When 8-year-old Stella could no longer move without pain, it was time to heal.
UPDATES
Residency 5
Cardiac and Thoracic 6
Critical Care 6
Pediatric 7
Obstetric 8
Quality, Efficiency and Patient Safety 8
Global Health Equity 11 Stanford Medicine
Outpatient Surgical Center 12
VA Palo Alto 12
Well-being 34
Regional 34
DEPARTMENTS
Editors’ Letter 2
Faculty Profiles
Hassan Farhan 22
Roya Saffary i(nside front cover)
Post-Op (inside back cover)
OUR NEXT GENERATION
Sraventhi Puranam 3
Michael Bizer 9
Karen O’Laco 13
David Wu 10
Allison Wolkin 19
Larissa Kiwakyou 23
PROFILES
Jodi Sherman (back cover)
COVER STORY
A Healing Journey 15
After pain hindered her carefree 8-year-old life, Stella Caissie and her parents turned to Elliot Krane, MD, to help her be a bouyant child again.
BY SONYA COLLINS
FEATURE ARTICLES
Glimpse of the Future 20
Research, career fulfillment for faculty, and clinical excellence: These are some areas new anesthesiology, perioperative and pain medicine department chair Brian Bateman, MD, hopes to further strengthen.
BY RACHEL B. LEVINLighting the Path 24
When anesthesiology, perioperative and pain medicine professors and clinicians teach Stanford medical students, it ignites a fire within both professor and student.
BY RACHEL B. LEVINThe Road to Recovery 28
Thanks to the skilled hands of anesthesiologist Harry Lemmens, MD, Eric Wittnebal is perservering after an intricate multiple organ transplant.
BY RACHEL B. LEVINKalra Goes Green 37
Praveen Kalra, MD and his team lead an innovative, award-winning initiative to reduce waste and promote sustainability in the Stanford operating rooms.
BY ERICA DEMARESTExploring Careers 38
A novel new program promotes early career exploration through simulation and pandemic preparation.
BY MARCIA FRELLICKON THE COVER
Organ transplants are complicated procedures, and Stanford anesthesiologists such as Harry Lemmens, MD, are particularly suited to help.(illustration: Larry Chu, MD)
Time moves slower here at a family-run Riad in Marrakech where Tadelakt (a lime plaster mixed with black olive soap) glazes the walls in a beautiful amber glow and a lazy hammock swings between two olive trees. A family of adopted turtles happily lives here too, nestled underneath a picnic table.
They were a daily reminder to slow down.
Not only were we on the look out to avoid trampling a poor turtle, but slowing our pace allowed us to enjoy the shadows flickering along the candlelit walkways at night. And we followed the Riad’s house cat as it bathed in the Moroccan sun.
They were patiently waiting for us. And we were very glad to be there.
As we slowly emerge from the COVID-19 pandemic I think back fondly to our time in Morrocco. It’s a reminder of our place in the larger global community. But it is also a reminder to slow down and take time to appreciate ourselves and the things that make our community here so special.
From Stella Caissie’s healing journey as a pediatric pain patient, lighting the career paths of future physicians to the unique collaboration of multiorgan transplantation, this issue explores just some of the stories that make our community unique.
And it wouldn’t exist without you. We are grateful for the collaborative, welcoming and innovative workplace and community that each of you create for us to come home to. SA
The central theme of a recent Grand Rounds, given by Dr. May Pian-Smith, was the importance of developing trusting relationships. Trust has been defined as the assured reliance on the character, ability, strength, or truth of someone or something. Trust elevates the quality of our relationships and our work. It binds us together when we face conflicts and challenges. So much is changing in our department, hospital, and the world around us. We have new leadership and structures, hospital growth, a pandemic that won’t go away, divisions and conflicts within our society, inflation – the list is long, and it keeps changing, too. Trust in each other and trust in the importance and value of our work underpin everything we do.
Last Fall, I was fortunate to join clinical informatics colleagues from Stanford and UCSF around Open Notes led by Drs. James Xie (Farm) and Priya Ramaswami (City). We planned to survey anesthesiologists at both institutions about the federal requirement to make available a patient’s information to them immediately, including anesthetic records, and then write it up and get it published. However, the final manuscript bore no resemblance to our initial plan. We learned early on that most anesthesiologists from both departments were cautiously supportive about releasing anesthetic records to their patients. But that did not seem very interesting or reportable. As we met regularly over Zoom after work for three months, the discussions became more exciting
and wide-ranging, and our plans changed. We all agreed we needed to try and inform and educate our specialty about Open Note and its impact and importance for patients and our specialty.
We invited other colleagues with legal experience and a background in ethics. Drs. Neal Cohen (UCSF) and Alyssa Burgart (Stanford) brought the group’s size to eight. Most of us had never met before. We were a diverse group with disparate opinions. We shared ideas and thoughts. We challenged each other, and we learned from each other. The newness of Open Notes was refreshing and humbling –there were no experts and no body of literature within our specialty. Zero. The effort shifted from a research report to an exploration of what Open Notes would be for our specialty and the challenges, opportunities, and unknowns that would follow. None of us could predict the outcome of sharing anesthetic information directly, immediately, and without exception; not everyone agreed that it would end well. In part, we have the pandemic and Zoom to thank for our ability to collaborate over time and space. We all knew that this was important work to take up. To be sure, James’ and Priya’s leadership and efforts kept us all moving forward, but each of us contributed uniquely. Our work and the final manuscript would not have been possible without all eight members’ individual and collective efforts. We relied on each other. We trusted each other. And we trusted our process and the importance of Open Notes.
We titled our paper “Keeping an Open Mind to Open Notes.” We kept open to possibilities and each other. That opened the door to a remarkably fruitful collaboration. I still have never met Priya in person! Our experience was not a “oneoff.” Our name, the Department of Anesthesiology, Perioperative and Pain Medicine.e, is a statement that we are a group of individuals working together to care for patients, create opportunities for each other and the next generation of anesthesiologists, and advance our understanding and knowledge. We can only do that work together. I am grateful to have had the privilege to work with Drs. James Xie, Priya Ramaswami, David Robinowitz, Neal Cohen, Allysa Burghart, Angela Marsiglio, and Ellen Wang. And that effort has led to a new research project with Dr. Dan Gessner and Jonathan Shi, a medical student at Stanford, to extend the exploration by carrying out structured interviews with a group of patients about what they want to know about their anesthetic. No one has ever asked before.
We are all fortunate to be part of a department that places trust in us to care for patients, educate the next generation of anesthesiologists, extend the boundaries of knowledge, and foster collaborations like this one. We are all engaged in meaningful, demanding, and hard work. There will be challenges, sacrifices, and setbacks. But, with trust in each other and the value of our work, we will overcome hardships and do and create amazing things – together. SA
Hometown: San Jose, California
Medical School: Brown University
Status: CA-2
What’s best about living in the Bay area?
I have lived and traveled all over the world, and truly, there is no place more filled with nature, culture, and intellectual curiosity than the Bay Area. It is such a privilege to live in a place where people come from all over the world to learn, build and innovate as much as they come here to hike, surf, explore and climb. On a more personal note, I grew up in the area, so having my family and close friends here is such a gift!
What do you do in your downtime from training?
My downtime is centered around spending quality time with family and friends and nurturing my more artistic side by singing, dancing, reading and making art. You can almost always catch me on a hike or at a live music show on free weekends. I also volunteer at the [local] food bank regularly and find ways to stay engaged in my community. Prior to medical school, I was a community organizer, so advocacy is a very important part of who I am and a cornerstone of my career.
What most influenced your decision to come to Stanford?
I wanted to train at a top-tier academic program where I would be exposed to the entire breadth of anesthesia practice and graduate having seen most of what anesthesia as a field is capable of in a variety of clinical settings. I also have long-term career interests in global health and mobile health and knew Stanford would be able to nurture these interests with the right mentors and opportunities.
What unique thing you bring to medicine, that will impact (or already does) how to relate to your patients?
My work in trauma-informed care is something unique I bring to my anesthesia practice. Trauma-informed care is a well-established, universal framework in primary care and behavioral health settings that empowers clinicians to both identify and respond to patients who have experienced trauma and build resiliency to prevent their own vicarious trauma. In an age where physicians are “burning out” at record numbers, I am hopeful of bringing a framework like this to our field in order to more sustainably improve the way we care for our patients and ourselves at both an individual and structural level.
How would you describe yourself in one word? Grateful
Editors-in-Chief
Larry Chu, MD, MS
Cliff Schmiesing, MD
Art Director and Senior Designer
Larry Chu, MD, MS
Managing Editor
Susan Lorimor
Chairman
Brian Bateman, MD
Contributing Writers
Sonya Collins
Erica Demarest
Marcia Frellick
Chante Griffin
Rachel B. Levin
Susan Lorimor
Contributing Photographers
Christopher Beauchamp
Kris Cheng
Eric Lee
Marissa Leshnov
Wyatt Roy
Administrative Assistant
Mary Ellen Gazay
Design and Production
Jim Vranas
Printing
Giant Horse Printing
Stanford Anesthesia is published annually by the Stanford University School of Medicine, department of anesthesiology, perioperative and pain medicine as a service to alumni and friends of the department of anesthesiology, perioperative and pain medicine. © 2022 by Stanford University Board of Trustees. Letters, address changes and other correspondence should be addressed to Stanford Anesthesia Annual Report, Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Room H3580, MC 5640, 300 Pasteur Drive, Stanford, California 94305-5640. We can be reached by phone at (650) 723-4671 and by fax at (650) 725-8544.
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Stanford Anesthesiology Residency Update
Chief Residents
The department thanks outgoing Chief Residents Aya Abou-Nasr, MD, Larissa Kiwakyou, MD, and Andrew Kuo, MD, for exceptional leadership this past year. The newly elected 2022-2023 Chief Residents are Derek Smith, MD, Sami Hodapp, MD, and Joseph Hodapp, MD. Please check us out and follow us at https://www. instagram.com/stanfordanesthesia.
Residency Education Office Leadership Change
The Residency Education Office Staff is now led by Patricia Raines. Patricia succeeds Janine Roberts, who completed two decades of exceptional service. Pat comes to us from within our Stanford Medicine community, and has worked most recently in the department of surgery, where she spent 10 years as a Residency Program Coordinator. In her spare time, Pat loves spending time with her daughter and “furry”
son. One of her favorite pastimes is being outside by the water, listening to the waves and seeing people enjoy their time together as families and friends. She also loves spending time with her family in her home state of Texas, so you may hear her say “Hi, y’all.” Pat is also a huge fan of college and professional sports (basketball, baseball, football and track and field).
Stanford Housestaff Unionization
Stanford Health Care (SHC) residents and fellows have voted in favor of having the Committee of Interns and Residents (CIR), a local of Service Employees International Union (SEIU), serve as their collective bargaining representative. Negotiations will determine any changes to compensation, benefits and workplace programs going forward, after an agreement is reached between Stanford Health Care and CIR/SEIU.
The Health Equity Anesthesiology Leadership Pathway
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The Health Equity Anesthesiology Leadership (HEAL) Pathway was developed by faculty, residents and staff to address the need to prepare residents to lead diversity, equity and inclusion efforts. Stanford anesthesiology, perioperative and pain medicine department residents interested in becoming health equity leaders are mentored and taught how to take a vision to implementation, manage projects, delegate, conduct meetings, and create scholarly work from diversity, equity and inclusion efforts within an academic center. The experience is tailored to the individual’s background and goals but is intended to provide residents the knowledge, attitudes and skills to become health equity leaders.
The new CA2-CA3 Lecture series Curriculum Faculty Director is Natalie Bodmer, MD. She is working with the Chief Residents and education representatives from each class for feedback on curriculum to
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ANESTHESIA INFORMATICS AND MEDIA LABinclude more interactive sessions, more PBLD, more peer involvement and in-person/hybrid lectures.
Every year, there is a list of knowledge gaps that the residency receives from the ABA providing feedback on the topics that were missed on the ITE/Basic Exam/ Advanced Exam. Faculty Libero lectures target those areas. The question of the week was created to provide residents an additional resource for tackling missed topics and to reinforce those topics presented in previous Libero lectures. Each Monday, an email with the question of the week is sent to the residency classes. Residents who answer correctly receive points throughout the year. At the end of the year, the top three residents with the most points receive a small prize.
We are very excited to resume the in-person global health teaching electives: Block 5 Rwanda with Ana Crawford, MD; Block 6 Rwanda with Travis Reese-Nguyen, MD; Remote Tanzania 2 weeks with Cynthia Khoo, MD; and Remote Vietnam 2 weeks with Sara Strowd, MD. Tanzania and
I am honored and delighted to begin my term as the Chief of Cardiac Anesthesiology. I come from the University of Ottawa Heart Institute, where I was an Associate Professor of Anesthesiology and Epidemiology, Director of Big Data and Bioinformatics Research, and Clinical Research Chair of Big Data and Cardiovascular Outcomes. I am also an Adjunct Scientist at the Institute for Clinical Evaluation Sciences (ICES) in Toronto. I received my medical degree from McMaster University in Hamilton, Ontario. I completed my anesthesiology residency at the University of Ottawa and my Master’s of Science in epidemiology at the Harvard School of Public Health, followed by a clinical and research fellowship in cardiac anesthesia at the University of Toronto.
and operating room teamwork, I hope to foster a collaborative spirit across specialties in clinical care, including decision-making, as well as academically through interdisciplinary research and joint didactic and simulation-based education.
I enjoy a simplistic, team-based approach to clinical care and academic practice. My personal moto is “Just do it!.” I very much look forward to teaming up with our esteemed faculty and talented learners toward a productive and innovative future.
~Louise Sun, MD, SM, FRCPC, FAHA, Division Chief Critical Care
Vietnam are currently on a level 4 travel advisory and are both on hold. Residents can complete a two-week virtual rotation.
While in Rwanda, residents work primarily in Kigali rotating through three hospitals — one academic, one military and one private — with exposure to the general ORs, obstetrics, and pediatrics. There is an active regional anesthesia program as well at the academic hospital. On Mondays we have an all-day academic day in the simulation lab and facilitate not only simulations, but also case discussions, oral board exams, procedural skills and other engaging learning formats.
