New Era

On the way back to the OR from J6-6

My first patient today was a 41 year old man who ran a marathon last week in southern California.  He made several subsequent airline flights this week and 3 days ago noticed  painful swelling in his left leg. Not surprisingly, he had developed a DVT (deep vein thrombosis) in his leg.  I’m sure his relative dehydration post marathon coupled with the “trauma” of the marathon running and his air travel combined to precipitate the clot.  While the airline industry has published several studies denouncing a connection between air travel and DVT, the association has been drilled by anecdote into the public and medical psyche. Conflicting literature even cites an increased incidence of blood clots in highly trained athletes who travel by air explaining that the decreased heart rate in athletes may translate to slower venous blood flow (hence, more stasis and clotting).  Our patient’s clot extended from his calf through his thigh and pelvis all the was up to his Vena Cava (the main vein in the abdomen).  I successfully accessed his popliteal vein behind his knee and then we also got access to his Posterior tibial vein at the ankle.  We are now delivering lytic agents (clot busting drugs) to his entire left leg venous system.  The effectiveness of the drug is enhanced in the thigh and pelvis by the placement of a special ultrasound emitting guidewire inside the drug delivery catheter.  The EKOS catheter is used routinely to speed up the work of the clot dissolving drugs on both arterial and venous blood clots.  Although it is an expensive device it has been shown to reduce the amount of time for lysis AND the amount of expensive drugs required.

Ten years ago this patient would have been routinely consigned to heparin and coumadin therapy alone for his blood clot.  He would have had a painful swollen leg for many months and likely developed chronic venous hypertension.  The long term effect of that hypertension often results in skin breakdown in the form of venous ulcers at the ankle.  Hopefully this therapy will prevent that outcome.  Tomorrow will be very telling in that regard.

Well the last 48 hours have been life altering for me.  While making clear strides in my endovascular training with increased confidence and procedural skills I found out that “I can’t go home again.”  Jill (and I in absentia) reached an agreement of sale for our home of almost 17 years.  While on the market for nearly 14 months with many showings, we knew that our unusual design and layout was waiting for a special buyer.  We are quite pleased to have a young family looking forward to growing up together in this work of art.

The Barn

This home will always evoke great emotion for me.  It was an exploration of my own identity as well as the growth of our family’s identity.  Jill and I explored our likes, dislikes and tastes in designing this structure with George Zajacek.  We were able to marry very personal elements including the “goldfish pond”,  the open kitchen / family room and the covered flagstone patio with touches like hand wrought iron hardware, hand made doors and exposed “barn beams”.  I’ll always remember Chris and Drew playing every sport in the basement including “tennis” using boxes for a net.  As our boys have moved on, the upstairs loft lays quiet.  Dharma rarely ventures to the second floor anymore partly because age is making the trip harder but mostly because the futons filled with sleeping young men no longer beckon her for a romp.

Sycamores at Deer Run

Morning at Deer Run

I’m looking forward to the next chapter.  It certainly will be different.  Returning from Cleveland to …

Informal Conference

Monday evenings the residents and fellows gather in the conference room for an “informal conference” where Dan Clair discusses interesting cases.  Its a socratic session where he asks how they would handle particular cases asking them to venture their opinions and management choices and exploring those to their conclusions.  For me it is often amusing how our years of experience usually distill the choices to very similar treatments and interventions.

What I found most impressive, however, was the management of a particular patient where our thought processes were considerably different.  An elderly woman had suffered a cardiac event and required the placement of an intra-aortic balloon pump.  This devices inflates a balloon in the thoracic aorta in between heart beats to augment the pumping of the weak heart.  It is inserted through a puncture or “cut-down” in the groin.  In this case the balloon pump catheter was blocking off flow to the leg.  The pump was necessary to maintain her blood pressure and rest the heart – so it couldn’t safely be removed.

In my open surgery world I would naturally consider creating a bypass from the other (left) groin (fem fem bypass) to provide blood flow to the right leg below the pump. Alternatively a  bypass from the arm could also be tunneled down under the skin of the chest and abdomen to the leg.  What I failed to consider was the hybrid solution of opening the other femoral artery and ensuring that it would handle replacement of the balloon pump on that side by endarterctomy (eversion/remote removal of the plaques) of the femoral artery and stent angioplasty of the iliac arteries.  The iliac arteries had been shown to be rather diseased on the Pre CABG catheterization.  The balloon was then inserted on the other side through a open puncture of the endarterectomized femoral artery.  The damaged artery on the right side was also repaired by endarterectomy and stent.  This solution avoided any prosthetic and provided a durable solution should the balloon pump be required for and extended period.  The risk of infection was dramatically reduced by eliminating “artificial materials”.  Having ALL the tools available in your tool box allows you to think more creatively in urgent situations.  I suspect it will be some time after I master the guidewire and catheter manipulations that my thought processes start to take advantage of all these tools.

