A: Narrative Report of Clinical Practice:

In Guyana, South America

Intensive Care Unit in Guyana:
In addition to providing anesthesia for routine operating room surgeries, established a four bed intensive care unit for Guyana Mining Hospital, Linden, Guyana, South America. This unit was declared open by Ministerial representative of Government of Guyana in 1982. The unit was under my care during my tenure in Guyana. Patients with serious mining injuries, respiratory insufficiency and coronary patients benefited from this service.

In Barbados:

Pivotal role in the development of Anesthesia Department at Queen Elizabeth Hospital, Barbados.

Provided anesthesia care for routine and emergency cases at the government owned 650 bed QEH (A teaching affiliate of University of West Indies, 6000-7000 operations/year, a referral hospital for a million population from Anguilla in the north to Grenada in the south.). I was an active member of the team responsible for refurbishing operating rooms and purchasing monitoring equipment, as well as establishing an ICU (Project undertaken with World Bank Loan). I was a key member of the group responsible for training ICU nurses required to staff the unit. In addition to routine anesthesia and teaching responsibilities, I was also instrumental in developing an anesthesia auditing program to keep track of anesthesia disposable items. Such a program was found to be necessary to prevent acute and unexpected shortage of imported disposable items in the island. In addition, I also designed and organized clinical research studies in capnography utilizing available limited resources. Furthermore, studies were also conducted in areas specific to third world developing nations such as; anesthesia without nitrous oxide (nitrous oxide is expensive); suitability and cost effectiveness of providing oxygen from oxygen concentrators to meet the demands of the hospital; and methods to prevent condensation of water in air pipelines due to excessive humidity. The development of the anesthesia department in Barbados was the focus of my special article published recently.

Brigham and Women's Hospital:

As a fellow in Obstetric anesthesia, I was a team leader in assigning day to day clinical responsibilities to residents in the labor and delivery section as well as operating room division. In addition, I was actively involved in the provision of anesthesia care to high risk obstetric patients as well as patients requiring In-vitro-fertilization.

At the conclusion of obstetric anesthesia training, I was appointed as staff anesthesiologist at Brigham and Women's Hospital. Major responsibility includes provision of anesthesia care (sub-specialty) to obstetric patients. Brigham and Women's being a high risk obstetric referral center, a substantial number of patients fall into high risk category requiring anesthesia care during delivery. Recently, a new dimension to obstetric anesthesia care has been added, which is providing care to patients undergoing in-uterus fetal surgery.

In addition to subspecialty care of obstetric anesthesia, a portion of time is spent in providing anesthesia care in main operating rooms, which includes general surgical, thoracic and vascular patients, as well to patients out side of main operating room in areas such as in MRI and CT scan.

As a member of transfusion committee, I am actively involved with other members in revising and implementing several policies in compliance with JACHO to enhance safety of transfusions in various circumstances.

B. Short Report of Research That Contributes to Care of Patients

Primary Research interest: Capnography

Clinical research is centered on capnography, thromboelastography and obstetric anesthesia. Clinical research in capnography extends over a period of 16 years resulting in publication of original papers, review articles, case reports and correspondences on capnography. The main area of clinical research in capnography is on arterial to end-tidal carbon dioxide differences in pregnancy, including those during laparoscopic surgery. I suggested a standard terminology for time capnography and highlighted current limitations of this important monitoring device. This terminology has been included in most text books including "Nunn's Respiratory Physiology". I also review papers on capnography as a consultant to editorial board of Anesthesia and Analgesia as well as guest editor to 'Anesthesiology'. Achieved the status of 'Guest Editor" for Anesthesia and Analgesia in the year 2002. I am committed to educating colleagues and residents as well as students in capnography via my participation in grand rounds and day to day clinical teaching. I produced a multimedia on capnography using computer software for teaching purposes. 'Ohmeda' (Datex-Ohmeda Inc, Manufacturer of anesthesia equipment, anesthesia machines and capnographs) considers my article entitled "Capnometry and Anaesthesia" an important teaching material for anesthesiologists, customers and employees of Ohmeda.

Web Based Education: Site on Capnography.com:

A website on capnography has been designed, produced and maintained without external sponsorship to provide a complete review on end-tidal carbon dioxide monitoring during anesthesia and intensive care. This site uses several animations designed to explain underlying physical and physiological concepts of capnography in addition to highlighting clinical applications. The purpose of this site is to fulfill my long standing goal of developing an easily accessible educational site on capnography. This is an "All-In-One" on capnography. This site has attracted several good reviews: (Approximate time spent in construction of the website - >1000 hours)

Anesthesiology - October 2001: (see the issue for full version)

"Dr Bhavani Shankar Kodali, a well published expert on the subject of capnography, has created the Capnography website without sponsorship from any equipment or pharmaceutical company.