This will be the 12th year Stanford Anesthesia has visited its partners in Rwanda, as 2021 was the only year we skipped. The program has suffered challenges during the pandemic, including fewer teachers and fewer applicants. We were one of the first anesthesia residency programs to formalize a global health equity residency track and fellowship and aim to be the leading program for improving health outcomes for vulnerable populations both near and far.
~Alex Macario, MD, MBA, Vice Chair for Education and ProfessorI enjoy being active in the scientific community. I sit on a number of editorial boards, grant review committees and collaborate nationally and internationally on a variety of population health and data science initiatives. Being a mathematician at heart, I rely on quality data, advanced statistical and machine learning techniques and biotechnology to direct operations, do risk stratification, and personalize and improve access to the quality of patient-centered care. I have authored over 90 peer-reviewed papers and book chapters in leading clinical journals including JAMA, JAMA Internal Medicine, JAMA Cardiology and Anesthesiology. My research program is well funded by the Canadian Institutes of Health Research (CIHR), the Heart and Stroke Foundation of Canada, and the Ontario Ministry of Health. My vision for the cardiothoraicic division is one of innovative clinical and academic excellence. I believe in the power of data and technology in driving clinical and administrative efficiency, and that of adaptive modeling of everyday processes in advancing personalized care, improving patient safety, reducing cost, and benchmarking performance equitably and objectively. I will encourage the addition of highfidelity, interdisciplinary simulation, augmented by modern technology, to our already strong cardiac education curriculum.
I wish to empower our colleagues and trainees to work together to transform everyday queries into impactful and practice-changing research that directly addresses clinically relevant problems. Being a health services researcher with an active program in cardiovascular
In 2021 to 2022, the division of critical care medicine (CCM) faculty members not only led clinical critical care at Stanford University Medical Center (SUMC), but also shone as leaders in multiple national critical care and anesthesiarelated professional societies and scholarship.
Starting off his faculty tenure with distinction, new faculty member Micheal Chen, MD, presented a case report at the Society of Cardiacvascular Anesthesiologists’ 2022 Conference and also, under the mentorship of division faculty member, Frederick Mihm, MD, published a case report about abdominal compartment syndrome in a gorilla in the Journal of Zoo and Wildlife Medicine. Director of Critical Care Ultrasonography, Jai Madhok MD, ,completed research concerning anticoagulation in extracorporeal membrane oxygenation (ECMO) patients that led to a hospitalwide change in anticoagulation monitoring for all SUMC patients.
An Diem La, MD, continues to lead the critical care residency rotation for the departments of anesthesiology, perioperative and pain medicine; medicine, and emergency medicine and was awarded a 2022 Arthur L. Bloomfield Award in Recognition of Excellence in the Teaching of Clinical Medicine.
Amy Kloosterboer, MD, was not only a graduate of the 2021 Intensive Course in Clinical Research, but also stepped in as division lead for liver transplant patient protocols and was an invited speaker at The Johns Hopkins Hospital concerning liver transplant critical care and anesthesia.
Nicole Arkin, MD, was appointed Associate Program Director for the critical care fellowship program and, along with Program Director Erin Hennessey, MD, initiated a novel holistic review process to better ensure equitable assessment of
candidates for the highly competitive fellowship.
Adjoa Boateng, MD, presented the “Year in Review: Anesthesiology” session at the 2022 Critical Care Medicine (SCCM) Congress in April, published articles in the October 2021 issue of the ASA Monitor (and JAMA Network Open, along with a poem in Anesthesiology and Analgesia. She was also a co-
on the “Future of Critical Care Medicine,” with findings published in Critical Care Explorations journal, was one of six featured thought leaders presenting at the SCCM 2022 Congress, continued as CoChair of the SCCM 2023 Guidelines for Family-Centered Care in the ICU, presented at the SCCM, ASA, American Academy of Hospice and Palliative Medicine, and International Anesthesia Research Society (IARS) annual meetings, and was the primary author of the 50th-anniversary article for SCCM, “Palliative and End-of-Life Care: Prioritizing Compassion Within the ICU and Beyond” published in Critical Care Medicine
instructor for the Stanford medical students’ Medical Humanities and the Arts course, and was featured in the podcast, The Doctor’s Art, thedoctorsart.com/episodes/ep8.
Critical care fellowship Program Director and Chair of the Program Directors Advisor’s Council for the Society of Academic Associations of Anesthesiology & Perioperative Medicine (SAAAPM), Erin Hennessey, MD, presented on “Organ Dysfunction – from the OR to the ICU” at the 2021 American Society of Anesthesiologists’ (ASA) meeting, moderated a breakout session on “Multi-Institutional Collaborations” at the SAAAPM meeting, moderated a group workshop on “Holistic Review Processes for Trainee Recruitment” at the fall Society for Education in Anesthesia (SEA) conference, and was an invited speaker at the SCCM Congress.
An anchoring divisional leader, Mihm, continued his work on the pheochromocytoma perioperative initiative, mentored multiple residents and fellows, and launched a quality improvement project on awake fiberoptic intubations.
Associate Division Chief and Co-Director of Adult Critical Care for SUMC, Javier Lorenzo, MD, was one of four national Co-Directors for the Society of Critical Care Anesthesiology (SOCCA) Board Review Course, was named CoChairof the Patient Safety Committee for Stanford Health Care, and graduated as part of the 2021-2022 cohort of the Stanford Leadership Program.
Critical Care Medicine Division Chief, Rebecca A. Aslakson, MD, PhD, led the SCCM Task Force
The critical care medicine anesthesiology group at the VA Palo Alto Health Care System continues to offer excellent clinical care, teaching, leadership, and unique training opportunities to CCM fellows rotating on the VA ICU Service. Juliana Barr, MD, FCCM, is the Co-Chair of the SCCM’s ICU Liberation Committee, working to promote adoption of the ICU Liberation Campaign’s ABCDEF Bundle in adult and pediatric ICUs worldwide, including the VA Palo Alto.
Ed Bertaccini, MD, continues his research in anesthetic mechanisms and drug design of new sedatives/ anesthetics, with both recent patents and publication in the Proceedings of the National Academy of Sciences, along with a presentation at a recent joint meeting of the Association of University Anesthesiologists and the International Anesthesiology Research Society.
Chair of the VA’s Code Blue and Rapid Response Team, Geoffrey Lighthall, MD, PhD, is the only critical care anesthesiologist at the VA Palo Alto who is trained and certified to perform bedside percutaneous tracheostomies and thus gives trainees the unique opportunity to learn how to perform this procedure during their rotations on the VA ICU service.
Carlos Brun, MD, continues to provide outstanding instruction in the use of bedside transthoracic echocardiography and point-of-care ultraSound (POCUS).
Lena Scotto, MD, in conjunction with An Diem La, MD, at Stanford Medicine, continues to create a new Intern and Resident CCM Curriculum comprised of online core and advanced lectures, weekly lecture schedules, evaluations and quizzes based on specific Society of Critical Care Anesthesiologists/ Accreditation Council for Graduate Medical Education/Society of Critical Care Medicine key topics.
Any discussion of the 2021-2022 critical care civision must finish
with celebration and recognition of division faculty member, Ronald Pearl, MD, PhD. In fall of 2021, Dr. Pearl stepped down after 22 heralded years as the Chair of the department of anesthesiology, perioperative and pain medicine and then, for the 2021-2022 year, served as the President of the California Society of Anesthesiologists. As a division and department, we continue to be grateful for Dr. Pearl’s o-going local, regional, national and international leadership in critical care and academic anesthesiology.
~Rebecca Aslakso, MD, PhD, FAAHPM, FCCM, Critical Care Division Chief; and Juli Barr, MD, FCCMThe division of pediatric anesthesiology continued to thrive over the past year despite the stressors of an ongoing COVID-19 pandemic, a nursing strike, and the never-ending fatigue generated by national and international events. Our faculty, fellows and combined pediatrics-anesthesiology residents have endured many struggles, personal and professional, and yet return daily to care for the sickest and most vulnerable children and their families. If there were a theme to the year, the theme would be change. And surrounding that change was an incredibly resilient group of dedicated pediatric anesthesiologists.
This was a somber year for our division, our department and the school, with the too-early loss of Lisa Wise-Faberowski, MD, MS, who had been a member of the faculty for over a decade. Lisa was a gentle, dedicated clinical pediatric cardiac anesthesiologist, scientific researcher, and beloved teacher and mentor. She was also a working mother. Her loss is felt deeply.
The division of pediatric anesthesiology moved to the contemporary Center for Advanced Medicine in March 2021 and in that space has continued to thrive. Ban Tsui, MD, who is a bridge with our colleagues on the adult regional team, received the Distinguished Service Award from the American Society for Regional Anesthesia. Danton Char, MD, received two substantial National Institutes of Health grants to explore his research interests of ethics and the use of artificial intelligence to aid complex medical decision-making. Rita Agarwal, MD, finished her term as president of the Society for Pediatric Pain Medicine. Travis Reece-Nguyen, MD, was named Chair of the Committee on Diversity, Equity and Inclusion of the Society for Pediatric Anesthesia (SPA). The pediatric anesthesiology Division Chief, Jim Fehr, MD, will assume the SPA presidency in the fall of 2022. And, Laura Simons, MD, PhD, was named president of the Society of Pediatric Psychology.
We are honored to have not one, but two members of our division as Assistant Deans of the medical school: Anita Honkanen, MD, the former Division Chief, was named Dean of the medical students for wellness, and Felipe Perez, MD, was named Assistant Dean for Diversity in Medical Student Education. Several members of the division have contributed to leadership through diversity, equity and inclusion efforts as leaders in the Anesthesia Diversity Council and at the Department’s Diversity Retreat, where James Xie, MD, led the task force on retention.
Another leader is Rebecca Claure, MD, who was named the Associate Chief Medical Officer of the Treatment Center of Lucile Packard Children’s Hospital (LPCH). We also had two faculty honored by the
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LPCH medical staff: Gail Boltz, MD, received the Distinguished Medical Staff Service Award and Alyssa Burgart, MD, received the Medical Staff Impact Award.
The division continues to manifest educational exceptionalism. Asheen Rama, MD, remains the lead of perioperative, interdisciplinary simulation efforts in our ORs.
Andrea Murray, MD, a Stanford Educators for Care (E4C) faculty member, received two awards from the medical students: the Franklin G. Ebaugh Award for Excellence in Advising Medical Students and an award for Excellence in Promotion of the Learning Environment and Student Wellness. James Xie, MD, received a Rathmann E4C Fellowship, which further enhances our division’s contributions to the development of Stanford’s medical students.
Our pediatric anesthesiology fellowship continues to thrive and expand under the leadership of PD Tom Caruso, MD, also an E4C faculty member, and APDs Romy Yun, MD, and Echo Rowe, MD. In an extremely competitive match this year, our fellowship filled with some of the best and the brightest prospects in the nation. Following the match, where 27% of programs didn’t fill, we attracted a ninth fellow to make up our largest and most diverse class ever. Ana Goya-Arce, MD, assumed the role of PD for the pediatric pain psychology fellowship from Rashmi Bhandari, MD, who continues as the clinical director of the pediatric pain psychologists.
After over two years, we were able to have our second Anesthesiology Family Day.
Spearheaded by Tammy Wang, MD; Natalya Hasan-Hill, MD, an honorary peds anesthesiologist; and Elena Brandford, MD, a combined pediatrics-anesthesiology resident, we had over 100 department members and their family members come together to explore what exactly mommy and daddy do all day. This family-centered, festive day of learning, camaraderie and mutual support typifies what it means to be a member of the division and the Stanford Anesthesiology family.
It has been a year of change and resilience for the division of pediatric anesthesiology and we look forward to a healthier and more joyous year to come with new and greater successes. The commitment, compassion and kindness of the division members will help propel us forward. Stay tuned — there are more great things to come.
The obstetric anesthesiology division has had a very successful
past year and certainly attained the mission’s goals to be global leaders in the field of obstetric anesthesiology and advance patient care through innovative research and education.
Our obstetric anesthesiology faculty and collaborators published an incredible 90 peer-reviewed articles in 2021. See https://med. stanford.edu/obanes/research.
html. At the Society for Obstetric Anesthesia and Perinatology (SOAP) Annual Meeting 2022 in Chicago, we presented 28 abstracts. James O’Carroll, MD, our research fellow scholar, won the SOAP 2022 Gertie Marx Award, for best trainee paper of the meeting, for his presentation: A multicenter evaluation of quality of recovery following cesarean delivery.
Authors were J. O’Carroll, L. Zucco, E. Warwick, N. Guo, B. Carvalho, P. Sultan and ObsQoR collaborators.
Maria Sheikh, MD, MPH, our recently graduated fellow, won the Research in Education Award with her Stanford-based study: Feasibility of focused cardiac ultrasound performed by novices during Cesarean delivery. Authors were M. Sheikh, W. Athar, B. Carvalho, N. Guo, C. Padilla and C.M. Ortner).
Moris Baluku, MMed,a Ugandan anesthesiologist mentored by Pervez Sultan, MD, and Brendan Carvalho, MD, won the 2022 SOAP/ Kybele International Outreach Grant to study enhanced recovery after cesarean delivery in Uganda. The SOAP annual meeting point-of-care ultrasound (POCUS) and simulation workshops were successfully led by Clemens Ortner, MD, and Gill Abir, MD, respectively.
Key Achievements
The division’s faculty made important contributions and received a number of awards over the past year. Edward Riley, MD, received the Lucille Packard Children’s Hospital (LPCH) Distinguished Service Award in recognition of 30 years of incredible achievements. Clemens Ortner, MD, received the LPCH Medical Impact Award for his leadership in POCUS and cardiac ultrasound for obstetric patients. Cedar Fowler, MD, PhD, received the 2021 Outstanding Interdepartmental Faculty Professor Award from the Department of Obstetrics and Gynecology.
Ortner was selected to lead the SOAP POCUS special interest group (SIG) as chair and Abir, to lead the SOAP Simulation SIG.