Starting week 6

Bifocals on my leaded glasses - "I can SEE!!"

 

Today started with a 2 am wakeup.  Checking my phone for the time is always a little painful at 2 am because the screen is too bright.  Waking up at 2 am is also painful but there is so much going on in my life right now that sleeping just seems to interfere with all my required worrying.  Trips home on weekends are a wonderful respite from the life of the Fellow but my real world issues all seem to be congealing simultaneously.  Family health issues with aging parents set the tone.  Two sons making their way out on their own always seem to have some unexpected stresses popping up.  Relaxing on the weekend in my beautiful home was complicated this weekend by another “showing”.  These have become somewhat tiresome after a year on the market but suddenly there is some nibbling on the line to rouse us “dozing” fishermen. The Ford F250 Supertruck suffered a dead battery this weekend and Dharma continues to age.  I think she’s had enough of carrying in the newspaper. 

Todays endovascular schedule started with an 83 year old woman having rest pain in her right foot.  This pain results from not enough blood flow to keep the nerves in her feet happy.  Unfortunately, after an extended effort to recancliz her occluded popliteal artery we are resigned to recommending prosthetic or cadaveric vein graft bypass.  Her right leg is currently perfused by a composite arm vein graft done by Dr. Ouriel 6 years ago (former Chairman of Vascular Surgery department). 

Our second case was cancelled for patient instability.  Third case was a diagnostic angio on a 50 yr old diabetic Prison Guard.  His OSH (OutSide Hospital) stents and PTFE bypasses have failed and he claudicates walking across the prison exercise yard.  Not a very safe situation for a prison guard.  He will need a vein graft bypass in his left leg to keep running ahead of the “Numbskulls”.

Tonight we have “Informal Conference” with the Fellows and Staff.  Pizza and Beer.

Friday

 

 

One of my favorites

My case today is scheduled for 11am so I have a little downtime this morning.  Both patients from yesterday did well and will go home today.  I spent some time talking with the fellows this morning discussing future plans and life issues.  One of our second year fellows, Jennifer E. is waiting on her final contract with the University of Rochester.  It sounds like Rochester is rebuilding their department after Karl Illig has left the chair for a position elsewhere.  They apparently have both academic tracks and clinical tracks so she doesn’t have to commit one way or the other.  Our other second year fellow Ravi R. is headed for Atlanta and found out that his background check conflicted with his application. He had indicated that he had no criminal record but was informed that he had a speeding ticket in 2004 and he therefore had to resubmit his application with CORRECT information.  He was RELIEVED (tongue-in-cheek) to find that he was not on the FBI most wanted list and had no Homeland Security alerts attached to his file.

Turn Left at "SuperFly" to reach the J building

 After a diagnostic angiogram with Dr. Srivastava this afternoon I was able to head out for Bethlehem.  The 6 hour drive is always a little shorter heading home than heading back to Cleveland.  The forecast today is for sun part of the way so I am looking forward to the drive a little more than my last trip.

No, he has NOT left the building!

 

Blue skies over North West Pennsylvania

 

Shortcut to the Atlantic

 

Trucks carry water for "Fracking" natural gas wells in the Marcellus Shale

 This drive is made a lot more tolerable by Audiobooks.  Listening to Donald Rumsfeld’s memoir ” Known and Unknown“.  There is so much history that I lived through but had already jumbled up in my head. I wonder how long it takes to get the facts that you experience confused or misconstrued.  It probably occurs much faster than we think .

Thursday with Dan

Patients being transferred to the Cleveland Clinic

I didn’t intend to be included in the picture.  It’s a bit surreal. Like this experience.

I think the heliport here at the Clinic might see a chopper ten times a day.

One of my struggles has been trying to negotiate dark guidewires into tiny catheters with the ambient lights lowered in the OR.  This is exaggerated because my leaded glasses which included built in bifocals decided to self destruct one day last week.  We wear leaded glasses to decrease the radiation to our eyes. Radiation has been shown to accelerate cataract formation.  Leaded glasses reduce this risk considerably.  Without the bifocals I am essentially fitting the guidewires into the catheters by feel.  I’ve ordered some “stick-on” magnifying lenses which hopefully will make this situation better.

