Clinical Program

The Durham Veterans Affairs (VA) Medical Center is conveniently located across the street from Duke University Medical Center. Our VA anesthesia faculty provide comprehensive clinical anesthesiology services for the veteran population at this institution, including patients undergoing cardiac surgery, orthopedic joint replacement, major vascular, thoracic, neurosurgical, plastic, ENT, urologic, and ophthalmologic operations. Outside the operating rooms, our staff care for patients undergoing electroconvulsive therapy and those requiring painful diagnostic and therapeutic procedures in the cardiac catheterization/electrophysiology laboratories, gastrointestinal, and radiology suites. Our service provides primary coverage for all patients in surgical intensive care (SICU), short stay unit (SSU), acute and chronic pain management services, diagnostic transesophageal echocardiography, and emergency airway management.

The staff bring special expertise and interests to all of these clinical arenas. Faculty with subspecialty board certification work in intensive care and pain management and contribute to accredited Duke departmental fellowship training programs in both of these areas. Other faculty members have advanced training and interests in cardiac anesthesia, regional anesthesia, geriatric anesthesia, fiberoptic techniques for airway management, and transesophageal echocardiography.

The expansion and renovation of the VA operating room was completed in 2002, leaving us with eight sizable rooms, a cystoscopy room, and support spaces including an anesthesia workroom, laboratory, office, and other storage spaces. Expansion of clinical staff accompanying the physical renovation has allowed us to increase workload as well. On a daily basis, seven operating rooms are staffed, allowing surgical case volume to reach a record high of more than 1,000 cases per quarter, which is a 20% increase over historical volumes.

Our group welcomed one new member during the past year: Dr. Terri Monk. With her breadth of clinical experience and outcomes research background, she has already made a substantial contribution to our division, particularly in her efforts to increase our clinical trials work.

VAMC Pain Clinic. This busy multidisciplinary unit is directed by Dr. Joel Goldberg. In addition to sympathetic, neurolytic, and other major conduction blocks, diagnostic thermography is used regularly in the evaluation of clinic patients. The pain clinic serves as a training site for the departmental Fellowship in Pain Management. Residents and fellows in anesthesia and primary care rotate through the pain clinic as part of their training. Since 2001, our clinic has served as one of nine federally funded training sites for Anesthesia Pain Fellowship within the VA system.

The most significant news of 2004 was the opening of our new clinic facility in renovated space on the 4 th floor of the VA. The new Pain Clinic suite consists of four spacious private examination rooms and one new large procedure room, capable of supporting fluoroscopic guided nerve block procedures. Since moving into the clinic in the fall, patient visits have already increased markedly as the new space better supports the multiple clinicians working in our clinic. This workload was achieved through the efforts of Drs. Goldberg and David Lindsay, and nurse practitioners, Marty Larson and Hali Frost.

Surgical Intensive Care Unit (SICU). This unit is an important responsibility of the anesthesiology service. Our faculty provide perioperative care for all surgical patients at the VA. Dr. Scott Brudney continues his role as medical director of this unit. He has shared attending responsibilities with Drs. Laura Niklason and Shahar Bar-Yosef. The newest member of our intensive care team is Dr. Mihai Podgoreanu, who joined the faculty late in 2003 and divides his time between the VA SICU, the Duke cardiac group, and his basic science laboratory. Residents from the Duke Departments of Anesthesiology, Surgery, Emergency Medicine, and Obstetrics and Gynecology provide house-staff coverage for this unit. This heterogeneous group of trainees provides a unique collaborative learning environment.

Short Stay Unit (SSU). This unit continues to grow and serve as the hub of perioperative patient preparation. It is conveniently located adjacent to our OR and recovery rooms. Each month, more than 300 patients receive care in the SSU, preparing them for surgical and invasive medical procedures.

Dr. Dana Wiener continues her effective leadership as the medical director of the SSU, and along with other staff anesthesiologists, she provides consultative medical direction to the physician assistants who perform most of the patient evaluations on this unit. The unit is staffed by our able physician assistants, Bud Shelton, Cori Corcoran, Roger Page, and Laurie Lee (who joined us in 2004). As of this writing, we still miss the able efforts of our fifth physician assistant, David Lewis, who remained on military leave throughout the year.

Transesophageal Echocardiography (TEE) Service. This service acquired new equipment in 2001 for digital acquisition and storage of echocardiograms. This state-of-the-art imaging system allows rapid retrieval and review of any echocardiogram performed at the VA or at Duke. Its value in clinical care and teaching continues to be evident. During 2004, the number of TEEs performed by the anesthesiology service reached a record, in part owing to the fact that we were performing many more TEEs outside of the operating room. This has been driven, in part, by the recent increased activity in our hospital Electrophysiology Laboratory, and the need for many of these patients to undergo TEE to rule out intracardiac thrombus prior to implantation and testing of an internal cardioverter defibrillator. Five faculty members, Drs. Bar-Yosef, Mark, Podgoreanu, Schroeder, and Sreeram, are all testamurs of the National Board of Echocardiography, and in 2004, Dr. Mark became certified by this medical board.

