate, and each time the patient was seen in pre-op evaluation by the anesthesiologist, the sodium level remained low. The anesthesiologists therefore did not feel safe taking the patient to the O.R. to give him an anesthetic.


Effectively, I was dismissed from the two conferences that morning so that Dr. Gibson and I could prepare the patient for surgery. The patient was already in the PACU, and we went about administering appropriate amounts of hypertonic saline over the next three hours to slowly bring his sodium level up to a point where we could feel comfortable taking him to the O.R. and giving him an anesthetic for his procedure. The anesthetic proceeded without complications and the patient did well afterward. With his tumor resected, he had no more issues with SIADH, so no residual hyponatremia. The events surrounding this patient were presented at the following week’s M&M. Luckily, my part in that presentation was a small one, merely presenting the therapy we gave preoperatively, the anesthetic we provided and a mention of the patient’s good outcome.


So where does the Surgical Home fit in to all of this? Obviously, had an anesthesiologist been in charge of this patient’s care from the beginning, we would have managed the hyponatremia so that the original case, as scheduled for Monday morning, would have proceeded. Even back in 1987, it was not enough for Dr. Arens that we cancel a case (for good reason). If there was something we could do to better prepare the patient for surgery, it was our responsibility to ensure that such actions occurred. So whether it was appropriate treatment of hyponatremia, or ensuring that NPO orders were written, or that an adequate amount of blood was typed and crossed for a procedure, all of that was Dr. Arens’ expectation of us.


And that education, for me, was solidified by this one encounter with a neurosurgical patient during my residency. Please read this issue’s articles on neurosurgical anesthesia. Then share with me any teaching points garnered from the readings or from similar personal experiences.