Bending the Curve? Implications for Anesthesia - The University of ...

THE DEPARTMENT OF
ANESTHESIOLOGY AT
THE UNIVERSITY OF
TENNESEEE IN
KNOXVILLE
FEATURES
Curve 1
Class of 2011 2
ASAPAC 2
Class of 2013 3
2011 ASA 4
2011 IARS 4
Man Run 5
Awards 6
NAC 7
LIfe 8—11
Research
12
Bagley 12
Teaching 13
Brutane
V O L U M E 1 , I S S U E 3
National Debt
The “cloud of doom” of an an‐
nual federal deficit exceeding $2
trillion per year for the foresee‐
able future has caused the na‐
tion and, hopefully, Congress
and the
Administra‐
tion to take
a hard look
at where
our nation
spends the
taxpayer’s
money. The
primary
areas of
focus re‐
main Social
Security,
Medicare /
Medicaid,
defense /
war spending, and interest pay‐
ments on the national debt.
While it is true that the deficit
could be reduced by limiting
“discretionary spending,” Sut‐
ton’s law remains true to this
day. Willie Sutton, the infamous
bank robber when asked why he
robbed banks stated, "because
that's where the money is". The
funded and under‐funded enti‐
tlement programs such as Medi‐
care and Medicaid on which so
many Americans have come to
depend remain one of the pri‐
mary targets for deficit reduc‐
tion.
Health Care Spending and the
GDP
The United States spends signifi‐
cantly more on health care than
any other industrialized country.
Rising costs are in part due to
consumer demand over the past
decades, which have fueled de‐
velopment of procedures. Treat‐
ment of chronic disease now
consumes 75% of national health
care costs as a result of our aging
population. Administrative
overhead accounts for 7 % of
expenditures. For these and
other reasons, the National
Health Expenditure in 2011 is
expected to be $2.8 trillion dol‐
lars according to the Centers for
Medicare and Medicaid Services
(CMS). As a result, health care
spending has grown from 7 per‐
cent of the Gross Domestic Prod‐
uct (GDP) in 1970 to more than
17 % in 2010. The Office of Man‐
agement and Budget (OMB)
estimated that if current spend‐
ing patterns continue, Medicare
and Medicaid alone would cost
20% of GDP—the current level of
F A L L 2 0 1 1
Bending the Curve? Implications for
Anesthesia
all federal spending combined—by
2050. Insurance premiums have
doubled since 1999 but some 15
percent of individuals remain com‐
pletely uninsured and another 10%
“underinsured” i.e. unable to fully
pay their
insur‐
a n c e
deducti‐
bles and
co‐pays.
If the
under
insured
cannot
pay their
health‐
c a r e
bills, the
hospitals
and pro‐
viders
either
write it off as bad debt or try to
shift the cost to those who can
pay, namely private insurers, the
federal government and the self‐
insured. In turn, commercial insur‐
ance providers are charging higher
premiums to their clients, both
businesses and individuals, to
cover their cost increases. As busi‐
nesses struggle with their em‐
ployee health care costs, they are
shifting a higher percentage of
overall premiums to their workers,
charging higher deductibles. De‐
spite the provisions in the Patient
Protection and Affordable (page 3 )
Care Act (PPACA) which seek to
decrease insurance cost, the aver‐
age cost of a family policy rose 9%
this year (see Page 3)

PAGE 2
“Well…….I’m not sure
that I would have done
that!!!!
Rocuronium-
cyclodextrincom- plex
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Adios Class of 2011
The following residents graduated from the University of Tennessee Department of Anesthesiology
in 2011: Carrie Francisco, Michael Godbold, John Gold, Robert McGee, Brigitte Messenger, and
Wayne Smith. Three of our former residents are practicing anesthesiology in Tennessee, Drs. McIlrath,
Smith and Messenger. Wayne is in private practice in Johnson City while Brigitte has joined
University Anesthesiologists and will be completing a fellowship in Cardiac Anesthesia at Vanderbilt.
Tim joined several of our former residents in private practice at ParkWest in Knoxville. Carrie,
Robert and John returned “home” to Richmond, VA ; Indianapolis, IN and Savannah, GA. Michael
elected to further his education as fellow in Pediatric Anesthesia at Emory University. The Department
of Anesthesiology is very proud of these graduates and their accomplishments!!!!!
Last year the Residents and Faculty of the Department of Anes‐
thesiology of the University of Tennessee set a milestone that
many thought was unreachable, namely 100% participation in
contributions to the ASAPAC. Once again, the Department
reached this goal and was joined by the University of Miami and
the University of Chicago in this accomplishment.

