To new cardiac anesthesiology residents, Dr. Jean-Yves Dupuis explains that it may be hard for them to predict the twists and turns their careers might take. “I tell them that the day I finished my internship back in 1979, I swore I would never go back to a university hospital—I wanted to travel the world for my career—but here I am,” said the recently appointed division chief. Dr. Dupuis assumed leadership of Cardiac Anesthesiology at the University of Ottawa Heart Institute in March of this year.
Far from never setting foot in a university hospital again, Dr. Dupuis is marking his 20th anniversary this year at the Heart Institute. The team he now leads is well-respected. “We have a very good group of anesthesiologists who are really performing at a high level, clinically,” he said. Heart Institute anesthesiologists provide anesthesia and patient monitoring in both the operating rooms and catheter laboratories. The division’s intensivists also monitor and coordinate care for patients in the Cardiac Surgical Intensive Care Unit (CSICU), a specialty commonly referred to as critical care medicine.
The major challenge he sees on the horizon is an aging patient population that suffers from multiple chronic conditions. Earlier improvements in practice have paid off. “What’s interesting is that, despite the fact that patients are now sicker and older, our results have remained consistent in terms of outcomes and mortality,” he said. But caring for these patients has been resource intensive, and he doubts that resources will increase at the same pace as the demand for cardiac care.
In the near future, he speculated, “Anesthesiologists and intensivists will have to learn to work a little bit outside the box.” He predicts a larger number of older patients will be rapidly transferred to the ward from the CSICU to increase capacity. Intensivists would serve as active consultants to the nurses and physicians on the ward, to help them avoid patients “bouncing back” to intensive care.
A new objective that will help address the changing nature of cardiac care is the development of a comprehensive quality improvement program encompassing all clinical areas covered by Cardiac Anesthesiology. An important aspect of this program will be improved documentation of critical and “near-miss” incidents in both the anesthesia and critical care medicine domains.
Dr. Dupuis stressed that incidents should not be confused with errors. “Incidents are not always a result of mistakes—a patient can have major complications when nothing was done wrong. It can happen when we follow state-of-the-art practice, but it may be that state-of-the-art practice needs to be improved,” he explained. “And we can’t improve practice unless we have thorough knowledge of our outcomes.” He plans a yearly quality improvement project for both anesthesia and critical care that will focus on internal documentation, reducing post-operative infection rates and shortening stays in the CSICU.
Interesting new challenges are also being posed by the development of minimally invasive cardiac procedures that require adaptation of traditional anesthesia protocols. Percutaneous valve replacements taking place in the catheterization lab are bridging the worlds of cardiac surgery and interventional cardiology.
The division’s wide experience in anesthesia has even led other specialties to seek out its support. For example, a group of neurosurgeons from The Ottawa Hospital requested the division’s help with an experimental procedure to clip a giant brain aneurism. The procedure required a complex combination of anesthesia, life support and monitoring called deep hypothermic circulatory arrest, which the division’s staff has performed for complex cardiac procedures.
“We may have to expand our role and go to other sites to help people do this, because we are the only group [in Ottawa] with experience in cardiopulmonary bypass and complex heart monitoring,” explained Dr. Dupuis.
Another major objective for Dr. Dupuis is to revive Cardiac Anesthesiology’s research productivity. The research program was impacted by the recent retirement of its longtime lead, Dr. Howard Nathan, and by a general time crunch that has kept staff members—all of whom actively participate in research—busy in the clinic.
The division has responded by expanding its personnel, recruiting Dr. Diem Tran, a former cardiac anesthesia resident at the Heart Institute who has been pursuing a master’s in clinical epidemiology with Dr. George Wells, in the Research Methods Centre, to co-lead future research efforts. She will be joined by Dr. Christopher Hudson, who is also completing a master’s degree in epidemiology and will focus his future research on epidemiological outcome studies related to the division’s practice.
Like all research at the Heart Institute, these efforts are tied to improving patient care and advancing cardiovascular medicine. For example, Dr. Hudson has begun a study of more than 15,000 cardiac patients, looking at how certain aspects of the practice of anesthesiology may be associated with poorer outcomes and how the Heart Institute can modify its current practice to get better results. The division will also continue existing research efforts in the areas of transesophageal echocardiography and patient-physician communication in intensive care settings.
“The quality of the care provided here is quite exceptional, and we have truly exceptional people working here. The Heart Institute is unique because we all have the same goals and we work as a family.” – Dr. Jean-Yves Dupuis, Chief of Cardiac Anesthesiology, UOHI
During his own residency, Dr. Dupuis met Dr. Earl Wynands, the first Chief of Cardiac Anesthesiology at the Heart Institute. Under Dr. Wynands’ tutelage, he became the first cardiac anesthesia fellow at the Heart Institute. What started as a detour from his intent to practice medicine in the developing world became his life’s work. “There was a door in front of me that was open, and I went thought it and explored, and I liked it and stayed,” Dr. Dupuis recounted.
After 20 years at the Heart Institute, Dr. Dupuis remains excited about the research and opportunities for outstanding patient care. “The quality of the care provided here is quite exceptional, and we have truly exceptional people working here,” he said. “The Heart Institute is unique because we all have the same goals and we work as a family. I think this comes from the people who founded the place—Dr. Wilbert Keon and Dr. Donald Beanlands—they prepared the ground for a fantastic culture here.”