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“It’s rewarding to connect with patients and provide their families help during their walk down a path they never expected to be on.” Michael L. James, MD, FAHA, FNCS Associate Professor of Anesthesiology Associate Professor in Neurology
From left: Drs. Michael L. James, Raquel Bartz and Jerrold Levy at Duke University Hospital.
set that an anesthesiologist brings into an ICU is the ability to immediately care for acute problems and quickly stabilize patients.” Additionally, she says anesthesiologists are seeing more patients with chronic diseases and acute medical illnesses in their operating rooms and understand how to partner with surgical colleagues to provide the best care for patients with complex medical needs. “Anesthesiologists are intensivists by nature and the ICU is a natural extension of the OR,” adds Dr. James. “We all realize that engaging anesthesiology intensivists with our surgical colleagues has a positive impact on the care of critically ill patients.” Another unique aspect within this division that Dr. Bartz continues to address with faculty recruitment is high patient volume. Nationally, the number of critical care beds has increased 15 percent from 2006 to 2010. Locally, in fiscal year 2016, there were 212 adult ICU beds in service across the three hospitals that encompass DUHS**. The number of adult ICU beds has grown by 72 percent in five years (123 adult ICU beds in 2012)**. Beds in Duke’s Cardiothoracic Intensive Care Unit (CTICU) alone have increased from 20 to 32 within four years, allowing for a better coverage model, according to Dr. Jerrold Levy, co-medical director of that unit. He adds that the severity of illness seen at Duke is much higher than many other places, noting that Duke University Hospital (DUH) is a major referral center for other hospitals when their high-risk patients require additional management strategies. One of the driving factors in the Critical Care Medicine Division’s growth is the ongoing expansion and innovation in providing MCS to patients with life-threatening cardiac and respiratory dysfunction throughout the health system, of which extracorporeal membrane oxygenation (ECMO) is one component. In 2016, Duke University Hospital was designated 22
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DUKE ANESTHESIOLOGY
as an Extracorporeal Life Support Organization (ELSO) Platinum Center of Excellence, the only center in the state and one of only five centers throughout the world. In that year alone, DUH supported 228 ECMO cases in four ICUs – the CTICU being the busiest with 153 patients requiring extracorporeal life support (ECLS). “These patients, specifically those with cardiopulmonary decompensation, require intensive care support until ECMO can be discontinued or until organ recovery occurs. The advantage intensive care physicians, particularly anesthesiologists, have in this domain is our multidisciplinary expertise, understanding the innovative cannulation and management strategies, along with our expertise in and the availability of transesophageal echocardiography needed for the ongoing management of patients on ECMO,” notes Dr. Levy, an internationally-recognized expert on anaphylactic shock and the coagulation system who was recruited to Duke Anesthesiology as faculty five years ago. His expertise in acute cardiopulmonary dysfunction, particularly his knowledge of blood coagulation, extracorporeal circulation, and inflammation provides a unique adjunct to the management of ICU patients at Duke. According to Dr. Levy, a key component of care for these patients is to spend as little time as possible on ECMO in an effort to avoid the risk of long term coagulation issues, blood loss and infection. “Our team has the visual tools, the clinical judgement, and a vast understanding of hemodynamic function of the ECMO circuit which helps determine positive patient outcomes.”