Latest / Style Points / Protecting Mothers with Kelly Fedoruk

Transcript

Protecting Mothers with Kelly Fedoruk · Style Points

0:10
anesthesia enthusiasts, and welcome to this month's
0:12
episode of Style Points. My name is John Crow.
0:15
Today, we have special guest Dr. Kelly Fedorek,
0:18
who is here visiting us in Cincinnati from Stanford
0:21
to do a journal club with our residents and to
0:23
give a grand rounds the next morning. Fortunately
0:26
for us, she also agreed to be a guest on the
0:28
show today. Before we get to her, I'll let my
0:31
co -host Dr. Nate Moore introduce this month's
0:34
RSI. Thanks, John. Presenting our RSI today is
0:37
Dr. Rachel Kidwell, anesthesia intern and weightlifting
0:40
enthusiast. With her max bench press of 135 pounds,
0:43
she has more than enough upper body strength
0:45
to intubate anyone rapidly, which is a perfect
0:47
match for her topic. Set the scene for us, Rachel.
0:50
It's your first call of CA1 year. You're getting
0:52
ready to order takeout, and the pager goes off.
0:54
A 56 -year -old man with unknown past medical
0:57
history presents following a gunshot wound to
0:59
the abdomen approximately 45 minutes ago. He
1:02
is awake but somnolent and is urgently rushed
1:03
to the OR for an emergency X -lab. You have just
1:06
enough time to introduce yourself and administer
1:08
oxygen before your attending is pushing propofol
1:10
and succinylcholine and you're placing an ET
1:12
tube. It all happened so fast. Congratulations,
1:15
you just successfully performed your first RSI.
1:17
On this episode of Style Points, the RSI is about
1:20
the RSI, rapid sequence intubation. This is an
1:24
anesthetic technique that results in nearly immediate
1:26
sedation and relaxation on induction, followed
1:28
by rapid intubation. I know what you're probably
1:31
thinking. It's in the title, RSI. Of course,
1:33
we're trying to provide anesthesia rapidly. But
1:35
how is this different from any other case? Well,
1:38
one of the primary reasons for performing an
1:40
RSI is to avoid aspiration in high -risk patients.
1:43
Pulmonary aspiration is a significant contributor
1:46
to morbidity and mortality, so it's important
1:48
to minimize this risk in a patient who may not
1:50
have an empty stomach. Preoperatively, this might
1:53
include giving medications to decrease gastric
1:55
volume and acidity, such as H2 blockers like
1:57
famotidine and sodium citrate, or using metoclopramide
2:00
for its prokinetic effects. One may even consider
2:03
performing a gastric ultrasound to evaluate for
2:05
gastric contents, if time allows, of course.
2:07
And in situations with particularly high aspiration
2:10
risk, such as a small bowel obstruction, it may
2:12
be appropriate to place an NG tube prior to induction.
2:15
Once in the OR, it's important to pre -oxygenate
2:18
as much as feasible and have suction easily accessible.
2:21
An ET tube and blade should be prepared and ready
2:24
as well as backup airway devices in the case
2:26
of an emergency. Although studies have shown
2:28
a greater first attempt success rate with video
2:30
laryngoscopy, literature on the use of direct
2:33
versus indirect laryngoscopy during an RSI is
2:36
limited. For induction, we want to administer
2:38
our medications quickly while continuing to pre
2:40
-oxygenate. Any of the usual medications can
2:43
be used for an RSI, such as propofol, etomidate,
2:46
or ketamine given patient -specific risk factors
2:48
and hemodynamic stability. Following induction
2:51
medications, administration of a wrapping -acting
2:53
paralytic medication such as succinylcholine
2:56
or a larger dose of a non -depolarizing neuromuscular
2:59
blocker like rocuronium should be given. It's
3:02
important to note that non -depolarizing NMBAs
3:04
tend to have a slower onset time than succinylcholine,
3:07
which has an onset time of approximately 30 to
3:09
60 seconds. Some providers may also opt to use
3:12
a defasciculating dose of a non -depolarizing
3:14
NMBA two to three minutes prior to administering
3:17
succinylcholine to help reduce the fasciculation.
3:20
rigidity, and increased intra -abdominal pressure
3:22
that can occur. One of the key differences of
3:24
an RSI in comparison to general induction and
3:27
intubation is foregoing manual mask ventilation
3:29
once the patient is paralyzed. This is done to
3:32
prevent excess air from entering the stomach
3:34
and decrease the amount of time the patient is
3:36
unconscious with an unprotected airway. Instead,
3:38
once complete paralysis is achieved, immediate
3:41
insertion of the ET tube with cuff inflation
3:43
is recommended prior to mechanical ventilation.
3:46
Confirmation of tube placement by listening for
3:48
bilateral lung sounds, absent sounds over the
3:50
stomach, observing chest rise, and confirming
3:52
the presence of expired CO2 is appropriate. The
3:56
tube should be carefully secured and oftentimes
3:57
an NG or OG tube is placed for suction and removal.
4:01
of any gastric contents. Now you're probably
4:03
wondering, when is this even necessary? Common
4:05
indications for performing an RSI are patients
4:08
with a full stomach or unknown last meal time.
4:10
This includes emergency surgeries, trauma patients,
4:13
or patients who have not appropriately fasted
4:14
prior to surgery. Although the risk of aspiration
4:17
is less in those who supposedly have an empty
4:20
stomach, one study found that 28 % of aspiration
4:22
events occurred in fasted patients. So what are
4:25
the other risk factors that contribute to risk
4:27
of aspiration then? A history of morbid obesity,
4:30
severely poorly uncontrolled GERD, ascites, esophageal
4:33
strictures, hiatal hernia, delayed gastric emptying,
4:37
and other gastrointestinal masses or lesions
4:39
are all examples. Another common population is
4:42
those who are pregnant after 16 weeks of gestation
4:44
or even earlier when those GI risk factors are
4:47
present. A common consideration for performing
4:49
an RSI includes the use of cricoid pressure.
