Abstract
This is the second issue that I have been Editor-in-Chief for the Seminars in Cardiothoracic and Vascular Anesthesia, and I am happy to present a variety of articles covering multiple topics. The underpinnings of this editorial are inspired by words from the guest speaker at the convocation for University of Colorado Denver School of Medicine class of 2011 graduation in late May. The guest speaker was introduced to the crowd as a PhD professor from Colorado State University, who had developed a center track restrainer system as well as curved chute and race systems designed for cattle, which are used worldwide. Her accomplishments include hundreds of publications in veterinary science, as well as authoring multiple books. Magazines that have featured her include Discover, Time, People, the New York Times, Forbes, U.S. News and World Report, the New York Times book review, and in 2010, she was named one of the 100 most influential people in the world by Time magazine. As I listened to this introduction, I was truly intrigued as to why this obviously successful researcher, from primarily the veterinary sciences world, was addressing this graduating class of medical doctors. Then, the speaker was introduced as Dr Temple Grandin. Dr Grandin, who has achieved tremendous success in her research career, has done this with a diagnosis of autism since she was a small child.
Dr Grandin went on to describe how she sees the world in a visual manner, which helped her as she spent her early professional years designing and improving systems to solve problems encountered in the livestock industry. However, she said that over time, she began to understand the importance of management in systems processing. She discussed how if she now had a choice between a top of the line technological system (like what she has designed), but only mediocre management, versus an adequate (but perhaps not the high-end technology) system staffed by superb management, that the second option would be the most successful. Dr Grandin then went on to compare this concept with medicine today, highlighting cases from her own medical history as examples of where new technology had resulted in erroneous findings; some of these tests her primary care physician had argued against from the beginning based on his physical exam and diagnostic skills. The point that she was making was that new technology is of course great and provides new therapeutic and diagnostic potential, but that the expert medical manager (the physician) uses his or her basic diagnostic skills and medical knowledge as the foundation with which to apply these new advances. Her charge to the class of 2011 was to strive to be like her primary doctor, maximizing his diagnostic potential gained from experience and basic skills before relying on expensive tests. This saves the patient money and time and provides a fundamentally sound use of the medical system in general from the perspective of serving the nation’s/world’s patients as a whole.
With this speech in mind, I think about much of what is present in the medical literature today. Rightfully, new technology, improved imaging, new procedures, and novel drug therapies dominate the published literature as we strive to achieve new and better solutions to medical problems. So how can we find a balance between mastery of the new and improved, without losing the key fundamentals of the old stand by techniques? I cannot say that I have the answer; however, the articles presented in this issue and upcoming issues will try to strike this balance by presenting new ideas and technology—but balancing these presentations with clinical didactics to keep focus on the basics.
The “Clinical Challenges” and “Roundtable Discussions” attempt to focus on the fundamentals of clinical medicine by presenting diagnostic or management dilemmas, and offering solutions to these problems. This month’s clinical challenge presentation is an obstetric case requiring cesarean section in a patient with osteogenesis imperfecta where the author describes the key factors complicating operative procedures in these patients. Our roundtable discussion is based on a difficult case of mediastinal tumor involving the superior vena cava (SVC)—requiring excision of the SVC “en bloc,” and subsequent reconstruction of the SVC. I am happy to present perspectives from both expert surgeons and anesthesiologists on this difficult case, highlighting the approaches in preoperative diagnosis, intraoperative management, and postoperative care.
This issue also includes 2 review articles. The first review is on acquired cardiac disease in the obstetric patient by Dr Wolff and is the first in a series that will finish in the March issue, where we will present a discussion of congenital heart disease in the obstetric patient. This review is includes examples of multidisciplinary case planning for various cases scenarios—hopefully providing some specific clinical examples within the general concepts reviewed. The second article by Drs Verduzco and Lighthall, discusses quite eloquently the evolution of preoperative testing in the setting of vascular surgery. This review strikes at the message above by reviewing current published trials on cardiac revascularization in the perioperative setting and relating this to the current use of the American Heart Association 2007 guidelines to cardiac evaluation in the surgical patient.
Stay tuned for future issues where we will be presenting coverage of minimally invasive heart surgery, tetralogy of Fallot, along with perioperative management decisions for patients requiring airway reconstruction. I hope that you enjoy these articles and keep Dr Grandin’s charge in mind in the upcoming months to years.