PAGE 3
“Well…….I’m not sure
that I would have done
that!!!!
Rocuronium-
cyclodextrincom- plex
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(from Page 1) exceeding $15,000 ‐‐‐ that's the largest increase
in cost in 6 years.
PPACA
The Patient Protection and Affordable Care Act, (PPACA) was
signed into law by President Obama on March 23, 2010. The
complex law expands coverage with insurance market man‐
dates: beginning in 2014 and bars insurance companies from
denying coverage based on preexisting medical condi‐
tions. The act also requires citizens to purchase federally ap‐
proved insurance or pay a fine, with the goal of maintaining a
financially sustainable risk pool for insurance firms. PPACA
increases affordability through almost $1 trillion in subsidies
over 10 years to fund state‐level health insurance exchanges
and expand Medicaid programs. By 2014, each state will have
created an exchange in which families and employers can pur‐
chase private insurance plans that comply with federal guide‐
lines. The federal government will provide refundable ‘tax
credits’ to families below 400% of the national poverty line.
The Congressional Budget Office estimates that the exchanges
will extend coverage to 24 million Americans. By 2014, indi‐
viduals not eligible for Medicare with incomes below 133 per‐
cent of the poverty level will be eligible for Medicaid, which
will cover another 16 million citizens.
Who Pays for the Expansion?
The PPCA will pay for @ one‐half of this expansion in coverage
through new taxes. An excise tax on high‐cost “Cadillac”
health plans which begins in 2018 is projected to raise $32
billion through 2019. An annual fee on health care providers
will raise $60 billion, and surcharges on individuals earning
over $200,000 annually will raise $210 billion. These and other
taxes are planned to generate $410 billion through 2019. The
rest of the cost is covered by reductions in Medicare reim‐
bursements to care providers, reducing spending by $491 bil‐
lion through 2019. Other pilot programs of unproven success
are also counted on to decrease cost such as investments in
medical information technology and penalties for hospitals
with high readmissions regardless of the cause of readmission
after discharge.
IPAB
The PPCA established an Independent Payment Advisory Board
(IPAB) with the explicit task of reducing the rate of growth in
Medicare without affecting coverage or quality. Under previ‐
ous law, changes to Medicare reimbursement rates were rec‐
Welcome to the Class of 2014
ommended by MedPac but required an Act of
Congress to take effect. Now the IPAB will deter‐
mine reimbursement rates and an Act of Congress
will be needed to overturn the decisions made.
Impact of IPAB & PPACA on Payment of Anesthe‐
sia Services
As documented by the Government Accountability
Office, Medicare payments to anesthesia providers
falls at @ 33 cents to the dollar as opposed to 80
cents to the dollar for other specialties. The perils
to anesthesia providers becomes readily apparent
when the aging population, the expansion of
Medicaid (whose payments to anesthesia provid‐
ers are two‐thirds of the Medicare rate in Tennes‐
see), and payment for the PPCA through reduc‐
tions in Medicare payments to as well as an annual
fee on health care providers are considered. Most
physician specialty groups have voiced opposition
to the Sustainable Growth Rate formula that was
intended to limit the increases in Medicare spend‐
ing. The PPACA wrapped one formula inside the
other, meaning that if for any given year starting in
2014 going forward the rate of Medicare growth is
lower than the SGR cut, then the SGR cut would
apply. In the past, Congress has passed last‐
minute legislation to off‐set the mandated SGR
decreases in provider payments. Remember that
@ ½ of the financing for the PPACA comes in man‐
datory cuts in Medicare payments to providers. If
the cut mandated by the PPACA law under the
IPAB mechanism exceeds the cuts required by the
SGR formula, then this new Independent Board
must recommend cuts to reach the statutorily
stated target to reduce Medicare spending. No
discretion in the PPACA law exists and, even if
Congress were to intervene, our legislative body
must do so during a narrow 60‐day review period.
As a result, most physician groups particularly
anesthesia providers are dedicated to IPAB repeal
and reform.
The Department of Anesthesiology would like to welcome the Class of 2014 who started their residency in July
2011. The members include: Brian Adams (Indiana University School of Medicine), David Dahl (East Tennessee
State University), Mary Ellen Graham (), Melissa House (Indiana University School of Medicine), Benton Pitkanen
(University of Tennessee), Zachary Rose (Wake Forest) and Christopher Strock (University of South
Florida).

