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OHSU APOM Grand Rounds May 19, 2014 Angela Kendrick, MD Associate Professor of APOM.

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Presentation on theme: "OHSU APOM Grand Rounds May 19, 2014 Angela Kendrick, MD Associate Professor of APOM."— Presentation transcript:

1 OHSU APOM Grand Rounds May 19, 2014 Angela Kendrick, MD Associate Professor of APOM

2 Why a history talk?  Jeff asked  I have a unique perspective on the department’s history  “Contrary to the quoted aphorism of Santayana, he who forgets the past is often Not necessarily doomed to relive it” – Norman Bergman, MD

3 Learning Objectives 1. Review key developments in science that led to the “discovery” of anesthesia during the 19 th century. 2. 20 th century refinements: equipment - delivery systems inhaled vapors monitoring anesthesia training will be presented as background for understanding 21 st century developments. 3. Oregon’s anesthesia history from Fort Vancouver through Oregon Health & Sciences University will be the context for modeling the historical changes in anesthesia care.

4 Timeline of Anesthesiology Progress in Oregon 1846 1867 1875 Hospitals built in Portland Early 1900s 1919 – post WWI, Marquam Hill 1938 – Dr. Hutton 1948 Dr. Haugen 1950s polio epidemic Halothane 1960s 1970s concept of MAC,bup Dr. Bergman 1980s isoflurane Dr.Steven s 1990s Dr. Kingston rapid growth OHSU 2002 Dr. Kirsch NIH funded scientists

5 Pre Industrial revolution  16 th century development of experimental approach to scientific problems  Robert Boyle: 1650 pressure volume relationship of gases  Robert Hooke: essential requirement for respiration is a constant supply of fresh air  Joseph Black: 1756 Discoverer of carbon dioxide  Cavendish 1766: Described hydrogen  Joseph Priestley :1772-discovered and characterized 10 gases –including oxygen and nitrous oxide

6 Industrial Revolution  1760 (in England) to 1840  Began in England, Scotland spread to US  Opium was the “miracle drug”  TB was a deadly disease with urbanization  Little progress in surgery from dark ages till middle of the 18 th century  Scientific inquiry – Royal Society  Pneumatic Institute ( 1798) ; Watt, Davy, Beddoes  Davy was a self experimenter  Ether Frolics in 1830s

7 Harnessing of steam 1780-1830 Electricity Manufacturing of goods Transportation of goods Urbanization of populations

8 Demonstration of anesthesia  Demonstration of Nitrous oxide for tooth removal – Wells and Colton 1844, “failed demo” at Mass General 1845  1846 – Morton demonstrated effectiveness of ether at Mass General ( 4 times)

9 Rapid transmission of this knowledge : It went viral !  Dr. Bigelow reported it in Nov  Oliver Wendell Holms proposed calling it “anesthesia”  American surgeon demonstrated it in France in Dec  John Snow began administering it in England in Dec, first used in labor analgesia in Jan ( Dr. Simpson)  Chloroform “discovered” in March of 1847- clinical use starts Nov 1847

10 What was going on in the PNW ?  The Oregon Territory encompassed a huge area and was disputed territory between the US and England  Map of territory in 1843

11 Ft Vancouver established in 1825  The chief “factor” was Dr. John McLoughlin  Hudson’s Bay Co sent well trained European doctors out to the fort beginning in 1831  Oregon Trail began in 1841  Treaty of 1846 established Canada –US Boundary

12 First recorded use of anesthesia in Oregon Territory  Forbes Barclay – trained in Edinburgh arrived in 1840 to be the physician at Ft. Vancouver  Decided to become US citizen after 1846  Moved to Oregon City in 1850  Wrote a letter to Oregonian describing his experiences giving chloroform in 1855  “I have used it (chloroform) since 1848 in many capitol and minor operations of surgery and physic and rejoice to have a drug that can alleviate the suffering patient. ”

13 Civil War 1861-1865  Chloroform and ether, used by both armies  Estimated use : 125,000 cases  650,000 injuries  Chloroform more popular: slightly quicker induction 9 min vs 16 min

14 Establishment of PNW Hospitals  1856 – St Joseph’s in Vancouver  1875 ( post US civil war) both St Vincent and Good Samaritan were established in Portland  Interns or nurses gave the anesthetics

15 First Medical School in Oregon  Willamette Medical School – est 1867  Moved to Portland in 1877, then back to Salem in 1895  A competing School : a two year Medical Department of University of Oregon opened in 1887, this is the start of what became OHSU  Description of course in Willamette University catalogue of 1886 “ “A surgical clinic will be given every Saturday by Dr. Bevan : The students will be instructed in the use of anesthetics, surgical appliances, bandaging”