Alex Butwick, MD, was the guest editor for the International Journal of Obstetric Anesthesia special issue on postpartum hemorrhage (PPH), published a study refuting epidural-autism association in JAMA Pediatrics
(JAMA Pediatr. 2021;175(7):698-705) and was a task force member for the California Maternal Quality Care Collaborative PPH toolkit Version 3.0. Fowler developed an MSD elective, “Reproductive and Gynecological Surgical Care Anesthesia Rotation,” and helped implement Gyn-Onc ERAS and Colorectal HIPEC pathways and a related Improvement Capability Development Program. Jessie Ansari, MD, and Pamela Flood, MD, published a practice-changing paper that highlights the long-term impact of dural puncture on headache and back pain (Br J Anaesth. 2021;127:600-607).
Ansari received the 2022 Foundation for Anesthesia Education and Research Mentored Research Training Grant for “Calcium chloride for the prevention of blood loss during intrapartum cesarean delivery: a single center randomized controlled trial with nested pharmacokinetic and pharmacodynamic study.” Ansari was also awarded the Maternal Child Health Research Institute (MCHRI) Clinician Educator Award, and published a pivotal pilot study for the role of calcium chloride for the prevention of uterine atony (J Clin Anesth. 2022;80:110796).
Pervez Sultan, MD, received MCHRI grants for his work that is redefining how we assess postpartum recovery using patientreported outcome measures. Cesar Padilla, MD, was selected vice chair of the Justice, Equity, Diversity and Inclusion Committee of the California Society of Anesthesiologists, and received the Young Physician of the Year Award of the National Hispanic Medical Association. Kelly Fedoruk, MD, was elected team leader for Stanford’s Clinical Effectiveness Leadership Training program and completed the Quality, Safety and Improvement Program for the faculty scholars program.
Naola Austin, MD, helped redesign the Stanford Emergency Manual, version 4. Abir was appointed Associate Division Chief of the OB anesthesiology division. We received ACGME approval to expand our fellowship from three to four fellowship positions, thanks to the efforts of Andrea Traynor, MD, Fellowship Program Director, and Lindsey Ralls, MD, Associate Fellowship Program Director, who continue to lead one of the best obstetric anesthesiology fellowship programs in the country. Traynor is also leading a multi-institutional effort to update the OB Anesthesia Fellowship curriculum nationally.
Our division now consists of 16 members. We were delighted to welcome our new Chair, Brian
Bateman, MD, who recently joined the division. Bateman is one of the most academically successful and respected thought leaders in the field of obstetric anesthesia.
Emily Stockert, MD, completed her fellowship and also joined our faculty in January. She has an MBA, was elected to the SOAP Finance Committee, and is leading our cost-savings and green initiatives.
Dominique Arce, MD, from Brigham and Women’s Hospital, will be joining our division in July. She will be a great addition to our division and department in her role as Associate Vice Chair of Faculty Development.
Fedoruk gave birth to a gorgeous baby girl, Gaby, the youngest member of our division.
The obstetric anesthesiology division is extremely grateful for the support received from outgoing Chair Ron Pearl, MD, PhD, and now current Chair Bateman, and to our many research, education and clinical collaborators within and outside thanalyst, who has been instrumentl in our division maintaining its academic productivity, and Perman Pandal, our excellent research assistant. A special thank you to our administrative staff, especially Nelia Porto, who joined us in January as our OB anesthesia administrator, Alyssa Martinez and Bernadett Mahanay for providing fantastic fellowship support, and Rosario Ngo for her amazing scheduling.
~Division Chair Brendan Carvalho, MD
William Gostic, MD, was appointed the Physician Improvement Leader for the anesthesiology, perioperative and pain medicine department and the Chair of the Quality, Efficiency, and Patient Safety (QEP) Committee in January 2022. The committee is open to all anesthesiology faculty and trainees and includes Quality Directors from each clinical division and representatives from perioperative services, medical informatics and green anesthesia.
Additionally, Kelly Fedoruk, MD, assumed the role of Quality Division Director for obstetric anesthesiology and Gillian Abir, MD, transitioned to Associate Quality Division Director. Edward Mariano, MD, MAS, FASA, was appointed Senior Vice Chair for Clinical Operations and Value, which includes the promotion of continuous improvement for highquality value-based care. Natalya Hasan-Hill, MD, was appointed Vice
(UPDATES continued, on page 11)
Hometown: East Palo Alto, California, and Mountain View, California
Medical School: Anesthesia Tech School:
Status: Anesthesia Tech: Initial training through Stanford; continuing education at College of DuPage in Chicago
Where’s your favorite place to hang out in the area?
I love driving the coast in either direction, with my beautiful wife. And stopping to visit any of the beaches. Also, I’m a huge Raiders fan, and loved watching the games at the Oakland Coliseum.
What made you want to become an anesthesia tech?
I was curious about the process for which patients were put to sleep [for medical procedures].
What do you like best about your job?
I love the fact that I’m able to help others. Stanford took really good care of my family when they were patients here. And I feel like it’s also my way of giving back.
What two words describe you best?
I think the two words that describe me best are resourceful and team player.
How would you convince others to find a career at Stanford?
I would tell anyone who wants a career in health care, and who wants to learn from some of the brightest minds to come to Stanford. SA
Hometown: Atlanta, Georgia Medical School: University of Washington School of Medicine
Status: Intern
Why did you choose Stanford?
For me Stanford had the complete package. It has rigorous training, a wealth of expertise in anesthesiology, a hospital situated within a thriving and innovative university community, and strong cardiac and critical care fellowships. It also has an active diversity council that receives genuine support from the department of anesthesiology. All in a sunny, supremely bikeable area with some of the best road cycling in the country.
What do you look forward to about living in the Bay Area?
I’m new to the Bay Area so there is so much to look forward to. If I had to choose a few things, though, it would have to be bike rides in warm, sunny weather and good Chinese and Ethiopian food. Also, this is not necessarily Bay Area-specific but my partner Natalie and I moved into a dog-friendly apartment and are looking forward to adopting our first dog.
Why anesthesiology?
I fell in love with every rotation during medical school and had a tough time choosing a specialty. In the end I chose anesthesiology for several reasons: how so much of the work is focused on thinking and doing (rather than documentation); how quickly we get feedback from our interventions; the collaborative environment in the OR; and the multitude of opportunities to conduct research and to innovate in the field. It also helped that I got along well with the CRNAs, residents and attendings that I met and relished early morning bike rides to the hospital.
What motivates you every day?
My parents ran a laundromat for a long time after immigrating to the U.S., and I spent many summers as a kid folding clothes and cleaning lint from dryers. I think often of how lucky I am to be able to pursue fulfilling, interesting work that also serves others in some way. Ultimately, I’m motivated to make the most of my life — both by making the most of the opportunities I’ve been given and by living well.
What are two things you can’t live without?
A good night’s sleep and leafy green vegetables. SA
PHOTO BY KRIS CHENGChair for Well-Being and Support and is involved with projects under the hospital domain for wellness. Michelle Arteaga, MS, was promoted to Process Improvement Specialist.
The committee offers a departmentwide forum for divisions to highlight their quality improvement (QI) work with clinical teams at both hospitals and receive feedback through open discussion.
Cardiac anesthesiologist Worasak Keeyapaj, MD, helped lead the OR i-STAT study that was designed due to anesthesiologists having quality concerns regarding discrepancies between i-STAT and Lab Radiometer ABL. The validating results of the study will be transformative for cardiac anesthesiologists during lung transplants. In response to multiple SAFE reports, regional anesthesiologist Dan Gessner, MD, led the implementation of new safety measures for patients who receive EXPAREL (liposomal bupivacaine), including alert wristbands, head-of-bed signs and nursing education.
In May 2021, the departmental QI Reporting System was unveiled as a framework to report adverse events and patient safety concerns. Will Gostic, MD, partnered with Larry Chu, MS, MD, and the Anesthesia Informatics and Media (AIM) Lab to design and implement an online electronic capture system protected by California Evidence Code 1157. In the first year, the form has been completed over 1,150 times and over 400 QI events were reported and reviewed by the committee. Systemic improvements continue to be implemented and communicated on a monthly basis.
James Xie, MD, and Roya Saffary, MD, were appointed the co-directors of the Resident Quality Improvement/Patient Safety curriculum and oversee the CA-2 class QI projects. The five 2022 class projects include improving written resident feedback, led by Derek Smith, MD; improving perioperative area experience with interpreter services, led by Derrick Wu, MD; Anesthesia STAT, creating a better way to call for help, led by Tracey Hong, MD; and process improvement regarding perioperative code status, led by Jason Batten, MD.
Michelle Arteaga, Jakaria Stewart and the Quality Division Directors led an inaugural cohort of eight anesthesiology faculty in the Quality Scholars program (formerly known as QSIP). Faculty scholars applied to work on a yearlong QI project and received hands-on training
in A3 methodology, peer learning opportunities and one-on-one coaching. Becky Wong, MD, has been appointed the new faculty director for the upcoming 2022–2023 program.
The new department Chair, Brian Bateman, MD, tasked the QEP committee with implementing a regular departmental morbidity & mortality (M&M) conference. The first M&M conference was co-presented in May 2022 by the Critical Care Anesthesia Division and Multispeciality Division. Divisions will continue to choose cases to be presented monthly at Grand Rounds lecture sessions.
The department submitted four joint projects to the Improvement Capability Development Program (ICDP), which gives 3 percent of clinical revenue back to the department, if successful in reaching its objectives. Ashley Peterson, MD, led a project on perioperative patient glucose optimization with cardiothoracic surgery with hopes to scale to the Multispeciality Division. Anil Panigrahi, MD, PhD, co-led a project on reducing crossmatch-totransfusion ratios with transfusion medicine. Cedar Fowler, MD, PhD, was the anesthesiology lead on a project to implement an enhanced recovery after surgery pathway for hyperthermic intraoperative peritoneal chemotherapy (HIPEC) patients at Stanford. Cliff Schmiesing, MD, will continue a joint project next year implementing frailty screening with vascular surgery. The department had three active projects in the Cost Savings Reduction Program over the past year and also participated in the Value Based Care program, which are all incentive opportunities offered by Stanford Health Care.
The QEP committee is focusing its efforts on implementing a vision to quantitatively measure the care our anesthesiologists provide and emphasize data to drive decisions and enhance patient outcomes. We will continue to prioritize projects with our department partners in environmental sustainability, wellness and health equity.
Special thanks and congratulations to the outgoing Vice Chair for Quality, Safety, and Improvement, Amy Lu, MPH, MD, who was recruited as the new Chief Quality Officer for University of California, San Francisco Health.
~ Michelle Arteaga, MS, Process Improvement SpecialistThe Stanford Anesthesia Division of Global Health Equity (SA-GHE) has continued to expand, with
increased outreach to learners across the globe and increased engagement of Stanford faculty, fellows and residents. Much of the work has continued online, given the ongoing COVID-19 pandemic. The division quickly realized that virtualbased innovation is necessary to reach providers and health systems in need.
Ana Crawford, MD, launched an online learning platform, the Global Anesthesia and Critical Care Learning Resource Center (LRC), to share information on the COVID-19 virus and clinical knowledge on how to save patients. Alongside partners at Assist International, Crawford created an interactive and locally relevant telementoring and blended learning program called the Oxygen Series. Covered topics included infection prevention and control, critical case management, and equipment maintenance and repair. The 18 months of live, interactive, case-based discussions allowed SA-GHE to prepare frontline health care workers to face the pandemic, armed with knowledge to protect themselves while effectively caring for their patients. The Oxygen Series is now being taught by 10 additional hubs, led locally across Africa and Latin America. To date, the program has reached over 9,000 learners from 145 countries. The LRC has also been used to help with critical care capacity building at Pine Ridge Native American reservation in South Dakota to prepare for a COVID-19 surge. Crawford received the Kevin Malott Humanitarian Service Award for this work in 2021.
Residents from our Global Anesthesia Pathway continue to collaborate with our partner site in Hue, Vietnam, at the Hue University of Medicine and Pharmacy (HUMP). For the second year, we held a twoweek virtual teaching elective. Sara Strowd, MD, along with residents Helen Heymann, MD, (CA-2) and Sean Miller, MD, (CA-3), engaged in a diverse curriculum that included interactive lectures, journal clubs, 3D virtual OR walkthroughs, oral board preparation, simulation, and question and answer sessions. The majority of respondents at our partner site reported that these rotations are as helpful as in-person. In the future, they would prefer both in-person and virtual teaching. Next year, the virtual Vietnam elective will continue to run with pathway residents.
For the past two years, SA-GHE has partnered with a nonprofit hospital in Karatu, Tanzania, the Foundation for African Medicine and Education (FAME), for remote regional anesthesia workshops. Cynthia Khoo, MD, along with regional anesthesia fellow Erica
Gee, MD, and senior residents Kelly Foster, MD, and Rudy Davis, MD, taught a six-week curriculum. With remote guidance, the FAME nurse anesthetists practiced ultrasound image acquisition and optimization on a local volunteer and practiced needle visualization on a ballistic gel simulation phantom. The nurse anesthetists have shown significant improvement in their knowledge and skills and were able to start applying those skills in performing transversus abdominis plane blocks for exploratory laparotomy and cesarean section patients. Gee presented the study results at the American Society of Regional Anesthesia and Pain Medicine meeting and Foster presented the residents’ experience at the California Society of Anesthesiologists meeting. Khoo has received the 2022 McCormick and Gabilan Faculty Award to enhance maternal pain management at FAME. In the upcoming year, four residents will be teaching regional and obstetric anesthesia topics.
Our Global Anesthesia Pathway, co-directed by Strowd and Michelle Arteaga, MS, has continued to engage residents in our mission of improving surgical outcomes both at home and worldwide. We currently have 26 residents enrolled, with three residents graduating this year: CA-3s Aya Abou-Nasr, MD, Kelly Foster, MD, and Rudy Davis, MD. The lecture series included topics in obstetric anesthesia and regional anesthesia, critical care, a journal club exchange with Vanderbilt’s global health program, and anesthesia in Vietnam, as well as a guest lecture from Rahel Nardos, MD, MCR, Director of Global Women’s Health at the University of Minnesota. Residents participated in the remote virtual electives in Tanzania and Vietnam, with the plan to return to Rwanda in person in the fall of 2022. We plan to expand our monthly lecture series to fellows as well as attendings this upcoming year.