View of Cedar Street from the OR bridge

I asked one of the staff, “are there really 77 OR’s?” He said, “there used to be 110 OR’s but they eliminated a few with some of the construction of the Miller Heart and Vascular Institute.  Now there are just over a hundred.” The current 2 new hybrid rooms where the FEVAR’s are performed (OR 76 & 77) were originally designed as a group of four OR’s at a a cost of $25 million each.  78 and 79 are currently empty shells adjacent to 76 & 77. They are starting construction in the fall.

We have a really superb group of Radiology techs who staff our endovascular cases.  They are a great resource for their knowledge of the devices.  In addition they guide fledgling endovascular surgeons like me when the Staff surgeon is not in the room.  Thankfully they can remember what each of the surgeons prefers so I can do it “the RIGHT way.”

This week has so far been a great learning week.  While I’ve been pushed by the staff I have also felt some respect from them which makes the scut work a bit more palatable.  I spent the day with Dan Clair.  The Chairman of the Vascular Surgery department, Dan is a high profile surgeon who brings great intensity to the care and treatment of his patients.  He has been a demanding teacher but an excellent one.  He has hammered into my aging head the fundamentals that are required for good technique and he has demonstrated sound clinical and academic thinking that always results in “doing the right thing for the patient.”  While his intensity still keeps me on edge, I feel I am getting the most from my experiences with him.  It will be interesting to someday play golf with him.  I think golf is often the clearest “lens to the soul” and I will enjoy looking at his!

Today we stented and Iliac stenosis, angioplastied a vein graft stenosis and revised an EVAR graft done elsewhere with a type I endoleak (blood flowing around a stent into the aneurysm) with a Gore extension.  We place a right renal stent to ensure perfusion to the right kidney as we were taking full advantage of what infrarenal aorta remained above the previous graft. Nice result.

Driving home I noticed this aging building next to the hospital.  Not sure what they do in there.

ORCA House Inc. - Hmmmm

Conversations under pressure

Marfan's syndrome?

Today started out with M&M conference. What astounds me at these conferences is the references to the literature by the staff.  Not only can they quote their own papers and statistics but can recall all the data points from the major studies.  These guys are really bright.  I don’t know that I could ever quote statistics the way they do but I’m fairly certain that I can’t do it now.  I’m pretty much reduced to phone numbers and addresses.  And it’s not just pontificating or posturing.  They are truly educating the fellows and residents with this information.  Tomorrow is a cardiology presentation on preoperative risk stratification and intervention.

After quickly discharging yesterday’s patient from J3-3 (many of the endovascular intervention patients stay overnight in this unit as “extended recovery” patients) I made my way down to the main OR for an elective EVAR.  The patient was a CEO from a Las Vegas company and he had flown in a few days earlier for “Cardiac Clearance”.  Right after induction of anesthesia he went into Ventricular tachycardia.  We cancelled this elective case and he will be further “cleared” by  the electrophysiologists.  Same stuff happens everywhere.

After a short delay the second scheduled patient arrived.   While my Staff vascular surgeon was fixing a leg bypass graft with an arm vein interposition graft in one room I repaired an AV fistula pseudoaneurysm for him in his other room.  We then were able to get to my only endovascular case of the day.  An 83 year old Ohio beef farmer had a 3.9 cm internal iliac artery aneurysm and a 3 cm popliteal aneurysm.  We coil embolized his iliac aneurysm and considered stent grafting his popliteal aneurysm (Dick Cheney procedure) but opted for open repair because of its extensive nature.  We used a Starclose® closure device on his femoral artery puncture and I then proceeded to hold pressure on the groin for 10-15 minutes.  I kind of enjoy this part of the procedure because I get to stand and talk to the patients.  We were talking about the Black Angus cattle that he raises when I realized that his ruddy complexion was a little different around his left eye. He also had a small steri-strip above his left eyebrow.  I asked, “did you fall and hit your eye?”  “No, one of our Angus cows had recently delivered a calf a few hours earlier and I was approaching her stall when she let out a defensive KICK to the stall gate flipping the chain up and hitting me above the eye.” ” They do that sort of thing with their first-borns – get very protective.  Don’t think they do that much with the second or third.  Just the first ones”.

Yeah,  I know exactly how that goes.