16 Development of anesthesia record  Cushing and Codman were interns together at Mass General in 1895, co-developed the anesthesia record  Cushing also became interested in the measurement of BP after a trip to Europe 1901, he already advocated using a stethoscope to listen to breath sounds and heart tones

17 1905 description from Willamette catalogue  “The subject of anesthesia so often neglected, and yet of vital importance, both to the patient and the surgeon, will be taken up at length and the essential features explained. Members of the senior class will be given an opportunity to administer these agents under competent supervision, thereby by gaining practical experience so necessary to their use.”

18 First Nurse Anesthesia training program  RNs trained at Good Sam nursing school since 1890  Interns passed resolution in 1908-09 “not going to spend internship giving anesthetics”  First school of Nurse Anesthesia in US founded at St. Vincent hospital in 1909- director was Agnes McGee ( graduate RN from Chicago)

19 School for Nurse Anesthetists at St Vincent  Not known how many trained per year in early years  Initial duration of study was 4 months, expanded to one year in 1939  By 1949, 142 students had graduated  School closed in 1956  Much of the anesthesia administered in Oregon was by non specialty trained docs or by RNs through the years prior to WW 2

20 Course description from University of Oregon’s catalogue in 1915  4 students who have been trained in strict asepsis enter the amphitheater with the operating surgeon: two of them assist the operator and take part in the operation, the other two students are stationed at the head of the bed under an expert anesthetist who studies anesthesia with them and instructs them in all methods of administration. While one student is engaged in giving the anesthetic, the other is being taught how to make observations with the sphygmomanometer studying the reaction of the patient to the various operative procedures. 6 hours per week entire 4 th year, Dr. Mackenzie  Dr. Browning is the instructor from 1916-18.

21 WWI 1914-1918  Face mask delivery systems  Nitrous-oxygen- ether popularized  Resuscitation and fluids  Beginning use of endotracheal tubes Eur J Anaesthesiol. 2007 Aug;24(8):649-57. Dr. Guedel served in American Expeditionary Forces in France as an anesthesiologist training orderlies and nurses to administer anesthesia.

22 1919 move to Marquam Hill  50 students in the first class  County Hospital opened in 1923 –state board now requires one year post graduate training  Doernbecher Children’s Hospital in 1926

23 Early version of tram ? 1924 Student Shuttle

24 1930s Development of IV inductions and anesthetic agents  Dr. Lundy at Mayo Clinic  Busy clinic practice;advocate of care team practice  Barbiturates and regional anesthesia  Dr. Ralph Waters at the University of Wisconsin  Advocate of training physician scientists  Barbiturates, inhaled agents, carbon dioxide absorber in circle system

25 Call for data aggregation  From the Mayo clinic in the 1930s  First look at morbidity and mortality in 1954 by Beecher and Todd

26 John Hutton, MD Division Head 1938-1948  Fellowship year at Mayo  Chief of U of O Surgery was Mayo Alum : Tom Joyce, MD  Began anesthesia residency, one resident per year  Restarted Nurse Anesthesia training  Maintained a private practice at Good Sam

27 WW II (1939 Europe, 1941 US entry ---1945 )  Service for Docs and RNs in both Europe and Pacific  Interruption of training to provide war time service  Pentothal, regional, tracheal intubations Anesthesiology. 2001 May;94(5):907-14.  Link to film  https://archive.org/d etails/Nitrousoxide- oxygen- etheranaesthesia3- wellcome

28 1948 Dr. Fred Haugen  Undergrad and medical School at the U of O, internship at Emanuel, anesthesiology Training at Bellvue beginning in 1936  Finished training, went to Philadelphia, established residency training program at Presbyterian Hospital  Recruited back to Oregon in 1948

29 1950s  Expansion of monitoring  EKG in OR  Development of Halothane, clinical use in 1956  Polio epidemic 1952, Denmark led to positive pressure ventilation, US epidemic : Iron lung

30 Heart Surgery 1950s-1960s  Thoracic surgery – TB  Congenital work initially extracardiac BT shunts  Starr co-invents Implantable mechanical valve 1960  First Open heart at OHSU 1957  Hospital South Construction 1955