After a three-year hiatus, we will resume the Stanford Global Scholars bidirectional exchange program, in which two early career faculty from a partner LMIC will apply for a five-week observational program at Stanford. The program will include observing dynamic aspects of anesthesia care, participating in lectures and attending the American Society of Anesthesiologists meeting in San Francisco. Many department members have enjoyed hosting Global Scholars in previous years. If you are interested in hosting a participant, please email Ana Crawford at anacrawford@stanford. edu or Sara Strowd at srmiller@ stanford.edu. For more information
or to make a donation to these programs, visit https://med.stanford. edu/globalanesthesia.html.
~Michelle Arteaga, MS, Process Improvement Specialist, Quality and Division of Global Equity Stanford Medicine Outpatient Surgery CenterAs with all other surgical sites, the COVID-19 pandemic has had a big impact on our operations and accomplishments. We were closed for elective cases from March 17 to April 27. During that time, we did about 125 Tier 2 urgent and emergent cases, such as fractures and nerve damage that could not wait 30 days for surgical intervention. We now have about 90+% of our pre-COVID surgical volume.
Our four new bays and third nursing station for the pre-surgical/ post-anesthesia care unit area have been completed and are ready to open, but we are still waiting for the California Department of Public Health to inspect and approve these additions.
We have had a 60% increase in registered nurse certification in the Pre/PAC area.There are currently five registered nurses on the clinical ladder.
Our outpatient surgery center staff are actively involved in shared leadership in MAGNET. Next year is the Outpatient Surgery Center (OSC)’s MAGNET recertification.
OSC is currently doing total ankle and total shoulder joint replacements, and peripheral neurosurgery and ear, nose and throat (ENT) have been successfully added to our schedule. We will be adding gynecology and expanding ENT. Our new orthopedic surgeons include: Jonah Mullens, MD; Brady Evans, MD, MBA; Joseph Donahue, MD; Seth Sherman, MD; Michael Freehill, MD, FAOA; and Robert Millard, MD.
Also, OSC has exceeded its Press Ganey Top Box Target in “Likely to Recommend” scores from September 2018, to May 2019.
~David Kaufman, MD, MPH, OSC Anesthesia Medical Director and Clinical Associate ProfessorVA Palo Alto
The 2021-22 academic year saw a return to in-person meetings for us. The Anesthesiology and Perioperative Care Service at the Veterans Affairs (VA) Palo Alto Health Care System held its first strategic planning retreat in years on Veterans Day, Nov. 11. With the COVID-19 pandemic still ongoing, and hospital systems across the
country dealing with supply chain and staffing shortages, the theme of this retreat was “Burning Bright and Not Burning Out.” Staff members of the service from all areas, including physicians, advanced practice nurses, respiratory therapists and administrative personnel, attended this one-day retreat. The service welcomed new pain management Nurse Practitioners Emily Hayes and Lorin Hoover.
Milo Lochbaum, MD, Clinical Director of Anesthesia Services, moderated an interactive discussion focused on the future of anesthesia staffing models in the face of expanded service demands and national labor trends forecasting a growing deficit of anesthesiologists. In small group sessions, Jody Leng, MD, Clarity Coffman, MD, and Kyle Harrison, MD, facilitated conversations with staff members on key topics related to professional fulfillment: practice efficiency, personal resilience and the culture of wellness at work.
The retreat closed with presentations of recent innovations that occurred during the COVID-19 pandemic in each mission area (clinical care, education, scholarship and leadership). Edward Mariano, MD, MAS, FASA , Service Chief, provided background context in terms of national and international trends to show that anesthesiology, pain management, critical care and perioperative medicine practices at VA Palo Alto are truly setting the bar, influencing policy and inspiring similar advances at other institutions within and outside VA.
In other news, Audrey Shafer, MD, was the inaugural recipient of the Leadership and Service Award from the Health Humanities Consortium, an international academic society for those who teach, research or practice health humanities. In collaboration with Professors Tanya Luhrmann, PhD, MPhil, and Laura Wittman. MA, MPhil, PhD, from the anthropology and comparative literature departments, respectively, Shafer submitted a proposal for a medical humanities minor for undergraduates that is under consideration by Stanford University. Shafer began co-editing a new section in Anesthesia & Analgesia with Tom Vetter, MD, titled “The Human Experience,” which has featured work by multiple members and alumni of our department, including Adjoa Boateng, MD, Lynn Ngai Gerber, MD, Hannah Rasmussen, MD, Ana Crawford, MD, Erin Loeliger, MD, PhD, and Jack Kan, MD.
Ed Bertaccini, MD, in conjunction with the MacIver Lab at Stanford; the U.S. Army’s CounterACT Lab, an initiative to
counter chemical weapons; and the Mashour Lab at the University of Michigan, presented the EEG effects of a novel class of anesthetics at the 2022 meetings of the Association of University Anesthesiologists and International Anesthesia Research Society. Bertaccini has initiated collaborations with multiple other labs to examine the effects of novel anesthetic compounds on mitochondria (Stary Lab at Stanford), the GABAaR alpha3 constructs (Pearce Lab at the University of Wisconsin, Madison), zebrafish models of anesthesia (Bedell Lab at the University of Pennsylvania) and in silico Markov state transitions of the GABAaR (Lindahl Lab at the Swedish Royal Institute).
The regional anesthesiology and acute pain medicine (RAAPM) service at VA Palo Alto, in collaboration with orthopaedic surgery, successfully piloted same-day discharge for total joint replacement patients during the COVID-19 pandemic — a first for a VA hospital. This effort required multidisciplinary coordination, including social work, physical and occupational therapy, pharmacy, and others to ensure that eligible patients could successfully follow this new pathway and avoid hospitalization. It was led by Jody Leng, MD, Director of RAAPM, and RAAPM and transitional pain service (TPS) nurse practitioner Tobi Hunter. VA Palo Alto was awarded funding from VA to expand transitional pain services under the leadership of Kyle Harrison, MD, Director of the TPS, and Hunter.
Leng was appointed Program Director of the Stanford RAAPM fellowship, one of the premier training programs in this subspecialty in the world, and was promoted to Clinical Associate Professor. In other appointments and promotions news, Clarity Coffman, MD, was promoted to Clinical Assistant Professor, and Amy Ye, MD, MPH, was appointed Clinical Assistant Professor.
Mariano was appointed Senior Vice Chair for Clinical Operations and Value in the department of anesthesiology, perioperative and pain medicine at Stanford and began his one-year term as president of the California Society of Anesthesiologists.
Two new anesthesiologists joined the VA Palo Alto team during the 2021-22 academic year: David Asseff, MD, a cardiothoracic anesthesiologist and Navy veteran, and Ehren Nelson, MD, a pain medicine specialist and simulationbased educator. VA Palo Alto also celebrated the well-deserved retirements of Larry Siegel, MD, and John Pollard, MD, after decades of loyal service to veterans who havebeen patients.
~Ed Mariano, MD, MSA, FASA, Chief, Anesthesiology and Perioperative Service, VA Palo Alto, Senior Vice Chair of Clinical Operations and Value, and Professor
Continued on page 34
Hometown: Ingleburn, New South Wales, Australia Medical School: University of California, Los Angeles
Status: CA-1
Why did you choose Stanford for your residency?
It was important to me to find a place where I could see myself happy at work, after work, and ultimately after residency. It goes without saying that Stanford’s diversity of opportunities and experiences would prepare me to provide the best care possible for my patients after residency. Also, I couldn’t argue with being in NorCal. Therefore, meeting the residents and faculty at Stanford solidified my choice. I have been surrounded by the most kind, intelligent people that both challenge and support me every day. I have become a better person and physician because of them.
What do you do in your free time?
I love a good adventure, whether it’s looking for the next best dessert spot or inadvertently hiking 10 miles up a mountain, I’m there.
What advice would you give those applying for residency?
Be kind to yourself.
What made you choose anesthesiology as a career?
I was so lucky to have early exposure to the field in my first year of medical school at an airway workshop. There was this intangible feeling that I had found my people. Add the real-time physiology, procedural dexterity, breadth of patient acuity and complexity, and sense of community in a crisis … I couldn’t see myself choosing any another specialty. SA
Stanford Children’s Health’s Pediatric Rehabilitation Program provides children broken down by chronic pain physical and emotional healing.
BY SONYA COLLINS PHOTOS BY KRIS CHENGIt’s a parent’s worst nightmare: their child is in excruciating pain and there’s nothing they can do.
That’s what it was like for Hillary Goddard and Rene Caissie, the parents of eight-year-old Stella. X-rays, MRIs and physical exams said that there was nothing wrong with Stella, but her parents knew that wasn’t true.
She was in so much pain, she could no longer walk. She couldn’t go to school anymore. Nights, she wouldn’t sleep. She’d just lay in bed and scream.
“We couldn’t put socks, shoes, or pants on her. Even the breeze, a blade of grass, anything at all would make it feel like her leg was on fire,” says Goddard.
I GOT MY CRUTCHES AND HANDED THEM [TO MY PARENTS] BEHIND ME, AND I STARTED WALKING. AND IT DIDN’T HURT,” STELLA SAYS. “I FELT VERY, VERY, REALLY HAPPY.”
The pain might have started with a fumbled dismount off the uneven bars in gymnastics in September 2021. Stella ever so slightly hyperextended her left knee on the landing. But it didn’t seem like a big deal, and her parents weren’t concerned at first.
Around that same time, Stella got a jellyfish sting on left foot. Her parents wonder whether that was what led to the insufferable pain. Within a day of the sting, Stella lost all the skin on the bottom of her foot. Still, even a severe jellyfish sting should heal in a couple of weeks.
But after these two seemingly minor incidents, Stella’s pain only escalated. First, she couldn’t bend her left knee. Then she was limping. Then she couldn’t put any weight on the leg at all. Within a week of the sting and the dismount, Stella needed crutches to walk. The pain only got worse from there. Soon, she couldn’t bear for the leg to be touched. That’s when the then-second grader stopped sleeping and going to school.
When multiple visits to urgent care led nowhere, and scans shed no light on the source of the pain, Stella’s
~ STELLA
father, Rene Caissie, MSc, MD, a maxillofacial surgeon and a graduate student in business at Stanford, started to search for answers on his own. He suspected the problem was neurological.
“The pain seemed to be following a single dermatome,” he says of an area of skin in which sensory nerves derive from a single spinal nerve root.
Caissie began asking physician colleagues at Stanford for advice. That led him to Kevin Shea, MD, a pediatric orthopedic surgeon at Lucile Packard Children’s Hospital. When they met with him, Caissie and Goddard felt for the first time that a doctor was taking their daughter’s pain seriously. Shea recommended an emergency MRI, which ruled out brain and spinal tumors and any other central nervous system problem.
Shea then had Stella admitted to the hospital. During the next week, the little girl underwent psychiatric evaluation to rule out conversion disorder — a mental health condition in which neurological problems arise with no medical explanation. She was screened for Lyme disease, cancer and potential orthopedic causes. Finally, a pain specialist took the temperature of each of Stella’s legs. The affected leg was seven degrees cooler than the other — a hallmark of complex regional pain syndrome (CRPS).
In CRPS, a should-be minor injury, like a jellyfish sting or an awkward landing in gymnastics class, can trigger severe, uncontrollable pain, usually in a limb, until eventually the person can’t bear to be touched there. It typically arises from a malfunction in nerve fibers that carry pain messages to the brain. The fibers send an urgent message regarding a minor issue.
If left untreated, the pain can become debilitating. When people experience the level of pain that comes with CRPS, the natural response is to immobilize and stop using the limb, as Stella did. She started walking on crutches. But when a person such as Stella stops using or putting weight on a limb that is already hypersensitive to touch, that exacerbates the problem. Unfortunately, this is the course of the condition for many people as it can take years to get a diagnosis and treatment. One study found it took an average of four years from symptom onset to diagnosis of CRPS. Stella was fortunate — she got her diagnosis within weeks of her first symptoms.
“We were so lucky to get a diagnosis. Most physicians wouldn’t even know what CRPS is,” Caissie says. “Some kids don’t make it through with this disease. It’s so rare that nobody believes them, and the pain is so severe that they take their lives.”
Though it’s common for adults, and even clinicians, not to believe children with severe, chronic pain
from CRPS, the condition comes with distinct, quantifiable symptoms that must be present in order for a physician to make a diagnosis. They include hypersensitivity to touch, asymmetry in the temperature or skin color of the affected and unaffected limbs, sweating or swelling in the affected limb and decreased function or skin or nail changes in the limb. Stella had all of these symptoms.
Once Stella was diagnosed, she was referred to Stanford Children’s Health Pediatric Rehabilitation Program (PReP), an intensive, interdisciplinary outpatient program for children with chronic pain. Kids often spend months on a waiting list and then travel from all over the world to enroll in PReP, one of very few programs like it.
Stella was lucky enough to live on Stanford’s campus and get a slot in the program not long after her diagnosis.
The full-time, outpatient program requires patients’ and parents’ participation Monday through Friday for nearly 40 hours per week for up to 12 weeks. It doesn’t typically interfere with school as most children have already withdrawn from school because of their pain.
The interdisciplinary care team includes physical and occupational therapists, anesthesiologists and a nurse practitioner who manage medications, and pediatric psychologists. “We are not a multidisciplinary program that refers
children out for physical therapy, psychotherapy, and so forth. This is an interdisciplinary treatment plan where those resources come together as one team to help a child rehabilitate,” said Anya Griffin, PhD, a pediatric psychologist and Director of PReP.
In PReP’s approach, intensive physical therapy is the foundation of treatment, and pain medication and psychotherapy help make physical therapy possible. Without this supportive care, physical therapy would be far too painful, but it’s the only way to reduce the pain and restore function in the limb.
“You have to desensitize, remobilize and reactivate the limb,” says Elliot Krane, MD, an anesthesiologist and founder of PReP. “But that’s too traumatic for most people with CRPS, particularly children. That’s why medication management and psychotherapy are so important.”
Stella was hospitalized for a week-long infusion of ketamine, an anesthetic intended to reduce her symptoms enough so that she could start the hard work that lay ahead.
“Ketamine works brilliantly for CRPS,” Krane says. “I’m not sure if it’s the psychiatric effect or the analgesic effect, or a combination of the two, but it works.” Ketamine can not only ease pain and lift depression, but studies show that it may also make people more receptive to psychotherapy that might not have helped before.