4:52
Cricoid pressure, or the Selleck maneuver, was
4:54
originally described in 1961 by Dr. Brian Selleck
4:57
as a method to reduce aspiration during induction.
4:59
This method is performed by placing the thumb
5:01
and index finger around the cricoid cartilage
5:03
and applying force to compress the esophagus
5:06
between the trachea and cervical vertebrae, thus
5:08
preventing regurgitation of gastric contents.
5:11
Pressure is held until the ET tube is appropriately
5:13
placed. Although this sounds like an effective
5:15
way to help reduce pulmonary aspiration, the
5:17
use of cricoid pressure is not without debate.
5:19
Studies have shown that application of cricoid
5:21
pressure can actually make mask ventilation,
5:23
laryngoscopy, and LMA insertion more difficult,
5:26
and if unable to directly compress the esophagus,
5:29
may even cause relaxation of the lower esophageal
5:31
sphincter, which could definitely increase the
5:34
chances of aspiration. With all that being said,
5:36
cricoid pressure continues to be widely used
5:38
in the anesthesia world, and specifically during
5:40
an RSI, but the literature on its efficacy is
5:43
variable. Due to the complexity of these types
5:46
of cases, having a well -developed plan and backup
5:49
plan with equipment, medication, and assistance
5:51
is crucial prior to performing an RSI. While
5:54
the standard approach and goal of an RSI is common
5:57
practice, there are several components that are
5:59
provider -dependent. So take this RSI on RSI
6:02
and feel confident performing your next rapid
6:04
sequence intubation. Dr. Fedorek, raised in rural
6:11
Canada, completed her medical training at the
6:13
University of Saskatchewan, followed by an obstetrical
6:16
anesthesiology fellowship at Stanford. After
6:19
working at the University of Toronto, she joined
6:21
Stanford as a clinical assistant professor in
6:23
2020 and became quality improvement lead for
6:26
obstetric anesthesiology in 2021. Kelly, thank
6:29
you so much for joining us today. Thank you so
6:31
much for having me. Today, we have sort of an
6:35
interesting topic. ahead of us. But before we
6:37
get started with that, can you tell us about
6:39
how you got interested in obstetric anesthesia?
6:43
Sure. I remember it very distinctly. So I just
6:48
mentioned to you, I'm Canadian, so our training
6:50
is a little bit different. So I was a second
6:53
year resident rotating on OB anesthesia for the
6:56
first time. Loved it. You know, loved obviously
6:59
the technical aspect. It's so fun for a junior
7:02
learner to get in all those epidural reps. But
7:06
we had an emergent placenta procreta patient
7:10
come in bleeding. And there's very few things
7:15
that really shocked me, you know, in medicine
7:19
like that can happen. And that was one of them.
7:22
It was just completely blew my mind that this
7:26
perfectly healthy woman was, you know, nearly
7:30
on death's door because she was pregnant. Right.
7:33
Because of this complication with her pregnancy.
7:35
And it just, it just fastened the whole process.
7:38
It was, you know, a very, very bloody surgery.
7:42
Several liters of blood loss, several units of
7:45
blood transfused, took her to the ICU. She, you
7:48
know, she did well, baby did well. But it just
7:51
really lit a spark for me in the fascination
7:56
that I was building with physiology of pregnancy,
7:59
you know, the risks that come to otherwise healthy
8:03
people. And it just kind of grew from there.
8:06
I realized that, you know, our role in that surgery
8:13
was so essential as anesthesiologists and grew
8:18
from there. I just really looked at OB differently
8:22
overall. I looked at pregnancy different overall
8:24
and chose that as my career path. That's awesome.
8:29
For some of our students who might not know,
8:32
can you describe? really quickly what a placenta
8:35
percreta is. Sure. So we have a, it's called
8:41
a spectrum, a placenta accreta spectrum now.
8:44
And in the last few years, they've changed the
8:45
name. So usually, and this is part of the fascination
8:50
and the beauty of pregnancy, placenta is an organ
8:52
that grows during pregnancy. It obviously provides
8:54
nutrition. essential gases and gas exchange to
8:59
the fetus. And at the time of delivery, even
9:04
though it's been adherent or stuck to the uterine
9:08
wall for nine months, it most of the time just
9:12
beautifully just peels off right when, you know,
9:15
right after the baby comes out. And these cases
9:18
of accreta are when, for whatever reason, there's
9:23
a series of risk factors that put people at risk,
9:26
but the placenta is adhering to some portion
9:29
of the uterus. In the most minor form, the creta
9:34
vera, it's just to the endometrial lining. It's
9:37
kind of stuck. In creta, it's invading into the
9:41
myometrium, into the muscle layer, and then percreta
9:44
is the worst, and that's where it's invaded through
9:46
and through the uterus, and it's often invading
9:49
other organs, most commonly the bladder, but
9:50
it really can invade anything else in the abdominal
9:53
wall. bowel, blood vessels, other organs. Here
9:57
at the University of Cincinnati, we have a CRITA
10:00
clinic that we will send patients to that's staffed
10:04
by us as well as the OPs. And we try to make
10:08
a plan for them ahead of time. It's such a scary,
10:12
complicated case. I do some of them downstairs
10:14
myself, but I can definitely see how that would
10:17
make a difference for you and point you towards
10:19
doing something like obstetric anesthesia as
10:22
a career. Yeah, and I've seen a couple learners
10:25
now behind me that, in fact, we just did fellowship
10:28
interviews last week and one of our own internal
10:33
candidates, that was the same story for him.
10:35
He said, you know, I was junior and somebody
10:37
grabbed me and said, hey, here's a really interesting
10:39
case, come and join. And it was just like, oh,
10:42
you know, so similar path for others, I think.
