Building diverse leadership in an academic medical center: The ACCLAIM program.

As healthcare systems become more complex, medical education needs to adapt in many ways. There is a growing need for more formal leadership learning for healthcare providers, including greater attention to health disparities. An important challenge in addressing health disparities is ensuring inclusive excellence in the leadership of healthcare systems and medical education. Women and those who are underrepresented in medicine (URMs) have historically had fewer opportunities for leadership development and are less likely to hold leadership roles and receive promotions. One successful initiative for improved learning of medical leadership-presented as a case example here-is the Academic Career Leadership Academy in Medicine (ACCLAIM) at the University of North Carolina at Chapel Hill School of Medicine. ACCLAIM is uniquely designed for faculty identified as having emerging leadership potential, with an emphasis on women and URMs. Using a leadership learning system approach, annual cohorts of participants (Scholars) interactively participate in a multi-faceted nine-month long learning experience, including group (e.g., guest-speaker weekly presentations and exercises) and individual learning components (e.g., an individual leadership project). Since its initiation in 2012 and through 2021, 111 Scholars have participated in ACCLAIM; included were 57% women and 27% URMs. Two important outcomes described are: short-term impact as illustrated by consistent improvements in quantitively measured leadership knowledge and capabilities; and long-term leadership growth, whereby half of the ACCLAIM graduates have received academic rank promotions and almost two-thirds have achieved new leadership opportunities, with even higher percentages observed for women and URMs; for example, 87% of URMs were either promoted or achieved new leadership positions. Also consistently noted, through qualitative assessments, are broader healthcare system knowledge and shared tactics for addressing common challenges among Scholars. This case example shows that the promotion of leadership equity may jointly enhance professional development while creating opportunities for systems change within academic medical centers. Such an approach can be a potential model for academic medical institutions and other healthcare schools seeking to promote leadership equity and inclusion.

Anesthesia for Global General Thoracic Surgery.

Anesthesia in low-to-middle income countries (LMICs) is often provided by nonphysician anesthetists. The training and resources for anesthesia in LMICs are limited, and this must be evaluated when starting or expanding a thoracic surgery program in LMICs. The ability to access a patient's baseline pulmonary and cardiovascular status is often based on rudimentary studies and a thorough history and physical. Advance studies, such as echocardiograms, cardiovascular stress test, cardiac catherizations, pulmonary function tests, and MRIs, are often not available. Careful assessment of both preoperative patient selection, intraoperative ability to provide one-lung ventilation, and postoperative critical care management must be considered when surgical planning is occurring.

Anesthetic Management for Combined Anterior Cervical Spinal Decompression and Fusion and Cesarean Delivery: A Case Report.

A 31-year-old G2P1 (gravida 2 para 1) woman at 34 weeks of gestation presented after a motor vehicle collision with an incomplete cervical spinal cord injury. The patient underwent emergent anterior cervical decompression and fusion (ACDF), immediately followed by cesarean delivery. We discuss the clinical decision making to perform ACDF first, weighing risks and benefits to both mother and baby. We also address important anesthetic considerations for this pregnant patient having emergent spine surgery, including positioning with left uterine displacement, rapid sequence intubation to minimize aspiration risk, choice of vasopressor, implications of total intravenous maintenance anesthetic, and the medical teams involved in this care.

Evidence-Based Medicine and Regulatory Oversight: Opioid Prescribing for Treatment of Pain.

It is no secret that our country is in the midst of an opioid crisis. With hundreds of Americans dying everyday due to opioid use, it is hard to ignore. Closely related, though not as often talked about, is another crisis providers are facing: chronic pain and its treatment. The treatment approach to this problem is multifaceted. Evidence-based studies are the hallmark of appropriate treatment; however, increasing patient concerns and regulatory oversight have added an additional layer that physicians and other prescribers have to incorporate. Navigating a balance between evidence-based treatment, regulatory pressures, and patient concerns is now at the forefront of pain management and patient care.

Using ventilator and cardiovascular graphics in the patient who is hemodynamically unstable.

The interaction of a mechanical ventilator and the human cardiovascular system is complex. One of the most important effects of positive-pressure ventilation (PPV) is that it can decrease venous return. PPV also alters right- and left-ventricular ejection. Increased lung volume increases right-ventricular size by increasing pulmonary vascular resistance, causing intraventricular cardiac-septum shift, and decreasing left-ventricular filling. Increased intrathoracic pressure reduces afterload on the LV and increases ejection of blood from the LV. Understanding and managing these complex and often opposing interactions in critically ill patients is facilitated by analysis of hemodynamic and ventilator waveforms at the bedside. The relationship of PPV to changes in the arterial pressure waveform gives important information regarding appropriate fluid and vasopressor treatment. This article focuses on effects of respiratory pressures on hemodynamics and considers how cardiac pressures can be transmitted to the airway and cause ventilator malfunction.