I have been enjoying my time and conversations with the residents and fellows.  A wonderfully diverse group with great energy and enthusiasm they willingly help me negotiate this place and my duties.  I have been very impressed by their academics and their technical skills.  While not all “superstars” several are clearly “First round draft picks”.  And they hail from around the globe.  Russia, Sudan, Peru, Jordan, India – a miniUN.  The office staff takes the time to “Highlight” one of the residents or fellows on the bulletin board periodically with an in-depth collage of personal and professional information, pictures, quotes and answers to an entertaining questionnaire.

Actually finished in the OR at a reasonable time today.  Had a chance to review tomorrows cases and even discuss one with the staff.  Before I left I had a chance to get some photos of the Vascular Surgery waiting room.  After checking in they are brought back to the clinic (exam rooms) or to the Hydration room  where they receive IV and oral hydration in preparation for their CTAngiogram.  The 64 slice scanner is right in the Vascular Surgery department.

Vascular Surgery Waiting Room

Vascular Surgery Waiting Room

Then I went outside…in the DAYLIGHT!!

The "back door" to the Cleveland Clinic

SUNSHINE in Cleveland !

Time for the Phillies.

Day ?? – They are starting to run together

Jay Fisher was absolutely right on when he said it took six weeks to start feeling a  little “comfortable”.  After a VERY long day yesterday, I needed a minute to breathe and today helped a bit.  While the earth didn’t move and there were no momentous achievments I enjoyed today for a few reasons.

In my first case of the day we were opening an SFA (the large artery from the groin to the knee) through a Popliteal approach.  That means the patient was lying on his abdomen and we put the needle in to his artery behind the knee.  While my staff was busy doing a carotid endarterectomy I was able to successfully gain access to the artery under Ultrasound guidance.  I “spun the wire” up into the femoral with the help of a QuickCross catheter and we employed a Pathways® atherectomy catheter to open the artery.  Pretty nice result angiographically with only one short eccentric plaque in the upper third of the artery.  This was nicely opened with a Zilver® self expanding stent.   Later I helped the young Walter Reed Fellow excise an infected pseudoaneurysm of an AV fistula (dialysis access) caused because someone decided to add two covered stents to this glorious vein and they became infected.  The patient had been successfully using a “buttonhole” technique for accessing the fistula over the last four years until the graft was added .  Unfortunately buttonholing and prosthetic grafts do not go well together.  Another example of interventional nephrologists thwarting good surgical technique.  A final mesenteric arteriogram on a young (58 yo) woman showed that her Supra-celiac aorto mesenteric bypass in 2003 (and subsequent graft occlusion) was probably not necessary and unlikely to have relieved her presenting abdominal pain because she still had a widely patent SMA and IMA with brisk filling of her celiac artery.  A lot of “stuff” happens out there at St. Elsewhere that passes for good surgery but falls short of good patient care.  Place like Cleveland Clinic and even St. Luke’s find themselves mopping up the bad judgements as well as the bad techniques.

Some interesting things I’m noticing.  The operating room schedule and the high level of care here play off each other.  There is NO SUBSTITUTE for volume.  Every aspect of the patient experience is enhanced by the high volume of cases performed here at the Cleveland Clinic.  One might suspect a level of complacency or cavalier behavior because of repetitive procedures but just the opposite is true.  The level of familiarity with procedures and the expected behavior of patients and staff breeds a knowledge base that helps to eliminate errors.  It’s not the EMR that makes it better it’s the nurse calling you when you missed an order because “they usually order that” that keeps things running smoothly.  It filters through all of the employee staff from housekeeping to unit clerks to radiology techs.  High volume breeds a team effect amongst the entire hospital culture.  There is not a single argument for quality care being enhanced by spreading it across geography.  I’ll step down from my soap box now.

Endovascular surgery ala Cleveland Clinic is truly done with a surgical feel.  While I can’t articulate it, there is clearly a difference between the procedure done here in the operating room (albeit a hybrid operating room) and what I’ve grown up with in Interventional radiology.  Speed is a noticeable difference.  Not in the duration of the case but in the routine repetitive aspects of the cases.  Simplified techniques for prepping, draping, throwing the routine equipment as well as rapid routines for various parts of the case create an atmosphere very much like a busy surgeons operative practice.  And yes, they are probably less religious about the imaging than our IR colleagues but only marginally so.

Lastly, I could feel the gravitas of the institution in the conversations between staff and patients and families.  There is no denying that the message patients take away from this place is that “I have been to the mountain and I have heard the word”. While I’m sure that they are not immune to malpractice claims here I can only imagine that they are a much smaller percentage than elsewhere given their volume.