Stella’s care team also used medication to get her sleep back on track at the start of the program.
“The sleep medication was a huge thing for her,” Goddard says. “Until then, she didn’t sleep. She just screamed in pain all night.”
Indeed, many children in PReP often need heavy pain medication and sleep aids simply to enable them to start the rigorous program. Many come to the program in wheelchairs. They are often depressed and have endured months of sleeplessness as well as skepticism and ridicule from others.
“You can’t sleep when your foot is on fire,” Krane says. “The way to break somebody emotionally is to deprive them of sleep. It breaks your resilience down to nothing, so all of us work together to put the pieces back together and make the child whole again.”
Once her pain was under better control and her sleep was improved, Stella was ready for the long road ahead. And, like other children in the program, she had to learn to tolerate even the softest touch again.
“We go through desensitization exercises, where we start with a firm touch with a soft cloth and work our way up to, say, terry cloth, then burlap, then rubbing the limb with jeans,” Griffin explains.
Gradually, patients work toward putting weight on the limb or allowing a foot or leg to touch the floor. For Stella, even imagining this caused intolerable pain. “In one exercise,” Goddard recalls, “we had to put stickers on the ground. She just had to walk over the stickers with her crutches while she imagined touching the stickers with her foot and it was very hard for her, very painful, but she did it.”
Pushing through distress is critical to children’s success in the intensive treatment program.
Often children need distraction just to learn that they can bear to even touch the affected limb. PReP offers several forms of therapeutic distraction. For some kids, virtual reality does the trick.
But for Stella, it was after meeting a horse named Honey that she turned a corner. PReP patients work with horses at the National Center for Equine Facilitated Therapy (NCEFT). The horses provide the children with physical and emotional support. There’s one condition though: Kids must wear closed-toe shoes to get on a horse.
It took one month of therapy before Stella could bear to wear shoes. Then she was ready to meet the horses.
Through equine therapy, children who haven’t walked for months or more can begin to rebuild their core
strength while sitting atop a horse. At the same time, they commune with a gentle but powerful animal that doesn’t judge or push them. “It builds a huge amount of confidence,” Griffin says, “and a connection with the horse. The horse is a therapist, too.”
Stella was enamored when she met Honey, her therapy horse. “She just had an amazing connection with this horse,” Caissie says.
Just to sit on Honey, Stella had to put pressure on her left leg. She also had to put weight on her left foot to get it into the stirrup. But to be with Honey once per week, it was all worth it. She pushed through the pain.
But about five or six weeks into her treatment, Stella hit a wall. The pain and the emotional distress of daily, intensive physical therapy were too much and her pain was once again unbearable. It didn’t help that in the few hours each week that she attended school, she was bullied by her classmates while her school looked the other way. Stella was now back in the hospital for a week-long ketamine drip to reduce the pain and stress enough so that she could carry on.
“Emotional distress increases the perception of pain, and I think that’s what was happening with Stella. Ketamine helped us get her over the hump,” Krane says.
One week later, she was back in the program and quite literally back on her horse. Honey gave Stella the motivation she needed to keep working, and she continued to improve.
Taking those first steps
It was the end of November, and Stella had been in PReP for nine weeks with just three to go. Stella and her mom were taking a walk in the courtyard of their apartment building. Though she had made tremendous progress in her recovery, Stella was still on crutches and was still in pain. She hopped along as her parents trailed a few steps behind her.
As she tells it, Stella suddenly felt a great deal of pain in her left leg, and then no pain at all. “I got my crutches and handed them [to my parents] behind me, and I started walking. And it didn’t hurt,” Stella says. “I felt very, very, really happy.”
To Goddard and Caissie, it felt like a miracle. “To moms and dads, it does feel like a miracle, but this is just another day at the office for PReP,” Krane says. “We got Stella early. She was a very resilient kid. And with kids her age, we have a 100 percent success rate. Everything was favorable for her to make a good recovery.”
At that point, Stella hadn’t walked without assistance in nearly three months. She managed to take about 10 steps before she needed a break, as she hadn’t walked in months. But it was still cause for celebration. Neighbors clapped, cheered and yelled from their doors and windows, “She’s walking,” they exclaimed.
From a walk to a trot to a gallop
Stella continued in PReP until the end of last year, for a total of 12 weeks. Though she had begun to walk without crutches, she still felt
pain and had to rebuild the muscles she hadn’t used in so long.
Today, pain free, Stella walks without crutches. But that’s just one of the spoils of PReP. She came out of treatment with a new love of horses and horseback riding.“I think she associates horses with her healing,” Caissie says. “She wants to be an equestrian now.”
Stella, who continues to work through the trauma and distress of CRPS with a psychologist, still has bad days. But when she does, she has a coping mechanism at the ready. “Sometimes, she’ll feel sad. She might wake up in the morning and say, ‘Papa, I don’t feel good,’ and we’ll go to the stables so she can spend some time with the horses,” Caissie says.
PReP has taught Stella how to deal with the emotional distress of having lived with chronic pain. The program also ensures kids know what to do if their CRPS recurs, which happens in up to 30 percent of people. “When patients have a recurrence, now they know what it is,” Krane says. “So, they are able to stay on top of it and turn it around right away.”
Stella isn’t letting fear of pain hold her back. She has moved on from equine therapy to competitive horseback riding. The little girl who, just months ago couldn’t walk, has overcome the pain of swinging her leg over the horse to mount it. She pushes her heels down in the stirrups and puts weight on her leg in order to rise up off the horse while it trots.
She can kick the horse to command it to go, a maneuver that was far too painful for her when
she first got started. “She rides beautifully,” says Amanda Styskal, Stella’s riding instructor at Dawson Grove Farm in Stanford, California.
“She’s moved on from a trot to a canter, which is when the horse runs or gallops.”
Stella has now participated in her first show with her horse, Haribo. As Haribo jumped over fences, Stella demonstrated for spectators and judges all the obstacles that she has overcome.“She wants to be seen as someone who’s made it through,” Caissie says. “She’s really proud of that.” SA
Hometown: Cleveland Medical School: Case Western Reserve University/ Cleveland Clinic
Status: CRNA
What made you want to focus on anesthesia as a nurse?
While my career, which began at the Cleveland Clinic [in Cleveland, Ohio] as an ICU RN, was extremely rewarding, I wanted to continue to learn and challenge myself within the nursing profession. I chose anesthesia after having surgery and being on the other side of the drape as a patient. My anesthesia team was amazing and I still remember my experience with them to this day.
Why Stanford?
I was looking for a small CRNA group within a topnotch teaching hospital when I first interviewed at Stanford. In my subsequent interviews I was impressed to learn that each CRNA team member’s opinion is taken into consideration for important group decisions [made] by their leadership, which is unfortunately not always the case at larger hospitals, and something I truly appreciate here at Stanford.
What do you bring to the role of a CRNA that is unique?
Not many people know this about me: I’m a nationally ranked synchronized team ice skater. I’ve been competing on a synchronized skating team since I was a kid, and continue [to do so] now on an adult team [Tremors
Adult Synchronized Skating Team in San Francisco]. Competitive team sports have taught me how to work in a team environment to achieve a collective goal. I use the team skills that help me find success on the ice and bring them to my team in the OR. Working together with my fellow RNs, anesthesiologists and surgeons is one of the most important elements in keeping our patients safe and in a positive supportive atmosphere.
What words of advice would you give your younger self? Follow your gut and stay true to yourself.
What motivates you every day?
Interactions and connection with my family, the people I work with and the patients we take care of are what motivates me every day. SA
New Chair Brian Bateman, MD, shares his vision for the department going forward.
Last October, Brian Bateman, MD, MSc, joined the department as Chair, taking over from Ronald Pearl, MD, PhD, who served as Chair for over two decades. One of the nation’s foremost experts on obstetric anesthesia and a prolific researcher whose National Institutes of Health-funded research in pharmacoepidemiology in
pregnancy has influenced national health policy, Bateman arrived at Stanford from Brigham and Women’s Hospital. There, he was Chief of the division of obstetric anesthesia and Vice Chair for faculty development in the department of anesthesiology, perioperative and pain Medicine. About one year after being named Chair, he lays out his hopes and plans for building upon the tradition of excellence in Stanford’s anesthesiology, perioperative and pain medicine department.
What do you hope to achieve in your first five years as Chair?
I will feel five years from now like we’ve been very successful if every faculty member can tell you that Stanford is a place where they’re having the kind of career that they
had dreamed of for themselves.… I would also really like to see us grow and strengthen our research enterprise. Continuing the excellence in clinical care and education that already exists and further diversifying the faculty … would round out the things I really want to do in this first five years.
Faculty development has long been an interest of yours. How will you bolster it at Stanford?
My vision is really that every faculty member is able to grow their career and make the impact that they want to have both at Stanford and nationally and internationally, and that we give everyone the tools and the skills to do that. A lot of my focus will be on building out our faculty development programs for every stage of people’s careers, from
when they first start at Stanford and helping them develop a vision for what a career as an academic anesthesiologist might look like, to mid-career faculty who are developing leadership skills, to senior faculty who are transitioning to a phase in their career where they’re actually focused on mentoring and building the careers of others.
How does faculty wellness factor into this?
The wellness of the faculty, that is something that’s top of mind for me. Faculty have come through this period starting with the opening of the new hospital, but then the pandemic. There’s been I think a high degree of demands on the faculty. We really need a period where we focus on people’s wellness
and allow people to rejuvenate a little bit … We’re looking carefully at how clinical work is structured and the supports that we can provide people in order to maximize their wellness.
What opportunities do you see for diversifying the faculty?
I think we’ve made great strides through the efforts of the Anesthesia Diversity Council and other groups in the department, particularly in terms of our trainee recruitment. We had the most diverse residency class that we’ve ever matched in this last cycle. Now as we diversify the residency, we’re starting to be able to recruit graduating residents who are diverse and bring them on to the faculty. But I still think there’s a long way that we have to go … Developing a strategic plan to increase the diversity and the opportunities for diverse people in the department is also a priority for me.
In what ways do you hope to strengthen research within the department?
Research is another area where I think we’re going to have a significant period of expansion. As part of my recruitment to Stanford, the department was allocated additional space for research. We’re looking to a period where we hope to recruit additional researchers and to build out our research infrastructure in a way that allows a broader range of faculty to become engaged in research. Data science is an area of research that’s particularly important to me and I think an area that is accessible to many of our clinical faculty, so that’s an area where I think we’ll grow a lot.
How will the research enterprise go hand in hand with innovation?
Innovation is also something that I want us to focus on increasingly. We are, by both being in Silicon Valley and part of Stanford University, really at the epicenter of technological innovation, and I think there are opportunities to have the department increasingly participate in that and find ways of really defining through our innovations how the field of anesthesia and perioperative and pain medicine is practiced in the future.
How would you sum up your first year as Chair?
I feel just exceptionally fortunate to have been selected for this, and I’m so appreciative of the way people have welcomed me and supported me as I’ve started in this role. I think there’s a huge amount of positive energy in the department. I’m just very excited to help harness that energy in moving the department forward. SA
When he was a young boy, a war propelled Hassan Farhan across continents — from Kuwait to the UK — as his family fled their home country of Kuwait in the wake of the Gulf War.
But it was love that propelled Farhan across continents a second time — from the UK to the US — after he met his future wife, Yasmin, while he was a student at the Imperial College London School of Medicine.
With the goal of eventually settling in California to be near Yasmin’s family, he searched for
positions that would land him on US soil. “I started off with a research fellowship in Boston [Massachusetts General Hospital] so I could do research while applying for residencies,” says Farhan.
Training in the Massachusetts General Hospital/Harvard anesthesiology residency program followed, along with subspecialty training as an ICU fellow at the University of California, San Francisco Medical Center.
Today Farhan is a clinical assistant professor in the multispecialty anesthesia division at Stanford.
Stanford became his ideal landing place, not just because of its location, “Stanford has a lot of programs that support people who are into medical innovation and quality improvement,” says Farhan, who has a growing interest in medical innovation.
He was accepted as a faculty fellow in the university’s 2022-2023 Biodesign Innovation Fellowship. “I’ll be working with a team to develop an idea I have for improving an area of care that I practice in,” he says.
For Farhan, who is in the process of filing a medical patent, that list of ideas to explore is endless. The patent is for a new endotracheal tube device that secretes a numbing medication so that patients are better able to tolerate breathing tubes.
He has other budding ideas that would enable residents to receive specific, real-time feedback during training, and for patients to own their medical data and can determine which researchers and corporations access it.
“That’s what gives me joy at work, making a patient’s quality of care better, and making the actual
working environment for residents and physicians better,” says Farhan. For him, the sky truly is the limit — and Stanford is the perfect place for transforming blue-sky thinking into medical realities. SA
Hometown: Born in Mountain View, California; Raised in Oregon House, California Medical School: Stanford Status: Fellow
What makes Stanford different from your other choices for residency and fellowship?
Some of Stanford’s opportunities to learn pediatric congenital cardiac anesthesia during residency, cutting-edge medical education through simulation and augmented reality, and a growing focus on physician well-being, including training in peer support and debriefing after critical events.
What unique perspective do you bring to your role as an anesthesiologist?
As a child, I was homeschooled in a rural town so much of my education was through real-world experiences. My environment continually provided me with feedback, whether it was learning to anticipate our goats’ movements during milking or seeing how small changes in temperature affected bread leavening. Anesthesiology involves a similarly immersive environment where each patient creates a unique set of conditions that require me to constantly revise my actions based on physiologic feedback. My childhood love of learning from life itself is one reason why I find so much satisfaction in this field.
What words of advice would you go back and give Larissa the intern?
You are enough. You will often feel inadequate to the immensity of this profession, but your worth is not on the line. Focus on progress over perfection; never stop letting your experiences and your patients teach you. You will be stronger for the challenges you face, and you will make it through. Do not be afraid to ask for help — your colleagues will be here for you, and you are never alone.
What two things can you not live without?
Coffee and audiobooks— both keep me alert and happy during my daily commute.
What do you do in your free time?