The clinical success of the VA service would be impossible without the ongoing contributions of an outstanding group of certified registered nurse anesthetists (CRNAs). Ms. Linda Skinner has provided superb leadership in her role as Chief CRNA. We continue to have a staff of excellent experienced CRNAs, including Pauline Brault, Mary Lo, James Neblett, Frank Titch, Robin Westbrook, and Sarah Christian. Our hopes for the future remain bright, as we continue to work with student nurse anesthetists from Duke. Each month, one of these students joins us on a clinical rotation in the VA operating rooms, and the enthusiasm, preparation, and burgeoning skills that they demonstrate are recognized by all our staff.

Members of the faculty also are active in hospital affairs and provide leadership in a variety of areas outside of the operating rooms. Dr. Joel Goldberg chairs the Pharmacy and Therapeutics Committee, Dr. Gautam Sreeram chairs the Transfusion Committee, and Dr. Shahar Bar-Yosef serves on the VA Institutional Review Board.

Training Program

Resident, fellow, and medical student education are top priorities for the entire faculty at the VA, as evidenced by the fact that our clinicians are consistently rated highly as effective teachers in the department. Daily didactic conferences at the VA supplement bedside SICU and operating room training. Each morning a departmental teaching conference starts the educational day, followed by bedside SICU teaching rounds later in the morning. Finally, a departmental Friday morning echocardiography and cardiac physiology conference is attended by our Duke residents and cardiac anesthesia fellows. VA faculty have been actively involved in training residents in the Duke Human Simulation and Patient Safety Center and in a variety of other departmental educational venues, including grand rounds, resident lecture series, and subspecialty conferences.

Medical students from Duke and other institutions rotate through our operating rooms and SICU at the VA. All of our faculty are involved in teaching students at the bedside and in small group conferences, and several faculty contribute to the medical school curriculum, lecturing in pharmacology and physiology, and serving as research mentors for third-year student projects.

Research Program

During 2004, a number of VA faculty continued productive basic science and clinical research efforts. Two investigators maintain significant commitments to bench research. Dr. Laura Niklason continues her outstanding work in tissue engineering of artificial blood vessels, and Dr. Mihai Podgoreanu was the successful recipient of his first NIH RO-1 grant, as the Co-Principal Investigator of a five year award to study the genetic determinants of graft failure following coronary surgery. Several clinicians remain active in clinical trials, including Dr. Rebecca Schroeder (studying perioperative delirium), and Dr. Shahar Bar-Yosef (studying adrenal insufficiency in SICU patients and also investigating the role of perioperative temperature changes and neurocognitive outcomes following heart surgery). Dr. Ellen Flanagan continued her clinical research training through the Department of Anesthesiology NIH Training Grant and submitted multiple IRB applications for new studies focused on the issues surrounding “Do Not Resuscitate” orders during the perioperative period. A new research assistant, Mr. William Chisenhall, joined us this year and has been instrumental in providing support for all clinical investigations.

In addition to these original laboratory and clinical research efforts, the VA faculty continued to contribute to the medical literature in 2004 by authoring numerous peer-reviewed articles, chapters, and reviews in the fields of cardiovascular monitoring, transfusion medicine, transesophageal echocardiography, and many other topics in anesthesiology and intensive care medicine.

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Jonathan B. Mark, MD

Chief, Anesthesiology Service
Veterans Affairs Medical Center
Professor and Vice Chairman
Department of Anesthesiology
Duke University Medical Center

Faculty

Shahar Bar-Yosef, MD
Atilio Barbeito, MD
Charles S. Brudney, MB, ChB, FRCA
Joel S. Goldberg, MD
David R. Lindsay, MD
Terri G. Monk, MD
Rebecca A. Schroeder, MD
Dana N. Wiener, MD

Pain Clinic

Joel S. Goldberg, MD, Director
David R. Lindsay, MD
Martha Larson, RN, ANP
Hali Frost, RN, ANP

Surgical Intensive Care Unit

Charles S. Brudney, MB, ChB, FRCA, Medical Director
Atilio Barbeito, MD
Shahar Bar-Yosef, MD
Mihai V. Podgoreanu, MD

CRNA Staff

Linda W. Skinner, CRNA, Chief CRNA
Robert Dickinson, CRNA
Li-Yuan M. Lo, CRNA
James M. Neblett III, CRNA, MSN

Short Stay Unit

Dana N. Wiener, MD, Medical Director
Cori Corcoran, PA-C
David Lewis, PA-C
Roger Page, PA-C
Colleen Vogele, PA-C

Research Assistant

William Chisenhall

Support Staff

Julie A. Rosato