10:46
So let's back up just a little bit and learn
10:49
a little bit more about you. Let's say that you
10:53
could have dinner with anybody in the world.
10:55
It could be somebody from the past or even from
10:57
fiction. Who would you want to have dinner with
10:59
and why? I would love to have dinner with the
11:04
late Anthony Bourdain. Sadly, he passed a couple
11:08
of years ago. He has nothing to do with medicine,
11:12
obviously. He was a chef, author, and then probably
11:16
most familiar to everybody, host of several different
11:19
TV shows. looked at the intersection of food
11:24
and travel and culture. I love food, love eating,
11:28
love restaurants, love cooking when I have time
11:30
now. But he just really used food in such an
11:36
interesting way to, you know, experience new
11:41
cultures, meet new people in a very unpretentious
11:44
way. And I have to say during residency, you
11:48
know, 10 years ago now, In the thick of things,
11:51
I would watch his show and it was just such an
11:54
escape. Like, you know, it was on whatever part
11:57
of the world talking to people who have nothing
11:59
to do with what I was doing that day at work.
12:02
And I really, really cherish that. And it served
12:07
me really well at the time. Where would you take
12:10
him for dinner or what would you make him for
12:12
dinner? Oh, gosh, I don't think I would make
12:15
him anything. Yeah, that's a little scary. You
12:18
know, so I'm Canadian. I'm from rural Saskatchewan.
12:23
So it's a very, very, very tiny, small part of
12:26
the earth, very scarcely populated. The town
12:29
I grew up in is a thousand people. I don't think
12:31
he's. been to anywhere like that, you know, very
12:35
remote rural Canada. He did some East Coast Canadian
12:39
experiences in the Maritimes, that kind of thing.
12:41
So I think I'd bring him to where I'm from. There's
12:42
a really large Indigenous presence and also European,
12:49
Eastern European population as well. So kind
12:52
of a cool mix of food that I think he'd find
12:55
interesting. That would be interesting. I definitely
12:58
agree. So when I emailed you, to get this all
13:02
started off you were coming to us to give one
13:04
of our grand rounds which we really appreciate
13:06
you coming and doing thanks for visiting us um
13:09
you said that of all the topics that we could
13:12
discuss the thing that you were interested in
13:14
was talking about the maternal mortality crisis
13:17
tell me a little bit more about that yeah um
13:21
so obviously i'm an ob anesthesiologist so this
13:24
is front of mind for me i take care of a lot
13:27
of healthy pregnant patients but a lot of sick
13:29
pregnant patients as well And, you know, I think
13:32
if you open up a news app or something, you know,
13:37
you're going to be hard pressed not to find some
13:39
sort of headline to do with the maternal mortality
13:41
and morbidity crisis in the U .S., you know,
13:45
over the past couple of years. So we are at a
13:49
point of crisis. So the U .S., despite being
13:51
one of the wealthiest nations, if not the wealthiest
13:53
nation in the world, has maternal mortality rates
13:56
that are double what are, you know, neighboring.
14:00
countries in the sense of socioeconomics are
14:02
and has been on the rise for about the last 20
14:05
years. So there is a little bit of a debate.
14:08
There's a little bit of controversy with the
14:11
way we've been recording maternal deaths and
14:14
pregnancy related deaths. But overall, you know,
14:18
we were definitely higher than a lot of our counterparts.
14:22
And I think the most striking part of that is
14:27
there's a huge disparity within who's dying.
14:29
So we know that Black women and Indigenous women
14:32
are dying two to threefold the rate of white
14:37
women overall. And we've done a fair amount of
14:42
studies investigating the granularity of who
14:45
those people are. And when you level things like...
14:48
education, socioeconomic status, zip codes even,
14:52
that holds true. So it seems to be some systemic,
14:57
probably bias -related issues contributing to
15:00
that disparity. I think we're at the point where
15:05
we've very well defined the problem. And my other
15:09
area... of interest in OB anesthesia is quality
15:12
improvement. So we know the current state, but
15:16
we have yet to really leap forward into doing
15:19
something about it. So I think it's worth talking
15:21
about. So what are some of the factors that contribute
15:25
to maternal mortality in these pregnant women?
15:28
The cause of death overall in pregnancy and in
15:32
the postpartum period, which over half of maternal
15:35
deaths occur and has evolved over the past 20
15:39
years or so as well. Worldwide, the big three
15:43
killers of pregnant or postpartum women are still
15:48
hemorrhage, infection and hypertensive disease.
15:51
And that used to be the case in the U .S. about
15:53
20 years or so ago. We've now evolved that leading
15:57
cause of death in that population is secondary
16:01
to cardiovascular disease. And that's probably
16:04
a reflection of the risk that people are coming
16:09
into pregnancy with. We know that typically pregnant
16:11
women are older, coming with more comorbidities.
16:16
But, you know, we've definitely seen that change.