I love exploring bookstores, picnicking in Mountain View’s beautiful parks, collecting sea glass along the ocean, and going for long walks with my wonderful husband. SA
Anesthesia faculty help shape the early health care education of future doctors. The students’ zest for learning is its own reward.
BY RACHEL B. LEVIN PHOTOS BY KRIS CHENGWhen medical student Tyler Raclin first arrived at the Stanford School of Medicine in 2020, he was eager to pursue research that merged his interests in medicine and computer science.
Browsing faculty profiles, he stumbled upon professor Larry Chu, MS, MD’s page and was immediately drawn to Chu’s many projects investigating technological solutions to improve health care practice. Raclin decided to cold email him.
I’M GLAD THAT I CAN GIVE THESE KIDS THE KIND OF SUPPORT THAT I DIDN’T HAVE.
LARRY CHU, MS, MD
Chu responded quickly and enthusiastically. Soon, he enlisted Raclin to work with him on a research project about incorporating public and patient perspectives into the development of machine-learning algorithms. Raclin was thrilled just to participate and wasn’t expecting what came next: Chu asked Raclin if he’d like to become a co-author on papers he intended to publish on the topic. He explained it would help give Raclin a competitive edge as he approached the next stage of his medical career.
“I could tell he was already ten steps ahead of me and was thinking about what was best for me,” Raclin says.
Over the past two years, Raclin’s relationship with Chu flourished. Chu has helped Raclin hone his research skills and connected him with people and opportunities to develop his interests. Their first paper as co-authors was recently accepted into the Journal of Medical Internet Research. “I think of him as a mentor,” says Raclin.
Chu is among a passionate subset of Stanford anesthesia faculty who devotes their time to shaping
the early health education journeys of future doctors. From serving in mentorship roles to designing forward-thinking curriculum and modeling compassionate practice, these educators are invested in giving students a strong start in a challenging profession. In the process, the enthusiasm and freshness that young scholars bring to the study of medicine serves as its own reward.
“It’s really a boost in energy and my spirit seeing people who are just so excited about health care,” says Chu, who also works with high school and undergraduate pre-medical students in the Stanford Anesthesia Summer Institute (SASI), an internship program he founded. “They remind me of why I’m here and why I do what I do.”
Working with students early in their medical education journeys offers faculty the opportunity to influence the very foundation upon which students build their identities as physicians. The skills and values they master early on can reverberate throughout their entire careers.
“The impact is so profound that you can make,” says clinical
take care of, I want you to think of what you would do if it was them sitting in that chair.”
She doesn’t just tell this to students — she shows them through her own example, even at times she’s not fully aware of it. Recently, one of Murray’s medical students, Brian R. Smith, MS, surprised her by announcing that he had published an essay in Anesthesia & Analgesia about observing Murray while she put a fearful pediatric patient at ease before an induction. From playing along with the patient’s Spider-Man outfit to cheering for his newly lost t, Smith followed Murray’s empathic lead as he assisted her.
The piece brought Murray to tears. “I had no idea he was paying that close of attention to write an article about it,” says Murray, who received two teaching awards from Stanford Medicine this year. “One of the greatest honors you can have is to be able to mentor people and for them to … be inspired by that.”
development of HIV antiretrovirals, and the racist underpinnings of unethical medical experimentation.
“Incorporating that aspect … is really a way for [students] to reflect on their own role in science and medicine,” says Aggarwal. “I’m a firm believer: if you don’t know [the history], you’re going to repeat it.”
Aggarwal enjoys serving as a sounding board for his students as they navigate the contradictions inherent in medicine, find ways to advocate for change, and seek to answer the important question, “How do I reconcile what I want to do with how the real world operates?” he says.
His students have expressed gratitude for his forthright approach in various ways. One memorable student who was biking past Aggarwal in Stanford’s quad stopped to thank him for the way he teaches and the perspective of medicine it gives him. “That was really rewarding to know that this is a passion of mine that does make an impact on people that is more than just reading a textbook or going to lecture,” says Aggarwal.
assistant professor Andrea Murray, MD, who began teaching in Stanford Medicine’s Educators-4-CARE (E4C) program last year. CARE stands for the values of compassion, advocacy, responsibility, and empathy that E4C faculty model and cultivate in medical students through small-group, didactic learning and supportive mentorship.
Prior to training in pediatric anesthesiology and joining the Stanford faculty in 2020, Murray practiced pediatrics and internal medicine at a federally qualified health center in Memphis, Tennessee. Her experiences working with homeless patients, refugees, and individuals from underserved minority groups now inform the perspective she shares with her students.
As Murray broadens students’ awareness of health care disparities, she coaxes them to go the extra mile for their patients. That may mean helping them secure a drug they cannot afford or taking the extra time to have a conversation with them that makes them feel cared for.
“Every single patient, I tell them, you should see [them] as though it’s your family member,” says Murray. “Think of the family member that you love the most, and every patient that you
As students internalize the contours of compassionate practice modeled by faculty like Murray, it can sometimes open the door to a new challenge — the battle between realism and idealism, says clinical assistant professor Anuj Aggarwal, MD, who began teaching in the E4C program this year.
Aggarwal finds that many of his students struggle to balance the way they would like to practice medicine with the limitations they’re confronted with during training. For example, they may want to spend an hour with each patient, but the system only allows for 15 minutes. “They’re learning the culture of medicine, for all its good and bad,” he says.
That’s definitely the case in Aggarwal’s pharmacology course. Serving as the theme lead and course director for pharmacology since 2020, Aggarwal developed a curriculum that draws on his expertise in the history of medicine. While the study of drugs and how they work is typically a very cut-and-dried subject, Aggarwal places pharmacology within a complex sociohistorical context that helps students understand the ecosystem in which new treatments are developed and delivered.
He fosters discussion of some of pharmacology’s darker chapters, including the exclusion of women from drug trials, the impact of LGBTQ politics on the
After completing didactic coursework, students arrive at another crossroads in their health education journeys: entering clerkships. Raclin says taking care of patients full-time is why he’s at Stanford. “[That’s} what I want to do,” says Tyler Raclin on the eve of beginning his first surgery rotation. “But it’s also definitely a little nervewracking … my job isn’t to read a book anymore.”
Clinical associate professor Erin Hennessy, MD, relishes the opportunity to support medical students as they cross the bridge from coursework to hands-on practice. Since 2019, she has served as the course director for the Transitions to Clerkship Capstone Pathophysiology Course, which prepares students to take the plunge.
Hennessey understands how anxious students can be about synthesizing their didactic learning and applying it in real time. She had this in mind when she developed the course’s case-based curriculum, which is modeled after live teaching on rounds and uses actual cases.
She and her co-instructor, nephrology intensivist Pedram Fetahi, MD, share authentic details of what it was like to care for each patient, including the setbacks. “Our ability to be very approachable and real. {That] makes it easier for [students] to connect with what it’s going to be like to be a clinician,” says Hennessey.
She also talks to students about her experiences going on maternity leave and raising young children while developing her career. She believes that being vulnerable about her personal journey allows students to feel less intimidated. “Adding the personal component to it [helps students] realize that the people that they’re going to continue working with and training with are real people … and [are] there to help you make this transition,” she says.
Hennessey, who is also the director for the critical care core clerkship, particularly enjoys having medical students as part of her team once they’ve enrolled in the clerkship. She notes that their inquisitiveness and eagerness to learn keeps her on her toes and makes her job more fun. “I feel like I get as much out of teaching them as they do learning from us,” she says.
Offering a head start
Even as medical students advance to clerkship, the path to becoming a physician can be fraught with uncertainty. While some students enter medical school with a clear vision of the specialty they hope to pursue, others, like Raclin, must juggle the demands
of clerkships with figuring out their future. “You get exposure to all these fields and you have to pick one that you want to do for the rest of your life,” says Raclin. “That’s always in the back of your mind.”
The process can be especially difficult for students who come from underrepresented backgrounds and may not have had much exposure to medicine prior to enrolling in medical school. Chu, who grew up in the Midwest in an immigrant Chinese family, says that was the case for him. He didn’t know anyone inside or outside of his family who worked in health care —nor did he see anyone who looked like him in the medical profession. He says that entering medical school without informative guidance was a leap of faith.
His desire to help young people from underrepresented groups gain early exposure to health care careers motivated him six years ago to found SASI, which is a twoweek summer internship program. Students learn clinical skills such as suturing and intubation and receive mentorship from Stanford medical students and faculty to cultivate career development. For the first time this summer, students
also had the option of completing an additional week of advanced clinical skills practice, in which they provided care for real patients with chronic conditions.
Chu says that building a diverse faculty and a curriculum centered on the value of inclusion has allowed the program to attract students from underrepresented backgrounds. “I’m glad that I can give these kids the kind of support that I didn’t have,” says Chu.
In the summer of 2021, Chu invited Raclin to teach and mentor SASI students. Raclin signed on to run clinical workshops and answer students’ questions about what the journey of a medical student is like.
The flow of mentorship from Chu to Raclin on down to high school and pre-med students is an example of how medical education is inherently cyclical. Today’s trainees are poised to become tomorrow’s educators.
Murray and Aggarwal both cite the impactful mentorship they received during medical school as a core motivation for becoming involved in medical student education. Their hope is to pay that
impact forward. In fact, opening medical students’ field of vision to include future careers in medical education is one of Aggarwal’s goals.
“I think part of my role is to start bringing new trainees into being educators as well, so that we have the next generation of near-peer physician educators,” he says. “At the end of the day, I feel really full from having done this. That’s what I want the medical students to achieve at some point in their own career, however that may be.”
Raclin, for one, is already getting a taste of how satisfying it can be to give back. As he gets his feet wet in medical education through SASI, he envisions one day lending his expertise to medical students as a clinical professor. “I don’t know how you couldn’t want to go and talk to excited medical students about your research and what you’re doing,” says Raclin. “That, to me, seems like a good time.” SA
Stanford’s Intestinal and Multivisceral Transplant Program flourishes through innovation and collaboration
BY RACHEL B. LEVIN PHOTOS BY MARISSA LESHNOVA multivisceral transplant helped auto mechanic Eric Wittnebel resolve complications from Gardner syndrome — and get back in the driver’s seat of his life.
On a hot week in late July, Eric Wittnebel was busy doing what he loves most: auto repair. The project at hand was his 21-year-old son’s 2009 Honda Civic, which needed an engine replacement. A seasoned mechanic, Wittnebel verbally guided Nathan step by step to perform the engine swap. Though the Rancho Cordova resident would have liked to get under the hood himself, he considered it a miracle that he was up and about and spending time with his son at all.
ALL IN ALL, THE EXPERIENCE WAS JUST MIND-BLOWING: SEEING THE THINGS THAT I GOT TO SEE AND … MEETING THESE PEOPLE THAT WERE JUST EXTRAORDINARY..
~ ERIC WITTNEBELJust four months prior, Wittnebel, 51, had undergone multiple-organ transplant surgery at Stanford. Abdominal transplant surgeon Andrew Bonham, MD — working alongside transplant anesthesiologist Harry Lemmens, MD, and a team of fellows, residents, and nurses—replaced Wittnebel’s pancreas, liver, and upper and lower intestines with donated organs.
“It’s not a simple thing, like changing the spark plugs on your car,” says Wittnebel. “This is like a major overhaul.”
Indeed, multivisceral transplant surgery is highly complex. “We were essentially removing everything in his abdomen and replacing it,” says Bonham, who is the director of Stanford’s intestinal and multivisceral transplant program.
It’s rare for Bonham to transplant four organs at once. He says that in an average year, 30 or fewer of these transplants are done across the entire country. Stanford is one of only two programs on the West Coast that performs the procedure, the other being the University of California, Los Angeles (UCLA). In the past fiscal year, just two individuals have had multivisceral transplants at Stanford: Wittnebel and a pediatric patient.
“It’s a risky procedure, so there has to be a very good indication to do this type of case,” says Lemmens, who is one of a group of 12 anesthesiologists specializing in transplant surgeries at Stanford. He cites potential complications from the long duration of the surgery and the significant blood loss involved as two risk factors.
At the same time, “If patients can get through the surgery itself, the outcomes are good,” notes Bonham. “Our three-year survival [rate] exceeds 80 percent.”
Undergoing the transplant was Wittnebel’s best hope for resolving complications from Gardner syndrome, a form of familial adenomatous polyposis which predisposes people to colon cancer and various types of benign and malignant tumors. Prior to the surgery, Wittnebel had developed adenomatous polyps that had grown in his duodenum and into his pancreas, bile duct, and liver, putting him at high risk for cancer in these organs.
Wittnebel knew he might not make it through the surgery. But he chose to think positively about what lay ahead. “I’ve got an attitude of …
‘This is going to be fine. God’s got this. I’m not worried about it. Let’s just get going and get to the next step,’” he says.
A history of illness
Gardner syndrome runs in Wittnebel’s family. His maternal grandfather and mother, who died at 53 from liver cancer that had spread from her colon, both had the syndrome. He knew in childhood that he had it as well.
In 2001, Wittnebel, a member of Kaiser Permanente, had surgery to remove his large intestine in order to cut colon cancer off at the pass. He did well after the surgery and continued to work in his job as a master technician for Chevrolet.
But in 2005, he developed excruciating pain from a desmoid tumor — a noncancerous growth — in his abdomen. Surgeons removed the tumor, along with part of his small intestine, and performed an ileostomy, leaving him with short bowel syndrome and dependent on total parenteral nutrition (TPN). Unable to resume all of his usual activities, he left his job at Chevrolet. The challenges of living with short bowel syndrome prompted Wittnebel to elect another surgery in 2009 that added length to his small intestine. After that, though he
still had the ileostomy, he was able to get off TPN. “I could eat and get nutrients and have some sort of a life at least,” he recalls. He was able to do small automotive jobs, like brake changes.
Then, two years ago, he developed a blockage in his ureter caused by a mass. His doctors at Kaiser inserted a stent to unblock it. But Wittnebel knew something was still wrong. He didn’t feel his usual get-up-and-go.
Ultimately, his doctors discovered the adenomatous polyps that had grown throughout his abdomen. They recommended he have a Whipple procedure, which is a complex operation to remove the head of the pancreas, the first part of the small intestine, the gallbladder, and the bile duct. Wittnebel was informed he could go to Stanford or UCLA to have it done.