31 1970s Dr.Norman Bergman  Medical School Oregon 1951,residency Columbia Presbyterian, joined faculty there, then Utah VA for 12 years, recruited to become Chairman of newly created department of anesthesiology ( trained 93 residents here)  Early career : Respiratory Physiology, later career : anesthesia history  Became ASA History Laureate in 2000

32 Vietnam Era 1965-1973  1965 : Bupivicaine developed  Ketamine, more use of “balanced anesthesia” with barbiturate induction, muscle relaxant, ETT, plus narcotic  75% of general anesthetics used ETT in Vietnam  Military increased its training of both MD and CRNA personnel to meet the service demands Concept of continuous resuscitation and rapid evacuation led to marked decreased in mortality in injured servicemen in Viet Nam war

33 1980s Dr. Wendell Stevens  1980 ; isoflurane  Archie Brain in England begins work on Laryngeal Mask – avail UK 1988  First clinical use of pulse oximetry, quickly became a standard as did capnography  Dr. Stevens was born in Iowa  Residency at Iowa, then 12 years at UCSF, back to Iowa as Chair, then to OHSU as chair in 1982  Served as President of ABA 1987-1988

34 Equipment in 1980s VS

35 Additional year of anesthesia training started in 1988, so now internship plus 3 Departmental sub-specialization begun and with advent of statewide trauma system, staff required to stay in house ( 1987)

36 1990s Dr. H.G.G.Kingston  Originally from SA, trained in Liverpool  Returned to SA, cardiac anesthesia  Additional training at Toronto Sick Children Hospital 1980  Came to OHSU first as visitor 1980, but returned in 1982, became chairman in 1993  Clinical expansion  Emphasis on Quality management  Further growth of subspecialty care: Pain Center, Peds, OB and Cardiac  CEI, Free standing DCH

37 Department in 2000

38 Remember it has been done before  Child life : Ice Cream and movies  Trips to radiology

39 Popular in early 20 th century – resurgence in 21 st ?

40 Timeline of Anesthesiology Progress in Oregon 1846 1867 1875 Hospitals built in Portland Early 1900s 1919 – post WWI, Marquam Hill 1938 – Dr. Hutton 1948 Dr. Haugen 1950s polio epidemic Halothane 1960s 1970s concept of MAC,bup Dr. Bergman 1980s isoflurane Dr.Steven s 1990s Dr. Kingston rapid growth OHSU 2002 Dr. Kirsch NIH funded scientists

41 2002 Dr. Jeffrey Kirsch  University of Michigan Medical school, residency and fellowship at Johns Hopkins University Medical center  Joined faculty 1987  Vice Chair of Training and Education  Recruited to expand our academic research mission  Brought significant NIH funding through the research team who came with him including Richard J. Traystman, PhD, Patricia D. Hurn, PhD and joined by Nabil J Alkayed MD, PhD

42 Modern Era of Department  Growth in clinical mission: CHH, KPV  Educational leadership within Department, University and Specialty  Multiple fellowships  Specialized tracks  ICU leadership

43 Critical inventions of late 20 st century  Human Genome Project  Begun in 1990 – declared complete in 2003 Research combining these tools is the next revolution, a critical mass of inventions  Personal computer  1970s  As of 2008, the number of personal computers worldwide in use hit one billion.  Hand held devices

44 Current research prize to invent a hand held Star Trek ‘tricorder”  Qualcomm is offering 10 million dollars  Announced at 2012 Consumer Electronics Show in Las Vegas.

45 Next big discovery Intel collaborationKnight dollars Cardiovascular and Cancer Center OHSU Collaborative Life Sciences Building

46 Software Features Single click buttons Critical system alarms: - Displayed on all screens - E-mailed to key personnel Individual sensor fault reporting Remote locking and unlocking Programmable lighting Detailed maintenance reports Historical room sales and statistics Reports can be exported, E-mailed, or PDF’d Automatic perpetual inventory Windows Network ready Interface TCP IP / RS232 Automatic daily backup to separate hard drive Online manual 24 / 7 in-house technical support Free upgrades OR Equipment for 21 st century OMNICELL ?

47 Nope That was a description of the electronic hotel minibar !

48

49 University of Oregon Department of Medicine - 1887 University of Oregon Medical School - about 1919 University of Oregon Health Sciences Center -1974 Oregon Health Sciences University – 1981 Oregon Health & Science University – 2001

50 References  The History of Anesthesia in Oregon Klein and Kendrick eds 2004  The Genesis of Surgical Anesthesia Norman Bergman WLM 2008  The Wood Library Museum Digital archives  The OHSU History of Medicine Archives  The Wellcome archives


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