16:22
The reversibility or the ability to prevent is
16:26
probably a little less straightforward when people
16:29
are coming with these complex comorbidities,
16:31
whereas the things like hemorrhage infection,
16:33
hypertensive disease have thought to have been
16:36
a little bit more preventable or we can have
16:39
enhanced readiness and ability to prepare for
16:44
those. The other thing at play that I think,
16:48
and this is something that I've seen over my
16:52
time as a trainee in OB anesthesia and as a staff
16:54
is there really is a long -standing cultural
16:57
acceptance of women's suffering during pregnancy
17:01
and childbirth and you mentioned that you have
17:04
kids and you have a wife who's been pregnant
17:06
and I'm sure that you've been surprised you know
17:09
despite going through medical training at what
17:11
pregnancy entails and you know the The amount
17:16
of discomfort that we can feel and also the black
17:19
box and the mystery into a lot of what goes on,
17:22
right? And even people within medicine don't
17:24
have a deep understanding of it. But we know
17:27
that for generations, pain and complications
17:29
have really been dismissed as kind of part of
17:32
the process. And, you know, there's even like
17:35
historical religious roots where, you know, the
17:38
curse of Eve, you know, has come into play that,
17:41
you know, this is just part of. what we as women
17:44
have to deal with. And I think the consequences
17:47
of that attitude are real. We know that when
17:51
a pregnant woman says something doesn't feel
17:52
right, that any delay in taking her concerns
17:54
seriously can be fatal. And we know that at least
17:59
over half of maternal deaths involve some sort
18:02
of delay in diagnosis or treatment, and often
18:04
because symptoms were initially dismissed. So,
18:07
you know, in addressing maternal mortality, looking
18:12
at what we can prevent, how we can be ready for
18:14
it, how we can act on critical illness quickly
18:17
as part of it, but also changing our attitudes
18:21
and truly listening to pregnant women is going
18:23
to be a part of it as well. Well, if I count
18:27
up all the months that my wife was pregnant,
18:29
I listened to my pregnant wife for approximately
18:32
27 months. It's not easy being pregnant and going
18:38
through the delivery process. That's also Very
18:41
tricky. Fortunately, we had inductions and we
18:45
were able to plan and get epidurals, which we
18:48
had three working epidurals, which we were very
18:50
grateful for. It made things a little bit easier,
18:53
but it's certainly not 100%, right? But we feel
18:58
very fortunate to have been in the category where
19:01
things went well. So things don't always go well,
19:06
though, like you were describing. Can we talk
19:08
about some of the reasons why things don't go
19:11
well in pregnancy and childbirth in terms of
19:13
pain control? Yeah, and I've been privileged
19:18
enough to work at a couple different settings
19:19
as both a trainee and a staff, and I've definitely
19:23
seen different approaches to pain control during
19:26
labor. Some of the places definitely have more
19:33
of a technician type role of the OB anesthesiologist.
19:38
And I think most of us who've done OB call have
19:40
at least at some point felt like, you know, our
19:43
only role or our perceived role was just throwing
19:45
epidurals and kind of get out of there, right?
19:49
Whereas other places, and thankfully where I
19:54
currently work at Stanford, we have such a great
19:57
team, great communication with our nurses and
19:59
our OBs that our role is definitely respected
20:05
and honored quite a bit more. And we have a much
20:07
more active role in our patients' labor course
20:10
and experience overall. And I mentioned before
20:17
that my other area of interest is quality improvement.
20:19
Something that we follow as a metric is failed
20:24
blocks. So how many blocks do you have to replace?
20:27
To, you know, what percentage of the time are
20:29
you replacing epidurals so that they're effective?
20:32
And it's funny because we can look at that metric
20:35
kind of twofold, right? Whereas soap and some
20:39
of our governing societies give us kind of a
20:42
ceiling, like, you know, no more than 5 % or
20:44
10 % or whatever it might be should be replaced.
20:47
But the attitude where I work now is we're almost
20:50
proud of our replacement rate. And this is where,
20:53
you know, looking at different types of metrics
20:55
and quality improvement are important. So the
20:57
absolute replacement rate is an outcome metric.
21:01
But I think what is probably more meaningful
21:03
is the process metric of how often you're checking
21:06
up on these to see if they're actually working,
21:08
right? And if you're vigilant and you're following
21:11
up every couple hours and you're talking, you
21:13
know, and powering your nurses to reach out to
21:16
you to say, hey, this patient's in pain or, you
21:17
know, I don't think there's separate roles. As
21:19
good as it could be, you might have a higher
21:22
rate, which we actually do at Sanford. We have
21:24
a higher rate than what SOAP suggests, and we're
21:26
kind of proud of it because it means that we're
21:29
talking to our patients, we're listening to them,
21:31
and we're acting on their pain. I think that's
21:34
a really good way to look at maternal pain. It
21:38
kind of flips it on its head being proud of your
21:41
replacement rate. We're paying enough attention
21:44
to these women that we're replacing them more
21:47
often. for their benefit. I think that's a great
21:50
way to look at it. Yeah, for sure. And it does
21:52
require a little bit of socialization. Part of
21:55
our consent process is telling our patients about
21:57
our replacement rate and, you know, that it's...
22:01
can be a normal part of the process that we're
22:03
going to be here. We're going to be checking
22:04
up on you. We have some tools to troubleshoot.
22:06
But at the end of the day, if you're not comfortable,
22:08
what we often offer people is a replacement.
22:10
And that, you know, normalizes it. I myself had
22:14
to replace that patrol, which I'm very glad I
22:16
got. It was much more effective than the ineffective
22:18
one I had. And I had a great experience after
22:22
that. But, you know, I think planting that seed
22:27
early, you know, is important as well. So it
22:31
sounds like one of the really important things
22:34
to do is fostering good communication between
22:36
the anesthesia team and the nursing team and
22:40
the obstetricians. Can you talk a little bit
22:41
about how you do that? For sure. And I have to
22:46
give kudos to my mentors at Stanford. People
22:52
that came before me that are now retired that
22:55
established our division and truly, truly established
22:58
this amazing culture of safety and communication.
23:00
It's unparalleled to anything that I've seen.
