June 21, 2017
It has been a very busy few weeks! Orientation officially began for 12 out of 14 of our soon-to-be CA1s with lectures on perioperative assessments (including individualized Mallampati classifications for each new orientee), the mechanisms behind the anesthesia machine, practical tips on being an anesthesiology resident here at Duke, and more. Our chief residents and teaching scholars led the group to the OR for near-peer teaching on topics regarding basic setups, omnicell usage, and their perspectives on practical tips. Some of our fantastic faculty worked with smaller groups in the simulation center regarding induction, maintenance, and emergence. Friday, the rising CA1s were paired up with senior residents for true on the job learning. This week starts week 1 of 3 of their precepting period where paired residents will rotate in the main hospital, the VA, and the ASC, for more in-depth learning of the specialty and environment specific information.
Last week , we also held our spring session of mock orals for the CA-2s and CA-3s and minus the salad dressing disaster (yes, of course, I heard about it!), it went well. A special thank you to Nicole Guinn for directing the event and all of the faculty who stayed late to help our residents. We have a good number of faculty who write for the ABA exams and many bona fide oral examiners, so this is a great representation of what you can expect with the real exam.
Lastly, we celebrated our CA3s at graduation on Saturday night. Hope Valley did a fantastic job once again and a special shout out to Jessica and Shelby for organizing another great night. Dr. Mathew started the program detailing how important an anesthesiologist is to every single patient and the long standing impact you have on each of them. Dr. Kuhn gave a heartfelt speech for the last class that she recruited and each graduate said a few ‘thank yous’ to the department leadership, faculty, and their families for getting them this far. For those of you who couldn’t join us, as the ORs are still active, below are the awards and leadership positions deservedly recognized Saturday night. Every member of this department has a lasting impact on the program, but the residents and faculty listed below were recognized for their outstanding contributions to our program:
- Outstanding Graduate Award presented to Dr. Jenna Falcinelli
- Dr. Robert Sladen Teacher of the Year Award presented to Dr. Brian Ginsberg
- Mentor Award presented to Dr. Kerri Wahl
- Residency Program Contribution Award presented to Dr. Abigail Melnick
- Dr. Richard Moon weekly quiz awards presented to Dr. Annie Castro, Dr. Theresa Crowgey, and Dr. Taylor Herbert
- Chief Resident Leadership: Dr. Jenna Falcinelli and Dr. Chris Wahal
- Academic Chief Resident Leadership: Dr. Taylor Herbert and Dr. Kendall Smith
- Teaching Scholar Leadership: Dr. Stephanie Jones and Dr. Alex Reskallah
Remember to meet with your advisors! Graduating CA3s, this needs to happen before you leave the nest! Rising CA1s, make sure you’re thinking about who you’d like to be your advisor. Don’t hesitate to stop by for some advice if you’re having trouble deciding.
We still have an exciting few weeks coming up with our 15 interns starting their orientation this Friday and our two transitional residents starting their CA1 orientation on July 1. Stay tuned for updated on our exciting plans for interview season as well! Have a great week!
Presented at SCA 2017
Echocardiography Guidance of Surgical Excision of an Intra-Cardiac Pheochromocytoma
Dinesh Kurian, MD, MBA, Angela X. Li, MD, Srikar Rao, MD, Agathoklis Konstantinidis, M.D, Sanziana Roman, MD, Miklos D. Kertai, MD,PhD
Background: Pheochromocytomas are rare neuroendocrine tumors, with published incidence of 2 to 8 cases per million patients per year. The extension of these tumors into the vena cava and right atrium is rarely seen. Successful removal of a pheochromocytoma with intracardiac extension has been reported both with and without cardiopulmonary bypass. Previous studies also have described echocardiographic evaluation of intra-cardiac pheochromocytoma. However, to our knowledge, there have been no published reports of transesophageal echocardiography (TEE) to guide surgical management of an adrenal pheochromocytoma with intracardiac invasion. Thus, we present the first case in which TEE was used to guide intraoperative surgical decision making.
Methods: IRB approval was waived for presentation of a single patient case report. A form of written consent for case presentation was given by the patient. Medical data was obtained from electronic records review (Epic, Verona WI, USA). Intraoperative TEE images were obtained from a digital imaging storage archive (Xcelera, Amsterdam, The Netherlands).