I would love to post the OR schedule on this blog but I would be violating a lot of HIPAA rules if I did.  I do wonder about how I could ever match their “MGMA Percentiles” when the staff is often running two full OR’s simultaneously.  Talk about “Block Time”.

I thought we had a big vascular lab.  They generate 150-200 studies /day.  Everyone reads whenever they can. They do have some scheduled lab responsibility.

They have one vascular surgeon who is responsible for all equipment costs. He has “protected time” to deal with these issues.  They do pay close attention to product costs and utilize some products over others for cost reasons. I asked him how much more is a Proglide® than a Starclose®.  He said “for us… no difference.”  Volume has its privileges.

good night

Day 28 – too tired to write

The Little Stent Graft Store Room

You should see the BIG stent graft storeroom upstairs!!

Yes they actually do have Gore grafts at the Cleveland Clinic

The Endologix Corner

The pictures above represent a small fraction of the inventory kept in house at the Cleveland Clinic.  Each box represent about a $1

Sunset from the Parking Deck

Day 26 – Post call grind

Last night I was on call again.  I have a few memories and then the story starts to blur.  I’ll apologize in advance if this post lacks coherence or meaningful content.   More pictures in future posts.

After an aortagram and runoff Monday morning with one of the surgeons I hadn’t worked with I felt pretty good about my suggestion to go from the left arm since the patient had no Left femoral pulse.  Jay was right.  The arm is a frequent access point.  Its prepped out in at least half the cases.  The procedure ended up being diagnostic only and he may get a distal bypass or possibly a BKA as he has very limited conduit available.  There is some use of the cadaveric vein graft here – but limited.  By the way the arm access is almost exclusively at the elbow and the boomerang® is often used for closure assistance.  The rest of the day was spent seeing several consults, figuring out how to write them up in EPIC and waiting for a transfer to Cleveland Clinic from St. Luke’s (a Thoraco-abdominal aneurysm) who never showed up.  At 6 pm the “informal vascular conference” assembled in the conference room along with the pizza and beer.  Afterwards my solo call began and the “chinese water torture” of random and incessant calls started and continued through the night.  Far worse than my calls, however, were the constant pages received by the Cardiac Surgery Fellow in the call room two doors down. At about three am I came very  close to walking over to his room and showing him how to put his pager on vibrate!  I was first in line at Starbuck’s this morning (5:30 am) and had time to page two attendings for updates on overnight changes and then take a shower.

The staff surgeons are hard on the residents.  they question them incessantly and are often impatient with their responses but always take the time to finish the discussion.  There is a lot of very good teaching filtering through the “your killing me’s”.    They expect a lot from the fellows and residents and I have been impressed with the preparation that the trainees put into planning cases for the following day.  Some of this is facilitated by the EMR.  The operating room schedule is available to everyone online through EPIC.  Clicking on the scheduled case opens the patients chart and gives access to the attending’s preop visit note.  Before you give this capability too much credit you have to realize that the attending’s preop note may be as exhaustive as “Anatomy suitable for EVAR.  Will get Preop Stress test and PFT’s.”  Everything else is documented by the PA’s or NP’s.  The residents and fellows take the initiative to research the preop imaging and figure out graft sizing and operative approaches.  Aneurysm stent graft planning is so routine for most of the staff surgeons that the measurements are often estimated and available stock parts are normally available.  They rely heavily on the TerraRecon centerline measurements. Fellows are often found consulting online product catalogs and talking with the reps about stents and balloons. There is some pressure on the residents because everyone knows the night before who is assigned to what case.  They take a lot of responsibility for knowing the patient and having a detailed plan of attack.  It’s something we should expect more of in our residents.

Our aneurysm today was an 8cm angulated neck with two proximal seal zones.  An Endologix graft was planned initially.  I reviewed this with one of the fellows and planned a combination of grafts to meet the dimensions of the aorta.  As we prepared the patient the other fellow and I visited the staff surgeon who was taking the “Walter Reed Fellow” through an open Supra renal AAA in his second OR.  He looked up over his glasses and said “What’s your plan?” He asked that we pull up the CT in that room and run a “centerline” and show him our measurements.  The neck was 28mm, 34mm and 28mm over the course of about 3 cms. While we had 15mm of 28 neck and the Endologix graft goes up to 34mm I was concerned about the rapid bulge after the neck.  When pressed for “What do you want to do?” I fell back to my comfort with the 36mm Zenith graft to take advantage of the entire 3cm proximal landing zone.  The disadvantage here was that the renal artery to bifurcation distance was 160mm.  The longest Zenith was 113mm leaving the ipsilateral limb in the sac. While not a huge problem we actually talked about using a Thoracic graft as a proximal “kilt” but eventually decided to change the original plan, keep it simple and go with the Zenith and long limbs.  It worked out nicely with the larger graft conforming well to the  bulging proximal aorta. No endo leak after repeat ballooning of the Proximal stent

