Lori Deitte

Cricoid Pressure Results in Compression of the Postcricoid Hypopharynx: The Esophageal Position Is Irrelevant

BACKGROUND: Sellick described cricoid pressure (CP) as pinching the esophagus between the cricoid ring and the cervical spine. A recent report noted that with the application of CP, the esophagus moved laterally more than 90% of the time, questioning the efficacy of this maneuver. We designed this study to accurately define the anatomy of the Sellick maneuver and to investigate its efficacy. METHODS: Twenty-four nonsedated adult volunteers underwent neck magnetic resonance imaging with and without CP. Measurements were made of the postcricoid hypopharynx, airway compression, and lateral displacement of the cricoid ring during the application of CP. The relevant anatomy was reviewed. RESULTS: The hypopharynx, not the esophagus, is what lies behind the cricoid ring and is compressed by CP. The distal hypopharynx, the portion of the alimentary canal at the cricoid level, was fixed with respect to the cricoid ring and not mobile. With CP, the mean anterioposterior diameter of the hypopharynx was reduced by 35% and the lumen likely obliterated, and this compression was maintained even when the cricoid ring was lateral to the vertebral body. CONCLUSIONS: The location and movement of the esophagus is irrelevant to the efficiency of the Sellick’s maneuver (CP) in regard to prevention of gastric regurgitation into the pharynx. The hypopharynx and cricoid ring move together as an anatomic unit. This relationship is essential to the efficacy and reliability of Sellick’s maneuver. The magnetic resonance images show that compression of the alimentary tract occurs with midline and lateral displacement of the cricoid cartilage relative to the underlying vertebral body.

Challenges and Opportunities in Restructuring Radiology Residencies: The APDR Residency Restructuring Committee Report

Changes to the ABR certification process are imminent, with a core examination after 36 months of training and a certifying examination 15 months after the completion of training replacing the current examination structure for residents entering training in July 2010 and beyond. The Residency Restructuring Committee of the Association of Program Directors in Radiology was developed to analyze the challenges and opportunities of these upcoming changes and provide recommendations to programs. The guidelines included in this article represent a summary of the work of this committee to date.

The Cost of Disruptive and Unprofessional Behaviors in Health Care

RATIONALE AND OBJECTIVES In an era of decreased reimbursements and rising expenses, academic health care systems are seeking alternative sources of funding. We hypothesized that the costs associated with disruptive physician behavior represented a source of potential savings and hence a possible financial stream which could be redirected to support other academic activities. MATERIALS AND METHODS To test this hypothesis, we reviewed costs associated with disruptive behavior in clinical and education settings and estimated their savings in academic health care systems. RESULTS In a 400 bed hospital, the combined costs for disruptive physician behaviors (due to staff turnover, medication errors and procedural errors) exceed

What Is the Preferred Central Venous Pressure Zero Reference for Hepatic Resection

1 million. CONCLUSIONS Reducing disruptive physician behavior in academic health care systems is a potential funding stream with the added benefits of improved patient safety, reduced medical errors and improved medical student/resident education.

Entrustable Professional Activities

BACKGROUND: The common practice of maintaining central venous pressure (CVP) below 5 mm Hg to reduce blood loss during hepatic resection increases the risk of venous air embolism (VAE). We initiated this study after observing that the anteroposterior (AP) diameter of the liver can be much larger than 7 cm, which is the approximate hydrostatic pressure corresponding to a CVP of 5 mm Hg (1 mm Hg = 1.36 cm H2O). The purpose of this study was to characterize the liver AP diameter and thereby describe how this might affect the placement of the CVP transducer to balance the risks of bleeding and VAE. METHODS: We measured the AP liver diameter and its distance from other anatomic sites using consecutive archived chest tomograms with IV contrast from 100 adults. RESULTS: The results of our study demonstrate a large interindividual range in AP liver dimensions (17.9 ± 2.8 cm, range = 12.0–28.5 cm) and standardized anatomic landmarks relative to the portal triad. CONCLUSIONS: The significant variability in AP liver diameter, along with the variability in the liver surgical site, suggests that we rethink the zero reference point for the CVP transducer during hepatic surgeries. By considering the actual hepatic venous pressure itself, rather than the CVP, we can minimize the risks of VAE and hemorrhage. Two methods for zeroing the reference transducer are suggested.