23:04
And it's often like a recruitment point for our
23:07
fellows when we're talking about interviewing
23:09
people. They say, why should I come? And I'm
23:11
just like, oh, you're going to see like the best
23:13
example of how to communicate, how to promote
23:17
safety, how to work as a team. And, you know,
23:21
I can't say how they started that. I'm not too
23:24
sure. I know it was a lot of dedication and the
23:27
work of the champions being there, you know,
23:30
putting in a lot of face time. But now it just
23:33
kind of runs like a well -oiled machine. We really
23:38
promote multidisciplinary meetings. Two every
23:42
day as a large group where we meet with our antepartum
23:45
team to talk about patients who might be high
23:47
risk on the ward. We talk about our laboring
23:49
patients, our patients who are scheduled for
23:51
ORs that day. When we have a high risk patient
23:54
who perhaps we're planning a complex delivery
23:58
for, we might have several multidisciplinary
24:02
meetings in advance. And that's going to be involving
24:04
specialists that we're consulting. So cardiologists,
24:06
other surgeons, that sort of thing. And our team
24:09
is right there. You know, often planning those
24:13
and taking a leading role. Something else that
24:18
I'm lucky to take part of is simulation. We do
24:23
in situ multidisciplinary simulation, and it's
24:28
required that every nurse that works on L &D
24:31
cycles through every year. Our trainees at one
24:35
point in their training will all... do it as
24:37
well um it's not essential they do it every year
24:39
but our nurses do do it every year and because
24:42
it's in situ it's on our floor it's not all that
24:45
high fidelity i'll admit um but you know the
24:49
purpose isn't to drill people on their technical
24:51
skills or their knowledge it's really to highlight
24:53
systems issues and allow us to practice communication
24:56
and it is so effective um not only does it break
25:01
down a lot of barriers and allow us to dispel
25:04
a lot of misconceptions it just really helps
25:07
build the team you know it's a nerve -wracking
25:10
experience for everybody that takes part in it
25:12
but um come together you've got ob residents
25:14
ob anesthesiologists um and our nursing team
25:18
and and it's really a fun thing to take part
25:20
of that's super effective i think that's a really
25:23
good way to get everybody on the same page you
25:26
can debrief together what went well What didn't
25:29
go so well so that when the bad things happen
25:31
in real life, we're more on the same page. For
25:35
sure. And also breaks down that hierarchy as
25:37
well. This is where we really empower people
25:41
to speak up and use their voice and advocate
25:46
for their patients. Obviously, prevention is
25:50
a really important piece of the puzzle when it
25:52
comes to taking care of moms, taking care of
25:56
babies as well. However, oftentimes when people
26:01
come to the OB floor, we are meeting them for
26:03
the first time and we didn't really have a chance
26:05
to interact with them before because usually
26:08
these anesthesia providers were meeting them
26:09
because they went into labor that day and we
26:12
happened to be working that day. So we don't
26:13
have that benefit of having a long -term connection
26:16
where we can do any risk stratification or optimization,
26:21
that sort of thing. So let's talk about what
26:25
we do in the pre -op assessment. What can we
26:27
do? in the very short term, to try to optimize
26:31
people, to try to minimize morbidity and mortality
26:34
for these women. You're right. We're at a bit
26:37
of a disadvantage in that we're typically only
26:40
meeting people for the first time when they're
26:43
at that kind of critical moment in their pregnancy
26:48
journey. Obviously, the exception is if we've
26:50
done some prenatal planning for high -risk patients.
26:53
But most of the time, we don't get that. And
26:55
there's a lot of people who come in. With complex
26:58
conditions that only have arisen at that, you
27:03
know, later term moment in their pregnancy. So
27:07
personally, my assessment of those patients who
27:11
could be high risk, who I'm trying to triage
27:13
to determine if they're high risk, obviously
27:16
the basics, history, physical examination, chart
27:19
review, but, you know. Point -of -care ultrasound
27:25
is the reason that I'm visiting here. That's
27:26
what I'm going to be talking about tomorrow in
27:28
obstetrics. I think has absolutely revolutionized
27:31
personally my practice. And practice has the
27:36
potential to really change, I think, outcomes
27:38
for these women overall. You'll hear me tomorrow
27:42
talk a lot about point -of -care ultrasounds
27:45
role in hemorrhage, underlying cardiac disease.
27:51
And tonight at Journal Club, I don't know if
27:53
you're able to attend, but we're going to be
27:54
talking about its role in severe preeclampsia.
27:57
And I think that's one of the most impressive
27:59
areas that we can make a difference. I have to
28:02
say, I mentioned procreta was this like light
28:07
bulb moment for me when I was a trainee. But
28:09
severe preeclampsia for me, since I've been in
28:12
attending, has been one of the most humbling
28:14
diseases that I've come across. I've seen some
28:18
very sick patients and lost patients actually
28:20
due to it. So how can we triage these patients,
28:26
optimize them, give them precision medicine?
28:29
And it really, I think, comes down to point of
28:31
care ultrasound. Doing something as simple as
28:34
a lung ultrasound, which in the scheme of point
28:37
of care ultrasound is probably the easiest thing
28:39
that you can possibly do. Very good evidence
28:42
that a normal lung ultrasound dry lungs a -lines
28:47
is reassuring that this patient has normal cardiac
28:51
function and that they're not at least experienced
28:54
that type of end organ dysfunction whereas detecting
28:57
wet lungs is pretty closely correlated with diastolic
29:03
dysfunction and knowing that you need to perhaps
29:05
target fluid therapy very carefully in these
29:07
patients maybe they need some invasive monitoring
29:10
and these are the type of patients that you know
29:13
thinking about icu step down that kind of thing
29:15
could possibly save their life a lot of the bad
29:17
outcomes they experience are in the postpartum
29:19
period as well so ensuring that they get appropriate
29:21
follow -up after that so Having this tool now
29:26
to truly, no pun intended, have a window into
29:30
what's going on in their chest and these essential
29:33
organs along the heart truly is changing the
29:37
game. And I think the more of us that are skilled
29:40
in that, that can bring that, will perhaps pivot
29:44
at least a portion of this crisis that we're
29:47
in. Well, personally, I plan to be at your journal
29:50
club and I am. planning to be at Grand Rounds.
