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Introduction
Evidenced-based medicine is quickly becoming the mainstay of medical decision making.  In the field of anesthesiology and perioperative medicine, it is co= mmon to be confronted with situations that arise where decision making cannot be supported by published evidence.  We’ve identified a need in our institution for further development of analysis and implementation of decision making during criti= cal clinical scenarios for the residents and medical students.  One year ago, an evidenced-based interactive group discussion was begun in the department of anesthesiology attempting to address these issues.  Development of case-based learning sessions specifically aimed at concept development in areas where data is either insufficient or controversial are being utilized to further enhance residents’ decis= ion making skills.  A similar par= adigm would benefit medical students by instilling these critical medical thought processes earlier in their career development.  Anesthesia cases integrate numero= us medical disciplines such as physiology, pharmacology, and anatomy, which a= llow for broad medical concept development for medical students.  These sessions, incorporated with= novel teaching modalities, could stimulate interest and understanding in these g= ray areas of medical decision making.
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Project Outline
Anes= thesia Case Learning Sessions (A.C.L.S.) is an evidenced-based interactive group discussion that focuses on the analysis of clinical case scenarios that involve critical decision making.  Currently, the educational conference is held every Wednesday morni= ng and is moderated by Donald M. Voltz, M.D.=   Each week, the group is provided a challenging case scenario that contains numerous branching points concerning anesthetic and perioperative management.  The anesthesia residents in attendance are asked to formulate perioperative management pl= ans based on medical evidence to address the scenarios at hand.  Dr. Voltz then guides his student= s down multiple, acceptable patient care pathways and discusses how to defend eac= h of the plans that were concocted.  The residents are rewarded with the ability to participate in concept developm= ent strategies that will assist them by improving the quality of patient care while preparing them for the anesthesiology oral board exam.
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In addition to resident involvement, we would like to incorporate the additio= n of more medical students into our A.C.L.S. discussions.  We feel that concept development = and critical thinking are two skills that are highly required of physicians, in particular anesthesiologists, which cannot be taught in only four years of medical school.  By using case-based clinical scenarios, the students will be able to begin adapting their basic science knowledge into a foundation for clinical decision making.  In addition, we plan= to transcend traditional teaching methods by utilizing alternative sources su= ch as palm pilots, computers, and neural networking devices.
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Sample Case Presentation
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A 68 year-old male is to undergo a right hemicolectomy for cancer. He is an act= ive golfer who performs strenuous housework on a semi-daily basis. He has a history of tobacco use (20 pack years) for which he quit 20 years ago. The= re is a history of borderline hypertension which is under adequate control wi= th diet and exercise.  He denies= any other significant medical problems. He takes no medications other than a d= aily multivitamin and aspirin. He denies any medical allergies.
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T 36.9° C, BP 136/89, P 95, RR 16, SaO2<= /span> 97%= on RA
Neck: Supple, free range of motion
  Dentition: Full upper and lower dentures
Oral: Mallampati II, thyrome= ntal distance of  6.5 cm
Chest: CTA bilaterally =
CV: RRR without murmur =
EKG: NSR, L axis deviation, = poor R-wave progression
Labs: Hct 33 gm/dl, K 3.7 mEq/l
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1. Using the ACLS mindmap, develop an anesthetic plan?
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<= nobr>•Elective, urgent, or emergent? =
<= nobr>•Is preoperative workup adequate?
= •Regional vs. GA?
<= nobr>•What medications are appropriate?
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2. Following an e= asy intubation, the patient develops the following cardiac rhythm. What is your diagnosis and the management of this rhythm?
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<= nobr>•Diagnosis: Atrial Flutter.
<= span style=3D'font-size:125%'>•Causes: Usually by an atrial re-entrant rhythm, but can occur with enlarged atria secondary to diseases like COPD, mitral valve disease, tricuspid valve disease, pericarditis, and post-operative cardiac surgery.
<= span style=3D'font-size:125%'>•Treatment: Direct-current cardioversion and/or ablation of re-entry circuit.
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Consultation Focus
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Sin= ce the inception of A.C.L.S., we have generated a large core of eager residents a= nd students who are interested in expanding their critical thinking skills.  The participants seem to enjoy the theoretical case discussions which have unknown and unpredictable clinical branching points.  We are now seeking to have the discussion fueled mostly by  resident ideas and simply regulat= ed by the moderator as opposed to the moderator leading the whole discussion.= 3;
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= üHow can we encourage the residents to voluntarily submit their ideas and challenge other participants to defend their ideas = and suggestions in this setting?
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= üIs there a way to possibly measure the impact tha= t this conference is having on the residents’ decision making processes in = the operating room?
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= üCan this conference boost resident confidence in = both general anesthesia clinical practice and oral board preparation?
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Anesthesia Case Learning Sessions (A.C.L.S.):
A problem based learning experience for residents and medical students to assist in the development of clinical problem solving skills.
Donald M. Voltz, M.D. and Douglas T. Graham, M= .D. — Department of Anesthesiology, CWRU School= of Medicine, Cleveland, Ohio
It is our hope that this paradigm will bring back enthusiasm in medical education.  Through our appro= ach, we expect to elevate the quality of critical thinking from of our residents and medical students.  Most importantly, this model for teaching is not limited to any particular fiel= d of medicine.
Figure 1: Mindmap of Perioperative Planning.
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