Right away, Wittnebel knew what his choice would be: “I said, ‘I’ll go to Stanford.’ Because I had dealt with Stanford. I’ve known them since 1983.” That was the year that his nine-year-old sister, who suffered from cardiomyopathy, began receiving care at Stanford. In 1984, she became Stanford’s first
(continued on page 32)
IT’S A RISKY PROCEDURE, SO THERE HAS TO BE A VERY GOOD INDICATION TO DO THIS TYPE OF CASE.
~HARRY LEMMENS, MD, PROFESSOR OF ANESTHESIOLOGY
RECOVERY from p31
pediatric heart transplant patient. The transplant was a success and gave Lisa 11 more years of life.
Little did Wittnebel know he would become a Stanford transplant patient, too.
After careful deliberation, the Stanford medical team that evaluated Wittnebel concluded that a Whipple procedure was not the right step for him to take. Removing more of his small bowel would have left Wittnebel dependent on TPN again. Plus, the procedure would not have fully cleared the adenomatous polyps that extended up toward the liver. Instead, they proposed transplanting a new pancreas, liver, and large intestine and replacing what was left of his small intestine.
Wittnebel placed his trust in the Stanford faculty’s expertise: “I was like, ‘Okay, put it [all] in. Anything else you want to add while you’re in there?’”
Humor aside, he knew that multiple-organ transplant surgery and the recovery period afterward weren’t going to be a breeze. As someone who loves to be active, Wittnebel says he was more daunted by the imperative to stay off his feet for an extended period after the surgery than the surgery itself. But he was willing to do whatever his doctors said was best.
Once he decided to have the transplant, the difficult task of finding the right donor began. “It’s hard because you need perfect organs — all of them,” explains Bonham. “You can’t take just a liver or just an intestine.” The organs also have to be compatible with the patient in terms of blood type, antibodies, and size. Some patients wait for years for a match.
The Stanford transplant team appealed to the United Network for Organ Sharing, the organization responsible for national organ allocation policy, to bump Wittnebel to a higher position on the waitlist due to his cancer risk. The appeal was accepted. Within about a month and a half, Wittnebel had a donor.
On March 29, the day of Wittnebel’s transplant surgery, Lemmens was on call. He and Wittnebel talked at length before Lemmens induced him. “We spoke about the risks and what he had to expect,” he says. As Bonham was procuring the organs, his colleague Carlos Esquivel, MD, PhD, began the case at 4:00pm.
The surgical team expected a certain degree of blood loss to occur from dissection of the organs.
They also anticipated that removing Wittnebel’s liver would result in coagulopathy — an impairment in the blood’s ability to clot — which can often exacerbate blood loss.
But they were caught off guard when Wittnebel’s stomach began bleeding profusely. Lemmens notes that stomach bleeds are uncommon in a surgery of this type. But Wittnebel had stomach polyps and portal hypertension that made the lining of his stomach prone to bleeding. The team spent several hours stitching up various areas of his stomach lining to get the bleeding to stop. Wittnebel ended up losing a staggering amount of blood—about 40 liters in total.
Lemmens’ experience with complex cases was crucial in managing the blood loss.
“Anesthesia during this time had to maintain [Wittnebel], giving blood and blood products and clotting factors,” says Bonham. “Harry [Lemmens] has done a lot of these particularly difficult cases with us … He’s aware of what can happen and he is able to stay on top of it.”
“Teamwork is important,” adds Lemmens, who mobilized nurses and the blood bank to keep up with transfusion requirements. Once the bleeding was under control, the surgery proceeded without incident.
At 7:00am the morning after the surgery had begun, clinical associate professor Aileen Adriano, MD, another member of Stanford’s transplant anesthesiology group, relieved Lemmens — who’d been at Wittnebel’s side for 15 hours — and stayed on until the 20-hour surgery was successfully completed at noon.
Bumps in the road
Wittnebel now had a new set of abdominal organs, but — to use an automotive analogy — his “hood” wasn’t fully shut. “Once we put the organs in, we didn’t have enough abdominal wall to get him closed,” says Bonham. “For a period of time, he essentially had an open abdomen with a special dressing covering everything.”
Soon, Wittnebel was back on the operating table. Plastic surgeons reconstructed his abdominal wall with a piece of tissue, about the size of a large cellphone, taken from his thigh. Though the graft was a success, the leg wound became infected, prompting another surgery. Wittnebel also developed a blood clot in his lung that required intervention. Lemmens continued to provide anesthesia care during these procedures.
Wittnebel had expected to be in the hospital for a month after the surgery. But because of the complications with his lung and leg, his stay stretched into more
HARRY [LEMMENS] HAS DONE A LOT OF THESE PARTICULARY DIFFICULT CASES WITH US ... HE’S AWARE OF WHAT CAN HAPPEN AND HE IS ABLE TO STAY ON TOP OF IT.~ANDREW BONHAM, MD, ASSOCIATE PROFESSOR OF SURGERY
than two months. Even though the hospital staff treated him like a VIP, he says, he longed to go home. Still, he kept looking on the bright side. “After seeing what my mom went through with all her surgeries and stuff, I was like, ‘This ain’t nothing. Just keep going,’” he told himself. Bonham calls Wittnebel a remarkable patient. “He’s got incredible stamina … and has an incredible attitude,” Bonham says. “That’s been part of what got him through it.”
On June 18, Wittnebel returned home to his wife, Tracy, and his Great Dane, Roscoe. The next day, he was able to celebrate Father’s Day with Nathan. “It felt so great to get home,” he says. “Nothing beats being home.”
Because of the soreness and tightness in his leg from the graft, it’s taken him some time to get steady on his feet. But Wittnebel has been motivated to move around as much as possible. “Every day I do something more than I could do the day before,” he says.
He runs errands with Tracy. He attends church on Sundays. These
are “little things,” he says, “but it’s a big deal to me.”
His prognosis is good. “He’s gotten through all the surgical issues and the complications of that, [and] he hasn’t had a problem since then,” says Bonham. “We haven’t seen him back in the hospital, which is very encouraging.”
To his great delight, Wittnebel is now able to do some light tinkering with automotive projects in his garage. He’s planning to start an automotive ministry at his church where he can teach young people how to work on cars and trucks and help people in need with automotive repair. “I love the look on someone’s face when they find out you fixed their car,” he says.
Though replacing engine parts and internal organs are two radically different enterprises, Lemmens finds a parallel satisfaction from his work in transplant anesthesia. He says that seeing a complicated case such as Wittnebel’s end successfully is one of the most rewarding aspects of his career.
Reflecting on his time at Stanford Medicine, Wittnebel says, “All in all, the experience was just mindblowing: seeing the things that I got
to see and … meeting these people that were just extraordinary.”
He’s exceptionally grateful to Bonham, Lemmens, and the rest of the medical team. “I want them to know I really appreciate what they do,” he says. “They took such great care of me … Everybody was awesome. There’s no other word that can [describe] just how great of a job they did for me.”
“It’s been a long, hard road,” he adds. “But it came out fine.” SA
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The Stanford analgesia and regional anesthesia (SAARA) division has had a big year — continuing its growth trend as a practice and research center in the multispecialty division, ICU, cardiovascular ICU and emergency department. This past year we have performed more than 6,000 peripheral nerve blocks and close to 600 (mostly thoracic) epidurals, with increasing consults for regional anesthesia. In order to meet more demand, we have expanded our team to include nurse practitioners at both the main Stanford campus and Outpatient Surgery Center (OSC) as well as expanding our faculty. We enthusiastically welcome RAAPM 2021 fellow Richard Kim, MD, MSc, in January and graduating fellow Mariam Sarwary, MD, this August.
This year we introduced two new services: preoperative epidural placement and coordination with inpatient Acute Pain Service (APS).
The regional team now assists and places thoracic epidurals, which has greatly improved the efficacy and timeliness of epidural analgesia for large abdominal and thoracic cases. For example, for first-case epidurals, SAARA encourages all providers to place the patients in the regional preop area for both supplies and ultrasound access as well as regional staffing assistance. This process change allows for a better educational experience for the trainees, as time pressure is reduced and we can quickly pivot to an alternative block if unsuccessful with epidural placement.
The second new clinical service is the APS collaboration. The RA attending and fellow now round daily with the APS to improve inpatient acute pain and regional anesthesia care. This process has also generated many consults for the division, particularly for surgical patients struggling with acute pain issues in the hospital, and has allowed us to monitor the postprocedure progress of our block patients.
The division continues its education leadership in RA, acute pain and POCUS with daily lectures, weekly Q/I discussion, monthly journal clubs, workshops (ultrasound scanning and cadaver)
and regular M&Ms. Jan Boublik, MD, is the anesthesia lead for the Stanford-wide POCUS program and ASRA POCUS editorial board member. Cynthia Khoo, MD, PhD, established an innovative online and video training program for global regional anesthesia education — Stanford regional anesthesia is now shared around the world! We are also proud to announce that Khoo recently received a 2022 McCormick and Gablian Faculty Award for her efforts.
The academic mission continued with force this year with independent funding, multiple publications, and a strong presence at national and international conferences. SAARA presence at this year’s Stanford Research dinner includes 16 of the 87 presentations and SAARA faculty received one of the two awards.
We are also delighted to announce our fellows were recognized at this year’s Spring American Society of Regional Anesthesia and Pain Medicine (ASRA) Annual meeting: Mariam Sarwary, MD, with the Best of Meeting Travel Award and Alice Seol, MD, with the President’s Choice Abstract Award. We are also proud to mention that professor Chi-Ho Ban Tsui, MD, was selected for the prestigious Distinguished Service Award in recognition of his outstanding global service to the field.
Coming soon
Our clinical service is expanding to include innovative approaches for treatment of persistent pain, a Botox injections program and the institutional implementation of NR-Fit connectors for neuraxial equipment. While we grow, we seek to attract to envision to attract to Stanford world-class providers to join our team of 18 regional anesthesia faculty to practice, innovate and educate our academic community. In 2022, SAARA continues to thrive for the benefit of our patients, our colleagues, the department and the institution.
~Jean-Louis Horn, MD, Division ChiefThe academic year 2021-2022 was characterized by transitions — new leadership, the return of inperson events and the progression of COVID from acute to chronic as we entered year three of the
pandemic. While Zoom meetings remained a staple of our work lives, the loosening of restrictions allowed us to participate “in real-life” events on the beautiful Stanford campus and surrounding areas.
The importance of protecting health workers’ well-being was highlighted on a national level by our Surgeon General Dr. Vivek Murthy. In his New England Journal of Medicine (NEJM) piece, “Confronting Health Worker Burnout and Well-Being,” Dr. Murthy noted that even prior to the pandemic, health worker distress was a major issue in health care. The stacked challenges over the extended years of COVID, in addition to the prior strains on our system and society, have exacerbated health disparities, systemic racism, and social unrest.
“We need to take care of our health workers and the rising generation of trainees,” Murthy said in the article.
In our own department, wellbeing efforts this past year focused on themes of support, inclu-sion, psychological safety, workplace civility and work-life integration. Physician health advoca-cy and support, community-building events and practice environment improvements were the cornerstone of our integrated approach. Our department participated in the 2022 WellMD Fac-ulty Survey, which evaluated multiple systemic and cultural domains, including burnout, profes-sional fulfillment, turnover intention, workload, mistreatment, the impact of our work on personal relationships, protection and respect, isolation and lactation challenges. A report was generated for each division and allowed for tailored process improvement planning and strate-gic well-being initiatives.
“Culture change must start in our training institutions, where the seeds of well-being can be planted early,” Murthy said in his NEJM piece.
The Peer Support and Resilience in Medicine (PRIME) Program, our departmental residency well-being program, continues under the direction of Co-Director Jody Leng, MD, and Vice Chair of Well-Being and Support Natalya Hasan-Hill, MD,. The program has expanded its talented faculty facilitator group. Alex Ruan, MD, Mastoora Nasiri, MD, and Pat Minot, MD, will facili-tate for this year’s CA-1 class;
Brett Athans, MD, Albert Tsai, MD, Jennifer Lee, MD, and Clarity Coffman, MD, will facilitate for this year’s CA-2 class; Romy Yun, MD, Sarah Stone, MD, Sophie TurkmaniBazzi, MD, and Lena Scotto, MD, will facilitate for this year’s CA-3 class.
The PRIME curriculum continues to evolve. Workshops and didactics led by facilitators this year include:
1. Self-Care and SelfAwareness, Building your Support Network
2. Communication and Conflict Management
3. Addressing Workplace Incivility, facilitated by Clarice Nguyen, MD
4. Suicide Prevention Training—Decreasing Stigma, Encouraging Help-Seeking
5. Peer Support and Self-Compassion
6. Setting Healthy Boundaries
7. Digital Minimalism and Balance
8. Experiencing Mindfulness
9. Finding Purpose and Meaning Through Values Clarification
We are fortunate to have guest lecturers who spoke on the following topics: Daryl Oakes, MD, associate dean, post graduate education and continuing education at the School of Medicine, substance use disorders; Ellile Sultan, MD, flexibility and strength; Clarice Nguyen, MD, upstander training; and Maryam Makoswki, MD, Ph.D., worklife integration and health coaching. We are grateful they contributed their expertise to our program.
The PRIME Scholarship, funded by a philanthropic gift from the family of the late Amy Wang, MD, continues under the direction of Jennifer Lee, MD, and Clarity Coffman, MD. After years of limitations due to COVID, the scholarship was able to support the following projects for 2022-2023:
Arendash, MD. Rupa Patel, MD, and Brett Athans, MD; Community Physical Fitness Clarice Nguyen, MD, and Albert Tsai, MD; Residency Community-Building Events Michael Chavarria, MD, and Shirley Yang, MD, and Dog Playdates, Abby Wang, MD, Derrick Wu, MD, and Brett Athans, MD.
New Parent and Family Support
Candida Goodnough, MD, continues to lead the New Parent and Family Support Program, through which she directs efforts to support lactation, work-life integration and community. We are thrilled to have her join our faculty this autumn.
Family Day
Led by co-founders Tammy Wang, MD, and Elena Brandford, MD, Family Day 2022 was a wonderful celebration of family, spring weather and the best of medical technology and equip-ment. Held in the beautiful Center for Academic Medicine (CAM) atrium, over 25 faculty and resident volunteers and 100 participants gathered at outdoor interactive stations, including ones for airway, ultrasound, virtual reality, OB, pain and CPR.
