Rochester, MinnesotaOctober 2009.

Helga Komen Ušljebrka , MD anesthesiologist

Rochester,Rochester,MinnesotaMinnesota 1889.1889.

Scottsdale,Scottsdale,ArizonaArizona1987.1987. Jacksonville,Jacksonville,

FloridaFlorida1986.1986.

Mayo Clinic

1883. Tornado in Rochester, MN

St. Marys Hospital, 1889.

St. Marys Hospital, 1930s.

William and Charlie Mayo

Dr. Will Mayo: ‘The best interest of the patient is the only interest to be considered’

Operating room, 1890s

First X-ray image on Mayo Clinic, 1897.

- 1901. First Clinic Business Manager- 1905. L. Wilson, quick-frozen tissue stained with methylene-blue- 1914. Isolated thyroxin- 1915. One of the world’s first formal graduate training programs, many visiting physicians- 1920. System for grading cancer (AC Broders)- 1920. Basal metabolic rate (WM Boothby)- 1934. Isolated cortisone (E. Kendall) - 1934. First use of thiopental (JS Lundy)- 1944. First application of streptomycin

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Aero Medical Unit, 1942. (CA Lindbergh) ...developing prototype oxygen mask for pilots

Aero Medical Unit - centrifuge

- 1950. Nobel prize (Kendall and Hench)- 1954. Methodist Hospital - 1955. First open heart surgery (JW Kirklin)- 1969. Total hip replacement- 1973. First CT scanner in North America- 1975. Computerized system with bar codes - 1992. Mayo Health System – a regional network of clinics and hospitals- 2000. Mayo Clinic Transplant Center- 2002. Comprehensive Cancer Center- 2005. Electronical Medical Record

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St. Marys Hospital

St. Marys Hospital

St. Marys Hospital

Plummer building, 1928.

Lobby of Plummer building

Library of Plummer building

Methodist Hospital, 1954.

Gonda building, 2001.

Lobby of Gonda building

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Government

- Private group practice

- 33-member ‘Board of Trustees’- public members, Mayo physicians and administrators

-President and CEO of Mayo Clinic John Noseworthy, MD, Professor of Neurology, Interests - multiple sclerosis, Editor-in-chief of ‘Neurology’

2008. Personnel (MN)

- 2.000 staff physicans and scientists- 2.800 residents, fellows and students - 28.000 health staff - 32.800 TOTAL

Florida 4.869 total staffArizona 5.079 total staff

.......5 MILLION M2 .........

Mayo Clinic Hospitals

Saint MarysHospital

Rochester Methodist Hospital

Licensed beds available

1,265 794

Admissions/year

43,002 18,662

Operating rooms

55 41

Surgical cases/year

28,071 24,421

A typical day at Mayo Clinic:

Outpatient visits 5,746 Admissions to hospital 241Surgical procedures 205

Lab tests 41.000

Radiology procedures 3.779CT scans 647Chest X-rays 702MRIs 244

Units of blood components used 213

2008. Financial information

Revenue $7,222 millionsTotal Assets $8,333 millions

Education and Research Funding Sources $763 m. (Government $372 m., Benefactors $391 m.)

....Second best U.S. Hospital for 2009. (U.S. News&World Report, July 17, 2009.)

No.1 hospital in: Digestive disorders Diabetes and endocrine disorders Neurology and Neurosurgery Orthopaedics

Mayo Clinic Model of Care

Education

Clinical practice

Research

- Clinical Case Conferences- Core Curriculum Lectures- Introductory Lecture Series- Journal Clubs- Key Word Phrase Mini-lectures- Morbidity and Mortality Conferences- Oral Board Reviews- Formal practice oral examinations- Subspecialty Mini-lectures- Written Board Reviews

- Multidisciplinary Simulation Center

OBLIGATE! – BLS, ALS

Education Everyday lectures

.........Monthly evaluation of trainees by supervising faculty memebers

........Quarterly each trainee meets with their faculty advisor to review progress and goals

........Twice a year chair of Clinical Competence Committee gives written clinical competence evaluation of trainee

.........Trainees monthly evaluate faculty and rotations

....American Board of Anesthesiology (ABA) In-Training Examination yearly. ....nine members of Mayo’s current anesthesiology facultyCERTIFICATION – Written and oral exam by ABA

Education Evaluation

Dr. Will Mayo: ‘The best interest of the patient is the only interest to be considered’