29:53
So I am definitely looking forward to hearing
29:56
you talk about it. I wonder if you could, for
30:00
some of our listeners who won't get the chance
30:02
to do that, talk a little bit more about point
30:05
of care ultrasound and its role, because I think
30:08
it's very interesting when it comes to obstetric
30:11
anesthesia. For sure. I could talk about that
30:15
all day. Um, so point of care ultrasound or POCUS
30:18
for anybody who's not familiar is, um, using
30:22
the ultrasound machine at the point of care.
30:24
So the key here is that it's at the bedside.
30:26
Um, and it does need to be differentiated from
30:29
like a comprehensive, uh, ultrasound that a sonographer
30:32
cardiologist or radiologist would do in that,
30:35
um, they serve different purposes. So we're doing
30:38
point of care, um, to answer largely binary questions
30:43
as yes, no, is there pathology there? And to
30:46
help guide our direct management. So what is
30:48
the next step? Is this patient, is this going
30:50
to change this patient's disposition? Is it going
30:53
to change our medications that we're planning
30:55
to use? And is meant to be something that we
31:00
could do any time of the day, any time of the
31:03
night. And this is where it fits so well into
31:05
obstetrics. So as you know, obstetrics is a very
31:09
nocturnal specialty. Babies come at any time
31:13
that they want to. A lot of times they come more
31:15
at night, I think, statistically. And access
31:18
to formal examinations at that time and specialists
31:22
can be limited. An extra tool that will help
31:26
you triage your patients, optimize them, determine
31:29
the safest plan for them is going to be really,
31:32
really helpful. I think obstetrics is one of
31:36
the best places to start POCUS if you're just
31:39
learning as well for a couple of reasons. Our
31:42
patients are often awake. cooperative, especially,
31:47
and comfortable if they've had an epidural. It's
31:50
kind of the best population to target. You put
31:51
an epidural and circle back with ultrasound and
31:54
ask if you could do a little bit of practicing.
31:56
And even the anatomical changes of pregnancy
31:59
make. POCA is actually really amenable. So the
32:02
heart moves more anterior, moves more leftward.
32:06
And then our favorite position for pregnant women,
32:08
left lateral decubitus, is actually the best
32:11
position for doing cardiac echo anyway, which
32:14
is one of the trickier skills to gain. So, you
32:18
know, if somebody is looking to take a course
32:21
and they need a logbook, I would suggest spending
32:23
some time electively on OB and getting your reps
32:27
in that way. I have been doing point of care
32:30
ultrasound and I went through the ASA's course,
32:33
which I recommend to everybody. I think that
32:34
it's fantastic. And I'm one of the local mentors.
32:37
In fact, after the podcast, I'm supposed to help
32:40
somebody train on point of care ultrasound. So
32:43
you don't have to sell me on it for sure. But
32:46
I think that it's fantastic. It's a great tool
32:49
in our toolbox to have. I wonder, do you... You
32:53
often use point -of -care ultrasound for placing
32:56
epidurals as well, not just risk assessment?
32:58
Yeah. Neuroxial ultrasound has definitely been
33:02
a game changer too. Populations that I think
33:06
it's most useful are morbidly obese population,
33:09
people who don't have palpable landmarks. And
33:13
then I have to say the biggest, one of the most
33:16
rewarding experiences are the severe scoliotic
33:19
patients. And it's interesting. It's happening
33:22
less and less now because we've used it pretty
33:24
consistently in our practice for about 10 years.
33:26
But I remember when I was a fellow, this is when
33:29
we really started gaining some traction using
33:31
it. There had been patients who had delivered
33:35
a baby three or four years prior. failed and
33:38
abandoned epidural placement attempts, perhaps
33:42
requiring GA for their sections, that kind of
33:44
thing, that then when we pivoted to using ultrasound
33:47
had straightforward functional epidurals. So
33:51
just super rewarding that we can use it for that.
33:54
It makes a big difference. It's something that
33:57
I have certainly used in that patient population,
33:59
although I admit for most patients. I just, I
34:04
still palpate the spine. Yeah, you still need
34:06
that. I still need to do that. Was that part
34:09
of your residency training? It sounds like we
34:12
trained at about the same time. No, actually.
34:14
And I have to say, I think I can speak to some
34:19
of the challenges in learning a new skill when
34:22
you're an attendant. That is for real. Really
34:24
hard. Yeah, it's just the psychology of it changes
34:31
a little bit. You're coming in your days off
34:33
and thinking, what am I doing? But I picked up
34:37
most of these skills a little bit as a fellow,
34:40
but mostly as a junior attending. which which
34:44
was challenging um and i have to say truly ob
34:47
was kind of the the reason that i was able to
34:50
um really hone my skills in focus i did try it
34:55
a little bit in the main or but i have to say
34:57
pacu patients where where we do a lot of scanning
35:00
um and i do a lot of bedside teaching of our
35:03
residents now in the pacu limited mobility you
35:07
know they've just had a hip You're not going
35:09
to roll them around to optimize your view. Sometimes
35:12
not consentable. Sometimes they're in a lot of
35:14
pain. So truly, and now I mentor as well for
35:18
the ASA course. We sometimes have faculty or
35:23
other fellows that sign up. And I actually just
35:26
bring them to L &D and, you know, either go around
35:29
to comfortable laboring patients or antepartum
35:32
units. And those patients actually have some
35:33
interesting findings. And it's truly the best
35:37
place, I think. So I wonder if you have any cases
35:41
that come to mind when you think about successfully
35:44
using point -of -care ultrasound to help diagnose
35:48
or treat or manage some of these patients. What
35:51
kind of scenarios, of course, in a de -identified
35:53
way come to your mind? So I've, you know, I mentioned
36:00
preeclampsia, severe preeclampsia. Just last
36:04
week, Perhaps this is a little bit of a boring
36:07
case, but I think it really speaks to its utility.