Learning Portfolios in Radiology Residency Education: How Do I Get Started?

RATIONALE AND OBJECTIVES Learner assessment in medical education has undergone tremendous change over the past two decades. During this time frame, the concept of Entrustable Professional Activities (EPAs) was introduced to guide the faculty when making competency-based decisions on the level of supervision required by trainees. EPAs are gaining momentum in medical education as a basis for decisions related to transitioning from residency training to clinical practice. The purpose of this article is twofold: (1) define EPAs for radiology (EPA-R) and (2) illustrate radiology-specific examples of these EPAs. MATERIALS AND METHODS A multi-institutional work group composed of members of the Alliance of Directors and Vice Chairs of Education in Radiology convened at the 2015 Association of University Radiologists annual meeting to discuss radiology EPAs. The EPAs initially developed by the Accreditation Council for Graduate Medical Education (ACGME) Radiology milestone work group and the resultant ACGME Radiology milestones formed the basis for this discussion. RESULTS A total of 10 radiology EPAs and illustrative vignettes were developed to help radiology educators and trainees better understand milestone assessment and how this translates to the necessary skills and responsibilities of practicing radiologists. Examples of EPA mapping to the ACGME subcompetencies and methods of assessment were included. CONCLUSIONS EPAs offer an opportunity to improve our approach to training by increasing our focus on how we provide appropriate supervision to our residents and assess their progress. In this work, through suggested lists and vignettes, we have attempted to establish the framework for further discussion and development of EPA-Rs.

Radiology Resident EducationEntrustable Professional Activities:: Ten Things Radiologists Do

As medical education and continuous professional development shift toward an outcomes-based model, there is increasing focus on the documentation of physician self-assessment and a commitment to lifelong learning. The Accreditation Council for Graduate Medical Education is helping prepare trainees for these changes by increasing the focus of graduate medical education on outcomes through the development of the 6 competencies. As part of this process, the learning portfolio is a new component of the Accreditation Council for Graduate Medical Education radiology residency program requirements. The purpose of this article is to familiarize the reader with the role of portfolios in medical education and to discuss strategies for the implementation of learning portfolios in a residency education program.

The New Residency Curriculum: Professionalism, Patient Safety, and More

RATIONALE AND OBJECTIVES Learner assessment in medical education has undergone tremendous change over the past two decades. During this time frame, the concept of Entrustable Professional Activities (EPAs) was introduced to guide the faculty when making competency-based decisions on the level of supervision required by trainees. EPAs are gaining momentum in medical education as a basis for decisions related to transitioning from residency training to clinical practice. The purpose of this article is twofold: (1) define EPAs for radiology (EPA-R) and (2) illustrate radiology-specific examples of these EPAs. MATERIALS AND METHODS A multi-institutional work group composed of members of the Alliance of Directors and Vice Chairs of Education in Radiology convened at the 2015 Association of University Radiologists annual meeting to discuss radiology EPAs. The EPAs initially developed by the Accreditation Council for Graduate Medical Education (ACGME) Radiology milestone work group and the resultant ACGME Radiology milestones formed the basis for this discussion. RESULTS A total of 10 radiology EPAs and illustrative vignettes were developed to help radiology educators and trainees better understand milestone assessment and how this translates to the necessary skills and responsibilities of practicing radiologists. Examples of EPA mapping to the ACGME subcompetencies and methods of assessment were included. CONCLUSIONS EPAs offer an opportunity to improve our approach to training by increasing our focus on how we provide appropriate supervision to our residents and assess their progress. In this work, through suggested lists and vignettes, we have attempted to establish the framework for further discussion and development of EPA-Rs.

Imaging Artifacts in Echocardiography.

Graduate medical education programs are facing unprecedented challenges. Public expectations for professionalism and patient safety are at an all-time high. A new graduate medical education accreditation system is under way. The author discusses ways to modify the current residency curriculum and assessment tools to include greater emphasis on professionalism and patient safety in the learning environment.

Laparoscopic management of sigmoidorectal intussusception.

Artifacts are frequently encountered during echocardiographic examinations. An understanding of the physics and underlying assumptions of ultrasound processing involved with image generation is important for accurate interpretation of 2D grayscale, spectral Doppler, color flow Doppler, and 3D artifacts and their clinical implications.