Our first case of the day was a rather brief “re-angioplasty” of a carotid stent placed about a year ago in Kuwait.   There was a 70% stenosis at the origin of the ICA probably from an extrinsic calcified plaque.  The staff surgeon considered doing nothing but might have been swayed by the patient’s demographics.  We used a Boston Scientific Filterwire.

So far this week I have taken care of patients from Saudi Arabia, Kuwait, Tennessee and Georgia.

Tech improvements at St. Luke’s that would really make working there better would be having the OR schedule online and having access to the text paging system from the Intranet page (rumor has it this is coming).  Of course, an EMR would be nice.

Looking forward to going back to “St. Luke’s “Warren Hospital when I get back.

Day 23- Easter Weekend

A combination of light scheduling, my mom’s recent hospitalization and the holiday weekend allowed me to escape Cleveland for a few days.  I have now made the trip back to Bethlehem twice in continuous and unrelenting rain.  6 hours of uninterrupted windshield wipers, marginal visibility and occasional absolute blindness from truck splash leave me physically and mentally depleted.

My mom is noticeably weakened by her recent MI.  I suppose her 4 days in the hospital was a lot more demanding than my road trip.  Despite the strain, she maintains her sense of calm and humor.  I hope I can match her demeanor.

Going through some accumulated mail, I was greeted with two lovely photographs of my car zipping down Chester Avenue in Cleveland.  Operation Safe Streets was kind enough to document my excessive speed on two occasions at 48 and 53 miles per hour in a 35 MPH zone.  I can only hope that my fines will be used to purchase some ASPHALT to fill in the POTHOLES along this road!  And while they are at it, how about timing the traffic lights? But I digress…

So far my skill set has expanded in very specific and incremental ways.  I find I am now guarding the length of my thumbnail so that I can more securely grasp the very popular “glide wires” (these are extremely slippery guide wires) through my sterile gloves.  “Spinning the wire” both with and without “torque devices” (little handles applied to these slippery wires) remains both a physical challenge and a mental exercise as my Staff surgeons are quick to remind me.  “C’mon Jim, spin it Jim, spin it, roll it in your fingers like your rollin’ a ‘doobie’ …not that you’d know how THAT goes…”.  Some of the surgeons “always” use the torque devices and some of them enjoy disparaging them as “crutches” that “get in the way”.  Remembering who wants you to do what technique and when was a skill I got pretty good at back in the early 80’s but it has faded along with my ability to recall the names of my close associates, employees and even family members.  Keeping the wire /catheter combinations straight during manipulation is also slowly (but never fast enough) creeping int0 my “automatic” actions.  I spent some time this week with Brett, one of the Radiology techs, going over the controls for the imaging system.  Unfortunately, we have three generations of equipment at the CC so getting “automatic” with the controls will probably occur on my last day here.

We had a very fine presentation on Safety Programs and Patient care by Dr. Giuseppe Papia, MD from the Sunnybrook Campus of the University of Toronto.  Dr. Papia was a former fellow at the Cleveland Clinic and heads up the program for OR safety at Sunnybrook.  They use a three part checklist system modeled after the World Health Organization system with a Preop briefing, Time Out and post op Debriefing.  Their system was designed and refined by the staff at their institution and this resulted in a better staff “buy -in”.  I think he would be an excellent speaker for a Grand Rounds at St. Luke’s.  The Cleveland Clinic employs a variant of this Preop briefing called “the Huddle” which requires the staff surgeon, staff anesthesia, CRNA, OR circulating RN and tech to all appear in the OR for a brief discussion of the operation BEFORE anesthesia begins.  They all comply – despite the inconvenience.

One surprising absence in the OR is the “Neutral Zone” that we apply so successfully.  This agreed upon space in the operating field protects the OR team from carelessly passing sharp instruments and decreases staff injuries.  Each institution has its Plusses and Minuses.

Future topic: Technology systems enhance the work environment at the Cleveland Clinic.