36:10
We had a patient who had severe preeclampsia,
36:14
required a C -section, and appropriately per
36:17
the protocol was fluid restricted because of
36:19
the risk of pulmonary edema. She was on magnesium
36:21
and was a bit of a complicated C -section, a
36:26
little bit longer than usual, didn't receive
36:28
a bunch of fluid per our instruction, and was
36:32
hypotensive in the PACU. You know, somebody who's
36:36
not preeclamptic, the first reaction that we
36:39
usually do is to bowl some of some fluid and,
36:42
you know, check the urine output, that kind of
36:45
thing. But there was some hesitation to do that
36:47
in this patient. And grabbed POCUS, took a look.
36:52
IVC was completely flat. Lungs were perfectly
36:55
dry. So we knew that there was some room to bolus
36:57
there. So we just, you know, slow and steady
36:59
did small 250 ml. aliquots increments and monitored
37:06
her serially during her course in PACU and got
37:09
her optimized that way, which, you know, very
37:11
simple, but just like a really kind of rewarding
37:13
way to use it. I didn't pick up skills in the
37:20
FAST exam until I did the ASI POCUS course, and
37:23
I have found that to be incredibly useful on
37:26
OB. I'll talk about some cases tomorrow in rounds,
37:31
but post -cesarean bleeding. It's interesting
37:35
because if you think of the foundation of POCUS
37:38
is at the bedside, we're using it in real time
37:40
to make decisions. Our OB colleagues have used
37:42
it for years, right? OB floor if they don't have
37:46
a cardiac probe, at least has a curvilinear that
37:48
the OBs are using for their obstetric purposes.
37:51
And they're really good at assessing the pelvis
37:54
for bleeding, right? They look at the uterus,
37:56
they look at the cul -de -sac, they look for
37:58
free fluid around the uterus. But the FAST exam
38:03
just... explores a couple more areas where we
38:06
can see free fluid. And interestingly, we've
38:09
had a couple of patients who our anesthesia team
38:12
have diagnosed with that bleeding because of
38:14
our fast exam skills. We actually caught a uterine
38:18
rupture insidiously. It wasn't one of those dramatic
38:21
ones, but caught that on fast. And then several
38:26
times now have caught Post cesarean bleeding
38:30
in the other views, left upper quadrant or right
38:35
upper quadrant that have been negative in the
38:38
pelvis. So even though our obese, you know, we
38:41
have their skills where they're looking in that
38:42
area that's been negative. And perhaps in the
38:44
past that would have been sloughed off as unlikely
38:46
to be bleeding. But because we've kind of expanded
38:49
our views of the belly with that exam, we've
38:51
got some bleeding that way. So I think it's a
38:53
really easy tool and useful tool. That's fantastic
38:56
to hear about. Again, I'm looking forward to
38:59
hear you talk a little bit more about it in the
39:02
near future. So let's zoom out a little bit and
39:06
talk about OB4s in general and system level changes,
39:10
that sort of thing. What do you think our specialty,
39:14
obstetric anesthesia, can do to try to make the
39:19
biggest difference in maternal mortality rates?
39:24
Yeah, I think... Us as anesthesiologists are
39:30
trained to be and paid to be good pessimists
39:35
sometimes. Absolutely. We have to anticipate
39:39
the worst. And, you know, a lot of times our
39:41
preparation is looking at a situation and seeing
39:44
how many different ways it can go sour and preparing
39:47
ourselves for that. And, you know, a lot of the
39:49
time it doesn't. But then when it does, if we're
39:52
prepared, we're often in a better spot. Having
39:57
a role in our system preparedness, so protocols
40:03
for addressing hemorrhage, infection, hypertensive
40:07
disease, assessing being a part of the floor
40:12
readiness, like this is where hemorrhage carts
40:14
and tackle boxes for hypertensive disease come
40:17
into play, all of those kind of things. We should
40:20
have a leading role in all of those sort of initiatives.
40:27
The most effective tools that we have out there,
40:30
and I live in California now, so I'll quote what
40:35
we use with the CMQCC, the California Maternal
40:38
Quality Care Collaborative. I'm not too sure
40:40
if you guys have an equivalent statewide initiative
40:42
here. But they have open access to their protocols
40:46
and their readiness packages. We in California
40:49
have actually been able to pivot our maternal
40:52
mortality rate quite significantly because there's
40:54
been a statewide push to implement readiness
40:59
protocols and packages for the preventable causes
41:03
of death, hemorrhage, infection, and hypertensive
41:05
disease. And OB -GYN anesthesiologists have had
41:08
a big part of that initiative since its inception,
41:13
and we continue to. We're involved in preparing
41:19
and ensuring readiness. I think reviewing near
41:26
misses and misses, we should be a part of that
41:30
as well. And that's what also comes with our
41:32
care collaborative is confidential inquiries
41:36
into maternal deaths and severe morbidity. On
41:40
a local level, we go through, we have a series
41:44
of diagnoses that automatically trigger a review.
41:47
Obviously, any maternal or neonatal death or
41:50
fetal death in labor is reviewed. And then there's
41:54
a couple other parameters. And we have a seat
41:57
at that table. And then on a statewide level,
42:01
we're actually represented there as well. Learning
42:06
from those cases, looking at trends, looking
42:10
at systems issues that we can then convert into
42:13
protocols, packages for readiness is truly essential
42:16
for making a difference. So let's say that I'm
42:20
an anesthesia resident that's interested in learning
42:22
more about this and trying to figure out how
42:26
I can help with this. What are some resources
42:29
that you would recommend? Doing an OB anesthesia
42:32
fellowship. Soft plug there. Which we also offer
42:39
at our institution. Yeah, we do as well, and
42:42
we're recruiting right now. So I definitely advocate
42:46
for doing the Anesthesia Fellowship. It's a place
42:51
where not only do you learn a lot about your
42:56
role as an anesthesiologist, but you learn so
42:58
much about pregnancy and obstetrics, and it truly
43:01
changes how you, you know. can kind of get a
43:06
bird's eye view of what's going on on your L
43:09
&D floor, you know, for your population overall.