Dr. Patteson
PAGE 4
Rocuronium-
cyclodextrincom- plex
Drs. Bustamante & McIlrath
Drs. Messenger & Craft
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Several members of the Department of Anesthesiology
were active participants in the Annual Meeting
of the American Society of Anesthesiology held in
Chicago from October 15—19, 2011. Dr. Kip Robinson
again led two ‘sold-out’ Problem Based Learning
Sessions about the “The Irregular Patient: Atrial
Fibrillation in the Perioperative Setting”. Dr. Russ
Langdon served as an abstract moderator for sessions
in Clinical Neuroscience and Critical Care.
Several residents and faculty were featured in the
Medically Challenging Cases section: “Management
of Unanticipated Airway Obstruction during Bronchoscopy”.
S. K. Patteson ,B. Messenger and N. Doi-
ron; “Common Variable Immunodeficiency Disorder in
a Trauma Patient Undergoing Massive Transfusion”. C.
L. Greene and D. R. Bustamante; ”A Difficult Airway in a
Patient with Moebius Syndrome and Gingiva Hyperplasia”.
M. Kimball and R. Craft; “Critical Intrathoracic
Tracheal Stenosis Treated by Vascular Balloon Dilatation”.
L. M. Pittman, W. Smith and R. Craft; “Urgent
Surgery with Acute Anterior MI on EKG”; S. M. Strevels.
Our Department and state were also well represented
by two of our faculty, Dr. Eric Cox and Dr.
Daniel Bustamante who served in the House of Delegates
of the American Society of Anesthesiologists.
The Department of Anesthesiology was well represented at the 2011 Annual Meeting of the International
Anesthesia Research Society in Vancouver, British Columbia. Drs. Daniel Bustamante and Robert Craft again
served as moderators for several academic sessions as well as the faculty sponsors of resident poster presentations
such as: “Does a Consensus Exist in the Treatment of Peri-Operative Corneal Abrasions?” T. McILrath,
J. Ollis & D. Bustamante; “Acute Encephalopathy in Parturient with TTP/HUS”. N. Dorion, R. Langdon;
“TEG-Guided Massive Transfusion in Trauma Patients”. B. Messenger, R. Craft. “Malignant Hyperthermia in a
Patient with Pre-Existing Fever”. S. Patteson , M. Godbold.

VOLUME 1, ISSUE 3
The Man Run 2011
PAGE 5
55 members of U. T. Anesthesiology participated in the 4 th Annual Man Run 5K to raise awareness for Prostate Cancer. Team
U. T. Anesthesiology “smoked” the team competition in winning first place with a with a combined time of 1:22.04 beating 2nd
place SunTrust by over 21 seconds. Special congratulations are in order for Bob Adam (husband of Lally Lehmann, MD) who
repeated as the Overall Male Open Division winner with a time of 17:10. Lally Lehmann finished in first place in the 25 to 29
age division. A special thanks to David Ratliff for his tireless efforts as the Captain of Team U. T. Anesthesiology and who finished
third in his age division (Older than Dirt) in a time of 24:58 .
Overall winner, Bob Adams, with Lally
Lehmann and Team Captain, Dave Ratliff

