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 4,300 cases in FY2008, which is a 10% increase over historical volumes.
In 2007, the VA National Center for Patient Safety awarded a grant to the Durham VA Anesthesiology Service to establish a VA Patient Safety Center of Inquiry. This program, funded through VA patient care revenues, focuses on clinical improvement projects designed to make medical care more reliable and safer. Our group is using a high fidelity medical simulator to train nurses and doctors who provide moderate sedation for procedures outside the operating room.
VAMC Pain Clinic. In addition to sympathetic, neurolytic, major conduction blocks, and diagnostic thermography, spinal cord stimulator trials were initiated in 2008. 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. In 2004, our new clinic facility opened in renovated space on the 4th 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 and spinal cord stimulation procedures. Workload continued to increase in 2008 as the VA has seen an influx of patients from the Operation Enduring Freedom and Operation Iraqi Freedom wars.
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. Atilio Barbeito, Raquel Bartz, and Shahar Bar-Yosef. Residents from the Duke Departments of Anesthesiology, Surgery, and Emergency Medicine provide house-staff coverage for this unit. This heterogeneous group of trainees provides a unique collaborative learning environment. In 2008, the Durham VA was awarded funding for a full-time anesthesiology critical care fellow, and this role has been well filled during the year. These fellows focus on managing SICU patients and also gain advanced training in perioperative TEE that will allow them to meet the guidelines for certification by the National Board of Echocardiography.
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 managed by Cori Corcoran, PAC, and staffed by two other experienced physician assistants, Roger Page, and Colleen Vogele.
Transesophageal Echocardiography (TEE) Service. This service acquired new equipment in 2009 that allows 3D TEE echo imaging for the first time. Our digital acquisition and storage system allows rapid retrieval and review of any echocardiogram performed at the VA. Its value in clinical care and teaching continues to be evident. During 2008, 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. Four faculty members, Drs. Barbeito, Bar-Yosef, Mark, and Schroeder, all certified in Perioperative TEE by the National Board of Echocardiography, provide these services.
Certified Registered Nurse Anesthetists. 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 James Neblett, Robert Dickinson, Eric Nelson, Matt Rogers, and Craig Shanewise. 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 Pain Clinic.
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. Terri Monk chairs the Transfusion Committee, and Dr. Shahar Bar-Yosef serves on the VA Institutional Review Board. At the service level, tremendous administrative support is also provided by Dr. Dana Wiener, Assistant Chief for Clinical Affairs, and Dr. Becky Schroeder, Assistant Chief for Research Administration.
Resident, fellow, and medical student education are top priorities for the entire faculty at the VA. 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 Monday afternoon echocardiography and cardiac physiology conference is attended by our Duke residents, cardiac anesthesia fellows, and anesthesiology critical care 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. One outstanding example of successful mentoring is reflected by the accomplishment of a Duke MS-3 student who worked with Terri Monk for his 3rd year project. His study was selected by ASA as one of 10 best abstracts at the annual 2008 meeting, an extraordinary accomplishment given the level of competition.
During 2008, several members of the VA faculty continue to be productive in basic science and clinical research efforts. Dr. Raquel Bartz has expanded her work on mitochondrial DNA repair enzymes and their role in mitochondrial biogenesis with support from the Foundation for Anesthesia Education and Research (FAER). A primary focus in the clinical arena continues to be neurocognitive changes following anesthesia and surgery with Dr. Terri Monk and Dr. Rebecca Schroeder working with both cardiac and non-cardiac, elderly populations in projects funded by the National Institutes of Health and the Alzheimer's Association, while Dr. Shahar Bar-Yosef is investigating the incidence and natural history of heparin-induced thrombocytopenia as part of a multi-center trial funded by the National Heart, Lung and Blood Institute. A new initiative in 2008 in the VA division has been the development of the VA Clinical Simulation Program, supported by a grant from the VA National Center for Patient Safety, and currently tasked with developing training programs for clinicians administering sedation in the clinic setting and evaluating their efficacy.
In addition to these original laboratory and clinical research efforts, the VA faculty continued to contribute to the medical literature in 2008 by authoring numerous peer-reviewed articles, chapters in major textbooks (Miller's Anesthesia and Anesthesiology [Longnecker, Brown, Newman, Zapol]), and reviews in the fields of cardiovascular monitoring, transfusion medicine, transesophageal echocardiography, depth of anesthesia, patient safety, and many other topics in anesthesiology and intensive care medicine.
Jonathan B. Mark, MD
Chief, Anesthesiology Service
Atilio Barbeito, MD, MPH
Thomas Buchheit, MD
Surgical Intensive Care Unit
Charles S. Brudney, MB, ChB, FRCA, Medical Director
Short Stay Unit
Dana N. Wiener, MD, Medical Director
Mark Kirkley, Research Support