Clinical practice Patient orientated

- Collegial staff teamwork .....’no one is big enough to be independent of others’- An unhurried examination- Physicans personal responsibility for patient care- Comprehensive evaluation- Availability of advanced diagnostic and therapeutic technology

Clinical practice Patient orientated

- Clinical Research Units – inpatients, outpatients, mobile facility (research vehicle)- cca 400 projects/year- 2800 publications a year in biomedical journals

- Research training – clinical and laboratory....Optional - Clinician-Investigator Program

Research

Impact factor 4,81

h

Research

Some of projects...- Genetic markers for intracranial aneurysms among family members-The influence of tobacco on the extent and likelihood of proximal progression of ulcerative colitis-Supplemental method of controlling pain in pancreatic cancer patients-Left ventricular-based cardiac stimulation post AV node ablation evaluation (PAVE)-Effectiveness of sildenafil to placebo in patientswith diastolic heart failure-Comparison of Tacrolimus and Sirolmius immunosuppression in kidney transplant patients-Memory support system for patients with amnesticmild cognitive impairment

..........

Similarities and differencies Drugs

- phenylephrine vs. efedrine- glycopirolate vs. atropin- sucynilcoline vs. rocuronium- Isoflurane® vs. Sevoflurane® STUDIJA .....propofol, fentanyl

...Drug delivery in induction by Consultant

- bupivacaine vs. levobupivacaine

Similarities and differencies Ventilation in OR

- anesthesia machine BLEASE®

- protective lung ventilation: 6 ml/kg x f of breathing, etCO2 4.7-6.0 kPa, PEEP 5 kPa, recruitment every 1.5 hour

Similarities and differencies Regional anesthesia

- 2 month rotation – recovery days, OR days

- US (Sonosite® Micromax) guided blocks- Neurostimulator guided continous blocks

- aseptic conditions- premedication with midazolam, monitoring (SpO2, BP cuff, ECG, temperature probe)

Similarities and differencies Regional anesthesia

Examples:

1. Knee replacement – sciatic block (30 ml 0,25% bupivacaine) + femoral cont. block (test 5 ml xylo., bolus 20 ml 0,25% bupivacaine).......+ SAB

2. Hip replacement – psoas cont. Block (test 5 ml xylo, bolus 25 ml 0,25% bupivacaine) + femoral cont. block (test 5 ml xylo., bolus 20 ml 0,25% bupivacaine).......+ SAB

Mayo Clinic Model of Care

....Obama’s Model of Care Sept. 2009., ABC News

‘.....best quality and the lowest cost........because of the minimized patient tests, fixed doctors salaries, electronic records and team work....’

Referring patient to Mayo Clinic

.......Anyone can request an appointment at Mayo Clinic

Mayo Clinic’s Referring Physician Offices (24 hours a day) – tel: 800-533-1564

.....Online services www.mayoclinic.org/medicalprofs

Collaboration with:

J. Sprung, MD, Ph.D., prof. anesthesiologyO. Gajić, MD, Ph.D., anesthesiologist (head medical ICU)R. Flick, MD, pediatrician, anesthesiologist (head PICU)H. Smith, MD, anesthesiologist, regional ansthesiaB. Hoelzer, anesthesiologist , invasive pain proceduresM. Huntoon, MD, anesthesiologist, cancer painT. Harrison, MD, anesthesiologist (pediatric), pain clinic J. Munis, MD, neuroanesthesiologistE. Wijdicks, MD, Ph.D., neurologist (head ICU) W. Nicholson, MD, clinical pharmacologistR. White, MD, anesthesiologist, reanimatology

Art&Healing.....since 1955.

Ivan Meštrović, ‘Man and Freedom’Lobby of Gonda building

Art&Healing.....since 1955.

Dale Chihuly’s Chandeliers, Lobby of Gonda building

Art&Healing.....since 1955.

Auguste Rodin,‘Jaine d’Aire’Siebens building

Art&Healing.....since 1955.

Andy Warhol,‘Flowers’

Art&Healing.....since 1955.

Joan Miro

H Komen U, RD Miller, J Sprung Plummer house

Miller RD, Hyatt RE. Evaluation of obstructing lesions of the trachea and larynx by flow-volume loops.

Am Rev Respir Dis. 1973 Sep;108(3):475–481.

HVALA !