Anesthesia Critical Events Peer Support Program
Ninety percent of practicing anesthesiologists will experience at least one perioperative death or serious adverse event over the course of their career. Most people have feelings of guilt, sadness or anger that persist greater than one week. Many will have symptoms that last weeks, months or longer.
The Anesthesia Critical Events
Peer Support Program, co-directed by Alex Ruan, MD, and Natalya Hasan-Hill, MD, offers members of the Department of Anesthesi-ology, Perioperative and Pain Medicine support from a trained colleague (peer) after a chal-lenging clinical event and connects individuals with additional resources as necessary.
Morana Lasic, Associate Program Director at Brigham and Women’s Hospital in Boston, and Medical Director of Peer Support for her institution, led two trainings for our department in 2022. The trainings focused on peer support as an essential component of cultural change. Peer support represents an organizational shift away from a culture of silence toward one of sharing and acceptance, away from
Sami’s Hometown: Park City, Utah
Joe’s Hometown: Duluth, Minnesota
Their Medical School: Medical College of Wisconsin
Their Status: CA-3
Joe, What’s your version of how you two met?
We met on the second day of orientation at medical school. We were both running late with our roommates and crossed paths in the parking lot. I thought she was a total stunner! And as we got to talking more, her personality proved to be the clincher. We first connected over games of ping pong in the rec room at our medical school – nothing like a little conversation and competition to get to know one another!
Sami, who picked anesthesia first?
One hundred percent me!
Joe was the type of medical student who loved every specialty rotation, so he had a much more difficult time discerning his path. I, on the other hand, didn’t much enjoy any rotation until I reached anesthesia and knew that it was the right fit for me when I witnessed my first cardiac case.
Joe, who is better at intubating?
Tough to say, we’ve never had a “head-to-head” intubation challenge, so to speak. I have a distinct height advantage, but Sami probably has the gentle touch. Let’s call it 50-50
Sami, who cooks more at home after long days?
Mmmm ... this is either tied or Joe wins slightly — he’s the ultimate roommate. We both work hard and pick up the slack for each other doing more “life” chores when one of us is having a tougher week/are on a more time-intensive rotation.
Joe, Who leaves work at work more?
Sami, definitely. I take work home a lot, which is why anesthesia is such a good career choice for me. When your last case finishes or you get relieved, you’re done!
Sami, who is more organized?
Joe, definitely. To summarize: Right now I have 3,159 unread messages in my email inbox. He has one. SA
Green is the new black: that’s the message clinical assistant professor of anesthesiology Praveen Kalra, MD, is driving home at Stanford, where his team recently won the school’s inaugural Sustainability Ambassador Award for a series of green initiatives.
The initiatives are focused on reducing greenhouse gases and operating room waste. By removing the anesthetic drug desflurane from the operating room, Kalra says, his team has reduced the anesthesia carbon footprint by 83%
and generated savings of about $200,000 for the hospital. “This is how green became the new black,” he says. “The practices became greener for the environment and profitable for the hospital without sacrificing on patient care at any level.”
Kalra says he was inspired to pursue green initiatives at Stanford after reading an article that said anesthetic gases can release as many emissions as 1 million cars can. “Anesthetic gasses are greenhouse gasses; they contribute to global warming,” Kalra says, noting that he was surprised by the data and imagined his colleagues would be, too. “ … I felt like this was something that needed to be told so we can definitely change our practices to make them more environmentally friendly and clean and sustainable.”
He started with Grand Rounds on it to increase awareness of the issue, providing education to colleagues. And he didn’t stop with removing desflurane from the OR. His team worked to reduce operating room waste by focusing on recycling initiatives and reusable devices. Instead of discarding the blue wrap sheets used to cover surgical equipment, Kalra’s team found a vendor that can recycle the material into new plastic products. The team also partnered with Stanford environmental services to reduce biohazardous waste, in part through education, by creating an poster about the need to use sustainable practices. The use of reusable pulse oximeters, EKGs and laryngoscopes also cut down on plastic and metallic waste. And “because education is a key element in making changes,” Kalra also got approval to create an elective
ANESTHETIC GASSES ARE GREENHOUSE GASSES; THEY CONTRIBUTE TO GLOBAL WARMING.
two-week green rotation for Stanford residents wishing to work with faculty on sustainability projects. So far, three residents have gone through it, providing positive verbal feedback on the rotation.
Looking forward, Kalra’s team has its sights set on reducing pharmaceutical waste, transitioning away from single-use devices and collaborating with other surgical departments. As projects evolve, Kalra says the goal remains the same: “Making the practices less wasteful, more environmentally sustainable and also profitable for the hospital.” SA
Praveen Kalra, MD p
Students who completed their week with the new Stanford Anesthesia Summer Institute (SASI) Advanced Clinical Experience Internship in July likely won’t forget the simulated pandemic mass casualty event they were tested with on their last day.
BY MARCIA FRELLICK PHOTOS BY KRIS CHENGThe internship is new this year, as is the mass casualty event that featured “zombies.” Building upon the SASI two-week program that has been in existence for at least four years, the one-week Advanced Clinical Experience Internship provides high school and premedical college students continuous exposure to intensive and rigorous skills practice. Participants gain skills in advanced airway techniques such as video-assisted laryngoscopy and fiberoptic intubation. They also listen to lectures in pharmacology and physiology related to perioperative medicine.
The participants are mentored by MedicineX e-Patients and Stanford clinical faculty.
During the inaugural Advanced Clinical Experience Internship, Larry Chu, MD, the program’s director, wanted students to combine the skills they had learned during the week to navigate the simulated experience — it was what sounded at first like an all-too-familiar scenario of a novel virus causing increasing casualties. But to avoid triggering emotions from a too-close-to-home experience, the expected storyline was altered.
Instead of COVID-19 casualties, the “patients,” or course instructors, were dressed as zombies, contracting and spreading “Syndrome Z” in the year 2030.
The students were tasked with creating an emergency response plan that included discovering the humanity of the patients infected — who they are and how they
live — and discovering patterns to show how the disease started and how it spread, then diagnosing and treating it.
They had learned earlier in the week how to interview patients about their health problems and to perform an electrocardiogram (EKG) and some basics on interpretation. They had learned how to intubate, insert an intravenous line and read X-rays.
The students had to resolve a series of cases, including an X-ray that changed over days suggestive of zombie pneumonia, which prompted the students to decide whether intubation was necessary. Another case required suturing up a zombie bite. Another required resuscitating a zombie victim.
Though zombie attacks likely won’t be among the challenges the high school or college premedical students face if they do go into medical careers, the lessons of the exercise, including working in teams, most certainly will.
Chu said he wanted students to walk away from the intensive week feeling that they had skills to make positive changes in health care, something that many providers felt they lost in the pandemic.
“Many of the students have told us that with COVID they have experienced a loss of agency in their education, a loss of agency in their opportunities for internships,” Chu said. “We want them to feel empowered by what they can accomplish in health care in a short
Skills from p39
amount of time so they can feel new energy for pursuing their dreams.”
Jason Lin, 17, a high school student from San Jose, said the “incredibly creative” exercise gave him new motivation in pursuing a medical career. “It was brilliant,” he said.
The patient-first emphasis of the pandemic exercise and of the internship in general, he said, will stick with him.
“It always feels like the health care system was not designed with patients in mind,” he said. “As a result, there’s a disconnect between patients and doctors. The patient is the expert on their own life. That’s personally something I will take away from this when I enter the health ßcare field.” SA
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a culture of expected perfectionism toward an acceptance of our human fallibility, and away from a culture of shame and blame and toward a culture of psychological safety where we can learn from our errors.
Peer supporters at Stanford include: Jeffrey Arendash, MD; Brett Athans, MD; Jason Batten, MD; Vice Chair of Well-Being and Support Natalya Hasan-Hill, MD; Tracey Hong, MD; Joe Hodapp, MD; Sami Hodapp, MD, the School of Medicine’s Associate Dean of Wellness and Student Life Advising Anita Honkanen, MD; Mario Khalil, MD; Joy Le, MD; Cecilia Mogal, MD; Mastoora Na-siri, MD; Meg Quinn, MD; Alex
Ruan, MD; Sajan Shah, MD; Sarah Stone, MD; Mallika Tamboli, MD; Albert Tsai, MD; Sophie TurkmaniBazzi, MD; Ruka Umeh, MD: Vicky Yin, MD; and Justin Yuan, MD.
As we rebuild our organizational culture and prioritize the lessons that the pandemic taught us about well-being, we must prioritize workforce health. Our department is fortunate to have so many compassionate, caring, and resilient members who cultivate a culture of well-being through their work in diversity, equity and inclusion, bioethics, professional development, education, clinical operations, information technology, research, and quality improvement.
“Building a culture of inclusion, equity, and respect is critical for workforce morale,” says Murthy.
~Vice Chair of Well-Being and Support Natalya Hasan-Hill, MD SA
A 2022 program participant practices donning a PAPR as part of a simulated mass casualty incident pandemic exercise under the direction of Larry Chu, MD, Professor of Anesthesiology.
Medicine is a healing profession, but the media portrays physicians as “unwell individuals.” School, undergraduate college, medical school and then residency, followed by a work which might seem endless, all add to stress.
So how are we supposed to heal others? And particularly if the chosen path is pediatric cardiac anesthesia, a focus for me? Work that includes unpredictably long hours, and a noisy and often stressful environment due not only to the complex diseases in the children, but also their emotionally stressed parents, the challenging personalities in this field. In addition, the real and perceived shortage of resources adds to the daily chaos. So why do it at all?
Growing up, I helped take care of younger siblings and enjoyed being the big sister who made things happen. I chose pediatric medicine for a career. A change to anesthesia followed, with additional training in pediatric and cardiac anesthesia, which brought me full circle. My mother pointed out anesthesia seemed unglamorous compared to pediatric medicine. Mum was a Stephen King fan and I told her about “drama in the theatre” where things change on a dime. Perhaps she got it.
Despite the long hours, pediatric cardiac anesthesia is teamwork at its best. It provides continuity of care to form a long-term relationship with the patient and their family. Congenital heart diseases are often complex, leading to multiple trips to the hospital for surgery, catheterization and interventions. Familiarity with not only the child’s physical and emotional needs, but also of their family allows for trusting interactions even in the toughest of
situations. Here, excellence in care is the norm. We are not only an advocate for the anesthetized child, but also are a resource for the child’s medical care even in other facilities. It is a chance to attend their graduation, bar mitzvah and to be called “Doctor Auntie” and be hugged. This is my work life.
Homelife has a way of reminding me of the mundane essentials of life. The family and a pet all need attention when I walk through the door. There’s also that assignment due tomorrow or the project on work-life balance I promised to help with and oh, that gallon of milk I was supposed to pick up. And yes, I signed up for that marathon that is now only a month away; both my mileage, speed work and strength training are off schedule, but I want to place in my age group — so I can get good free swag!
Despite the long hours, the time pressure and the balancing act, I love what I do. Delegating and outsourcing are important words in my vocabulary. I might have been a wonder woman, but the wrinkles are showing. Pediatric cardiac anesthesia, like running a marathon, needs planning, focus and training. I learn something new every
day and I have been doing this for over two decades. The ability to learn “new tricks” from trainees and younger colleagues, work on projects which will never make me a star, but make me a better clinician — it all makes me happy. All of this takes time, but that is life. Work is life — not just the one that gets you a paycheck. It is also the family and friendships and everything else that makes for happiness.
One thing I should have started earlier in life was meditation; not to achieve Buddhahood, but to learn equanimity and patience; both are great qualities when going round in circles is wearing one down. Satisfaction at work leads to an overall harmonious life even when it seems like a BOSU ball, on which one tries to balance oneself, or a tightrope, but striving and getting the right balance — those lead to the eureka moments. They come and go, and I keep striving. I would do it all over again. If you are thinking about it, give it a try — not the tightrope, but pediatric cardiac anesthesia! SA
BY CHANDRA RAMAMOORTHY, MD PHOTO BY KRIS CHENGDr. Jodi Sherman’s career as an internationally recognized researcher in the field of health care sustainability all started with the troubling question as to how to reduce anesthesia waste.
Sherman was an anesthesia resident at Stanford in 2006, where she “was both thrilled to discover how much fun it is to provide anesthesia care, and also how disheartening it is because of all the stuff that we use and waste unnecessarily,” she says.
Now a professor of anesthesiology and epidemiology at Yale, she is also founding director of the Yale Program on Healthcare Environmental Sustainability and medical director at Yale New Haven Health System Center for Sustainable Healthcare. Sherman routinely collaborates with environmental engineers, epidemiologists, toxicologists, health economists and other health care
professionals, as well as sustainability professionals, to tackle the problem of health care sustainability.
But, it was back at Stanford when she realized there was a dearth of information and no information to guide better practice. “I made a pact with myself that I wouldn’t practice anesthesia unless I could also figure out how to do a better job of protecting the environment.”
That pledge has guided her robust career, resulting in funding from the National Sanitation Foundation, the Anesthesia Patient Safety Foundation, the National Institutes of Health, and others to study sustainability in health care, including the environmental and public health impacts of anesthesia alternatives. Although Sherman’s research started within anesthesiology, it’s much broader today, she says.
“Health care is responsible for nearly 5 percent of total global greenhouse gas emissions, and a quarter of that is coming just from the US, even though we only have 4 percent of the population,” she states.
Sherman works across disciplines with environmental engineers, social scientists, and business administrators to change this troubling statistic.
Sherman, who is a member of the Lancet Countdown on Heath and Climate Change, also serves on a working group for the National Academy of Medicine Action Collaborative for Decarbonization of the US Health Sector. She is a leading change agent in research and clinical practice. She encourages anesthesiology residents to have “a very inquisitive nature on how to make things better, and to look not just look for problems, but for solutions.” SA
I MADE A PACT WITH MYSELF THAT I WOULDN’T PRACTICE ANESTHESIA UNLESS I COULD ALSO FIGURE OUT HOW TO DO A BETTER JOB OF PROTECTING THE ENVIRONMENT.