43:13
Other resources, SOAP. So the Society for Obstetric
43:17
Anesthesiologists and Perinatologists is our
43:20
national governing body. We have conference every
43:23
year. Actually, it's coming up first weekend
43:25
of May. Attending that conference, just seeing
43:29
what we're doing, what the cutting edge research
43:32
is. We have amazing keynote speakers and very
43:36
inspirational talks, workshops as well. Actually,
43:39
we host a POCUS workshop every year that you
43:42
can come and get some basic certification and
43:44
hands -on experience with their website as well.
43:49
And then outside of SOAP, there are several other
43:53
really cool agencies. So the UK has been really
43:57
influential in their... mechanism for monitoring
44:04
maternal mortality and morbidity. And they're
44:07
actually the ones that started these confidential
44:08
inquiries that we've modeled our system after.
44:12
So the OAA is the Obstetric Anesthetist Association.
44:17
Similarly, really great resources on their website.
44:19
And they do have conferences if you want to make
44:21
it over there as well. So summing up, I wonder
44:25
if you have any, I know that this is sort of
44:28
an impossible question, but do you have any single
44:30
piece of advice that you would offer to anesthesiologists
44:33
that work on ob to try to minimize limit prevent
44:38
maternal morbidity and mortality listen to your
44:41
patients um you know i mentioned at the beginning
44:45
that we're kind of conditioned um i don't know
44:50
in medicine in society to downplay a lot of the
44:53
symptoms, reduce things, normalize them in pregnancy.
44:57
And a lot of the time that sixth sense that either
45:00
our patients have or that we have should be honored
45:04
and listen to them. And then from that, use all
45:07
the tools in your toolbox to help them and, you
45:12
know, tap into your fund of knowledge about pregnancy.
45:17
You know, we are. really unique in our role on
45:22
the L &D floor. We come with such great critical
45:25
care experience, internal medicine knowledge,
45:27
and then our technical skills as anesthesiologists.
45:31
So use that to advocate for your patients. Lastly,
45:35
I wonder if you could talk to us about some of
45:38
your style points, whether that's points of your
45:40
personal preference or things that have brought
45:42
you success in your career in and out of the
45:45
operating room. What do you have for us? So it's
45:48
funny, on a lot of my evaluations that I get
45:52
from learners, I'm quoted as being chill. And
45:57
nobody in my family would ever describe me as
46:00
that. Nobody in my family is in medicine, so
46:03
that might say something about the culture that
46:06
we live in. But it's... It's been something that
46:11
I've heard and I've kind of reflected a little
46:13
bit on it. And number one, I don't always feel
46:16
that I'm chill, but somehow I'm exhibiting this
46:19
vibe. And I think it boils down to my confidence
46:27
in myself. I know that I'm very well trained.
46:31
I've had world -class training in residency and
46:35
fellowship. you know, the CME that I've done
46:39
since then. But I also have a lot of confidence
46:43
in my colleagues, my trainees, and the people
46:49
that I work with, like they all have world class
46:51
training as well. And I think when you have that
46:56
level of confidence, not only in yourself, but
46:59
the people around you, things just get easier
47:02
and maybe a little bit more chill. It's, you
47:06
know. We've talked about parenting. If you can
47:09
keep your cool, you know, 90 % of the time, not
47:13
when you lose your cool, but maybe when you're
47:15
a little less composed, people know things are
47:18
serious, right? And I do not keep my cool 90
47:21
% of the time as a parent. Maybe at work I do.
47:25
And I think that that's effective, right? Like
47:27
if you're pretty relaxed most of the time and
47:30
you can kind of zoom out and look at the situation
47:33
that you're working in, you know, pretty objectively
47:37
that when things are serious and you really have
47:41
to, you know, ask pointed questions or use very
47:45
direct communication to save a patient's life,
47:49
it is effective. And then the other thing is,
47:52
I think, You know, for our generation of physicians,
47:57
the definition of professionalism is evolving
48:00
a little bit. You know, the old stiff, fairly
48:04
patriarchal definition that we were told to be,
48:08
I guess, is evolving with, you know, the changing
48:12
demographics of medicine, which I think is great.
48:16
And I'm not afraid to show my personality at
48:19
work, you know, all within being appropriate.
48:23
But, you know, sharing small details about myself
48:25
to my patients, to my colleagues, to my learners
48:28
really, I think, helps make me look human and
48:32
feel human to other people, which is also really
48:35
effective when you're working in a team environment.
48:39
Thank you so much for joining us. What I want
48:42
to do. when I get home is I need to look at the
48:45
evaluations that my children have filled out
48:47
on me and see if... Room for improvement. Yeah,
48:51
I'm sure they would probably say, especially
48:54
my one -year -old, she probably would prefer
48:57
for me to be mom 100 % of the time. If you could
49:01
only. Thank you so much for joining us. Thank
49:05
you so much for having me. Thanks for tuning
49:08
in to this month's episode of Style Points. And
49:11
if you're from Stanford, Thanks for sending Dr.
49:13
Fedora Garway. Since I recorded this outro after
49:16
her journal club and grand rounds, I can confirm
49:19
that she did a fantastic job. If you enjoyed
49:22
this episode, I would really appreciate it if
49:24
you leave a comment or a five -star rating. Though
49:27
I'm admittedly terrible at doing this myself
49:29
for other things, I personally decided that I
49:32
would break the habit and left a five -star review
49:34
for the person who cuts my hair because Christy
49:36
does a great job. You can do it too. It really
49:40
helps other people find the podcast if you leave
49:42
a rating or a review. As always, you can contact
49:46
me at stylepointspodcast .gmail .com. I can get
49:49
you a free StylePoints sticker for your water
49:51
bottle. Take a deep breath. Open your eyes. We're
49:55
all done.