PAGE 6
PAT Wins Award
At the annual meeting of the Centricity Perioperative National
User’ Group, GE healthcare named the Department of Anes-
thesiology at the University of Tennessee Medial center a
winner of its 2011 Customer Innovation Award. The award,
which recognizes a customer using GE’s perioperative tools
to impact health outcomes or internal revenue stream in
unique ways, was awarded to the Pre-Admission Testing Component
to Centricity Perioperative Anesthesia in the category
of Clinical Outcomes. Congratulations to Dr.
Craft and Ms. Babis!!!!
You are trying to correlate the amount of intra-operative fluid received
with the later incidence of a surgical site infection (SSI). If you
wanted to compare the mean intra-operative fluid received between
the group of patients that developed a SSI (n = 101) and those that
did not (n = 963), which test would you use if the groups were normally
distributed? Choose the best answer. The answer and explanation
are found on Page 11.
A. Chi-squared test
B. Fisher’s exact test
C. Mann-Whitney U test
D. Student’s t-test
BRUTANE
Sarah Nalle, a CRNA at the University of Tennessee recently received
the “Excellence in Clinical Practice” Award from Sigma Theta Tau
International (Honor Society of Nursing) for her outstanding contributions
for promotion of high quality patient care. Congratulations and
well deserved!!!
Board Review
UTMCK CRNA Honored
Which of the following conditions would probably be present after 24
hours of continued hyperventilation of an otherwise normal patient?
Choose the best answer. The answer and explanation are found on
Page 11.
A. PaCO2 < normal; CSF PCO2 < normal; CSF pH > normal;
CBF < normal
B. PaCO2 < normal; CSF PCO2 < normal; CSF pH > normal;
CBF = normal
C. PaCO2 < normal; CSF PCO2 < normal; CSF pH > normal;
CBF = normal
D. PaCO2 < normal; CSF PCO2 < normal; CSF pH = normal;
CBF = normal
E. PaCO2 = normal; CSF PCO2 = normal; CSF pH = normal;
CBF = normal

PAGE 7
Clinical Instructor of
the Year Award –
Patrick McConville, MD
Professional Excellence
– Catharine
Hatcher & Angela
McAmis
Dr. John C. Preston
Outstanding Graduate
Award - Nell Smith
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CON Class of 2011
Congratulations to the Class of 2011: Eric Atwood, Laura Black, Noelle Carter, Matt Clayton, Catharine
Hatcher, Melissa Kelly, Angela McAmis, Jenny Palk, Allison Sheffey, Nell Smith, Shannon Still, Chad
Tollett, Derrick White and Christy Woods. The Department of Anesthesiology wishes you well in all of
your future endeavors! .
Guatemala Medical Mission
This past January, Noelle Carter, Angela
McAmis and Shannurse
anesthetists 2011
non Still took part as student
during a weeklong medical
mission at the Obras Sociales Hermano
Pedro Hospital and Orphanage in Antigua, Guatemala. The students provided anesthesia care as part
of an anesthesia care team consisting of one anesthesiologist, two CRNAs and our three SRNAs.
These volunteers provided general and monitored anesthesia care for of pediatric and (see page 13)
Class of 2013: Welcome to the New SRNAs!!
The Department of Anesthesiology would like to
welcome the following SRNAs to the University of
Tennessee Medical Center: Crystal Allen. Kaitlyn
Boettcher, Andrea Bonnell. Kathy Foster, Maria
Geswein, Jessica Kimball, Betsy Lee, Laura Long,
Miranda Marsh, Phillip Reagan, Josh Rose, Bethany
Seale, Tyson Summers, Darlyne Teran and
Rachel White.

Caption
describing
picture or
graphic.
PAGE 10
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VOLUME 1, ISSUE 3
PAGE 11

PAGE 12
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Current Research Endeavors (See Page 14)
�� TEG Screening of OBGYN Patients for Thrombotic Risk Jack J. Chavez, MD, Robert
F. Elder, MD and Roger C. Carroll, PhD
�� TEG (Thromboelastograph) Guided Transfusion for Trauma Patients Robert Craft, MD,
Blaine Enderson, MD, Brigitte Messenger, MD, Roger Carroll, PhD
�� Coagulation Profiles Using TEG (thromboelastograph) After Subarachnoid and
Intraparenchymal Hemorrhages Russ Langdon, MD; Roger Carroll, Phd; Robert Craft, MD
�� Bioimpedance for Identification of the Epidural Space Stephen K. Patteson, M.D.;
Michael Doody, MD; Patrick McConville, MD; Matthew Vance, MD; Crystal Greene, MD; Jeff Staack, MD;
Lally Lehman, MD; Mark Murray, MD
�� Measurement of Hemostasis by Thromboelastograph (TEG) during Therapeutic Hypother-
mia After Cardiac Arrest Robert Craft, MD; Russ Langdon, MD; Roger Carroll, PhD, Tina Dudney,
MD; Barry Faust, MD
�� Epidural Fever Associated with Pyrogens Stephen K. Patteson M.D.
�� Use of Ecarin Clotting Time (ECT) to Monitor Dabigatran (Pradaxa) Therapy Using
Thromboelastograph® Roger Carroll, PhD; Robert Craft, MD, Dale Wortham, MD, Stuart Bresee, MD
�� Validation of the RapidTEG MA Compared to Kaolin in Trauma Patients Robert Craft, MD;
J Russ Langdon, MD, Roger Carroll, PhD, Brian Daley, MD
�� An Outcome Comparison of Pacemaker Protocols Robert Craft, MD; N. Misulia
�� Antihypertensive's Effect Upon Intraoperative Blood Pressure Variability Robert Craft,
MD; Jason Buehler, MD
�� PET Investigation of Anesthetic Effects on Progression of Alzheimer’s Disease in
Mice Robert Craft, MD; Cody Rowan, MD
�� Bioimpedance for Identification of the Intraperitoneal Space Stephen K. Patteson M.D.;
Dr. Warren Bagley Memorial Clinical Excellence Award
At the 2011 SRNA Graduation awards ceremony, the Clinical
Excellence Award was presented to Allison Sheffey, the nurse
anesthesia student who, in the opinion of clinical faculty, consistently
demonstrated a superior level of clinical knowledge
and expertise. The award was renamed as a memorial tribute