Results: A 50-year-old female with uncontrolled hypertension, weight loss and right upper quadrant abdominal pain for 3 weeks was found to have a pheochromocytoma with extension into the inferior vena cava (IVC) and right atrium (RA). She was scheduled for an elective open adrenalectomy with excision of intracardiac tumor, with possible left nephrectomy, splenectomy, and pancreatectomy after adequate preoperative medical control. Preoperative magnetic resonance imaging revealed a 15cm left pheochromocytoma extending intravascularly into the left renal vein, inferior vena cava, and right atrium. A nuclear medicine study demonstrated metaiodobenzylguanidine avidity of the mass across its full extension to the right atrium and no distant metastases. Initially, it was thought that this mass could be removed from an infra-diaphragmatic dissection with traction to mobilize and remove the mass. Intraoperative TEE revealed a 3.1 x 3.2 cm pedunculated mass within the right atrium. The mass extended through the IVC, occupying 80-90% of the cross sectional area of the vessel. After discussion with the surgical team, it was decided that the safest method would be to initiate cardiopulmonary bypass and completely remove the tumor and associated tumor thrombus via a combined abdominal and transcardiac approach in order to avoid tumor rupture and possible embolization. The patient underwent a successful and complete removal of the mass with preservation of the left kidney, spleen, and pancreas.
Conclusion: Although cardiac extension of adrenal tumors has been reported previously, this condition is considered extremely rare. TEE appears very valuable in delineating tumor extent and characteristics at the time of surgery, thus directly helping to guide surgical approach. In this case, TEE information was key to guiding a safe, and complete en block resection of a malignant pheochromocytoma.
CENTRAL LINE :: 6/25 – 7/1
- This is the LAST central line for the graduating CA-3s!
- This is the FIRST central line for the rising CA-1s! Welcome to the ORs!
- The Chief Resident State of the Union presentation is THIS Thursday June 22nd, 2017. Wellness days, lecture expectations, and lots of commonly asked questions will be addressed!
- July 4th is an OR holiday. If you are scheduled in the main ORs, you will be OFF that day. Please check with your respective rotations to confirm if you have it off if you are NOT in the main ORs. July 4th day OR day team will be Brockbank and Andrews (will be paid). ALL RISING CA-1s, you have that day off. Seriously.
7/7: AKT post exam @4pm (Rising CA-1s)
7/15: Duke Anesthesia Department Welcome party @5pm (ALL, please RSVP)
7/24: AKT24 (Rising CA-3s)
This weekend (6/24 – 6/25): Johnbull, Pleticha
Next weekend (7/1 – 7/2): Brockbank, Andrews & 7/4
This week (Sat PM 6/24 – Fri AM 6/30): Li, Cobert
Next week (Sat PM 7/1 – Fri AM 7/7): Garrett, Bangura
Friday Night Call
This Friday (6/23): Gamble, Mangubat
Next Friday (6/30): Crowgey, Donald
Liver Call Weekend (pager: 7320)
This weekend (Fri PM 6/23 – Sun PM 6/25): Van Hoomissen
Next weekend (Fri PM 6/30 – Sun PM 7/2): Horazeck
Liver Call Weekday (pager: 7320)
Liver day (Mon AM 6/26 – Fri PM 6/30): Gamble
Liver night (Sun PM 6/25 – Fri AM 6/30): Johnbull
Saturday 6/24 AM: Brockbank
Saturday 6/24 PM: Donald
Sunday 6/25 AM: Horazeck
Saturday 7/1 AM: Gamble
Saturday 7/1 PM: Cobert
Sunday 7/2 AM: Li
This Friday (6/23): Pleticha, Hall
Next Friday (6/30): Mangubat, Cotter
Simulator (4-6 p.m. — page charge CRNA *7853 to ask for relief at 3:45 p.m.)
*These are mandatory sessions*
Mon (6/26): Anderson, Chen, Fox
CA3 on call pager (970-9313) is covered by CA3 on general OR call.
Liver call pager (970-7320) is always covered.
Have a good week!
Please stop by during the office hours listed below. Or, please feel free to contact any of our leadership to schedule a meeting outside of standard office hours.
Duke Health wants to showcase our residents online! Please contact Jennifer Schwabel and Jessica Burkhart if you’re interested in creating a video for your physician profile page! Check out Dr. Thomas Buchheit’s profile video for a great example.
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This Week in Lectures
CA 1 (6/20): Physiology of Pregnancy by Dr. Jennifer Dominguez
CA 2/3 (6/21): Board Review by Dr. John Eck
Thursday (6/22): State of the Union with Resident Chiefs: Angela Li and Jack Gamble
Next Week in Lectures
CA 1 (6/27/): Nontechnical Skills by Dr Ankeet Udani
CA 2/3 (6/28): No lecture. Congratulations to graduating CA3s – we’ll miss you!
Thursday (6/29): No lecture.
Private practice group in Lewes Beach Delaware is expanding! See Dr Jay Hutson’s email in the jobs box account for more details about the job and how to reach him.
Emory is expanding faculty – high risk OB, peds, cards, thoracic, general cases, etc. Contact Dr Bola Faloye, 2013 alumni, for more information. Contact information is in box account!