VOLUME 1, ISSUE 1
Student's t-test is most commonly used to compare the
mean of two, normally distributed populations. The Chisquare
test is typically employed to compare two (or more)
proportions, as is Fisher's exact test. The Mann-Whitney test
is a nonparametric test used to compare the mean of two
populations that are NOT normally distributed.
You are trying to correlate the amount of intraoperative
fluid received with the later incidence of a
surgical site infection (SSI). If you wanted to compare
the mean intra-operative fluid received between the
group of patients that developed a SSI (n = 101) and
those that did not (n = 963), which test would you use
if the groups were normally distributed?
A. Chi-squared test
B. Fisher’s exact test
C. Mann-Whitney U test
D. Student’s t-test
Board Review (See Page 6)
Excellence in Teaching: Don Pearson, MD and Paddy McConville, MD
The graduating anesthesiology residents in the Class of 2010 awarded Dr.
Russ Langdon and Dr. Jack Chavez the coveted “Excellence in Teaching”
Award to the staff anesthesiologist(s) who demonstrates great dedication,
vast knowledge and immense skill in resident education. Our sincere congratulations
to both of them for their tireless efforts!!!
PAGE 13
After 24 hours of continuous hyperventilation, the patient’s
PaCO2 would, by definition, be low. As the blood brain barrier
(BBB) is freely permeable to CO2, the PCO2 of the CSF would also
be low; however, the pH of the CSF would have normalized. This
would result in normal cerebral blood flow, despite continued
hyperventilation.
Which of the following conditions would probably be present
after 24 hours of continued hyperventilation of an otherwise
normal subject?
A. PaCO2 < normal; CSF PCO2 < normal; CSF pH > normal;
CBF < normal
B. PaCO2 < normal; CSF PCO2 < normal; CSF pH > normal;
CBF = normal
C. PaCO2 < normal; CSF PCO2 < normal; CSF pH > normal;
CBF = normal
D. PaCO2 < normal; CSF PCO2 < normal; CSF pH = normal;
CBF = normal
adult patients undergoing orthopedic related surgeries such as congenital bone deformities and traumatic injuries. Most of the Guatemalan
population’s livelihood depends upon their ability to perform manual labor. A broken bone which fails to heal properly may prevent them
from having adequate food and shelter for themselves and their family. The Medical Mission Trip to Guatemala was not only an opportunity
to give back but also a life-changing experience for the student nurse anesthetists.
The Devil’s Causeway in Steamboat Springs, Colorado

The Department of Anesthesiology
The University of Tennessee Medical Center at Knoxville
1924 Alcoa Highway
Knoxville, TN 37902
ADDRESS SERVICE REQUESTED
Current Research Endeavors (See Page 9)
Michael Doody, MD, Christal Greene, MD, Lally Lehmann, MD
�� Algorithm Development for Cooling Catheter Use in
Head Trauma Russell Langdon, MD; Christal Greene, MD
Non-Profit Org.
U. s. Postage
PAID
University of Tennessee
Knoxville
Fall 2011 Volume 1 Issue 4