Dr Bhavani Shankar Kodali' has put forth great effort to produce the equivalent of a capnography textbook and made it freely available on the Internet. The site provides a complete review of end-tidal carbon dioxide monitoring during anesthesia and intensive care. In addition, this website provides animated graphics that are not possible to produce in a textbook and can greatly facilitate learning. Capnography.com is truly an "all-in-one" for the subject of capnography and a great teaching contribution."

British Journal of Anaesthesia - October 2001: (see the issue for full version)

"This website, the work of Professor Shankar ....... There is lot of material on this site, and it is impossible to list all the good things....

Certainly it provides fun. It will be a learning resource for students- and I will be recommending it. It may become a forum for specialists, as its author hopes...."

Journal of Neurosurgical Anesthesiology - October 2001: (see the issue for full version)

"While not a book, a web-based site may also be used as a teaching tool..... developed by Dr Shankar, an assistant professor of anesthesiology from Harvard Medical School.

The site uses extensive and colorful animations to explain the concepts....

I believe that a candidate for the oral board examinations might well find that 15 minutes spent at this site shortly before the interview proves invaluable. It is also an effective teaching tool for all residents and helpful for the clinician who wishes to better understand the disease process that generates an abnormal waveform."

Capnography.com website was presented as a technical exhibit at the 'American Society of Anesthesiologists Annual Scientific meeting' at New Orleans, USA - October 2001.

In addition, several complimentary comments have been received from various sections of the medical community, manufacturing firms, and paramedical staff. Some of these comments have been coming from abroad. In addition, the website is also an invaluable tool in the preparation of reports for technology classes. One such example is the Graduate School at Northeastern University. Website statistics reveal that, on the average, 500 pages of this website are accessed on a daily basis. Over 66,000 viewers have already visited this website. Major search engines (such as Yahoo.com and Google.com) rank this website as number one in capnography among non-sponsored websites, based on its popularity and content. Many organizations have provided a link on their website to www.capnography.com in order to provide a source of information on capnography for their clients.

Frequently, permission is sought from teachers and instructors in several fields to borrow material from this website for presenting in their conferences. Very often, individuals visiting the website from several countries often ask intriguing questions about Capnography, to which I respond in detail.

Patient Education (www.painfreebirthing.com):

Patient education is an important component of clinical anesthesia. With the technical experience acquired in the designing of capnography website, a website was designed and just completed to explain the details of pain free childbirth to pregnant women seeking childbirth options. This is the first site to use computer animation graphics to explain basic concepts to lay persons about pain free childbirth procedures so that the patients can make an educated decision regarding their childbirth. The patients can look at this site at their homes during their pregnancy, or can view the site even in the labor and delivery rooms if equipped with internet computers (such as at Brigham and Women's). The chairman of the department of Obstetric and Gynecology and the director of public relations at Brigham and Women's Hospital (BWH) recognized the importance of this endeavor to women's health and education. They decided to adopt the website's content into the pregnancy and childbirth section of the BWH website. They directed their web designers to create a platform for this purpose, which is now live at www.brighamandwomens.org/painfreebirthing. The importance of this patient educational endeavor also received its due recognition at a recently concluded meeting of the Society of Obstetric Anesthesia and Perinatology, where I was asked to demonstrate the website to the entire gathering.

This website has also been selected for presentation as a technical exhibit at the 2002 Annual meeting of American Society of Anesthesiologists in October at Orlando. Over 24,000 viewers have already visited this website since its inception in March 2002. Society of Obstetric Anesthesia and Perinatology (SOAP) and Obstetric Anaesthetists Association of Great Britain have provided links on their website to the Painfreebirthing website for the benefit of their patients.

This website was presented along with the capnography website at the Scientific Exhibition of Annual Postgraduate Assembly in Anesthesiology held in New York (December, 6th-10th, 2002) under the title "Education in the new millennium." This exhibit won a "Special Award" at the meeting.

Approximate hours spent in the preparation of this website - >400 hours).

Current Research Projects:

Projects completed and the data presented at conferences. Manuscripts are under preparation for possible publication. I am the first author of the following clinical studies:

Principal Investigator:

1. Airway changes in Labor
2. Upper airway changes in labor using acoustic resonance reflectometry
3. Intermittent versus continuous infusion of local analgesics during labor
4. Cerebral oxygen saturation during cesarean delivery (primary investigator).
5. Airway in pregnancy
6. Effect of amniotic fluid on coagulation using Thromboelastography

Review articles/Book chapters/Invited papers:

1. Bhavani Shankar K, Moseley H, Kumar Y. A Review of arterial to end-tidal carbon dioxide tensions difference during anaesthesia in pregnancy. Indian J Anaesth 1988:2.
2. Bhavani Shankar K, Moseley H, Kumar Y. End-tidal carbon dioxide monitoring and its clinical applications. Asian Archives of Anaesthesiology and Resuscitation 1990;32:41-54.
3. Bhavani Shankar K, Moseley H, Kumar Y. Capnography and its usefulness in the operating room. Journal de la SMAAR 1991;2:2-3.
4. Bhavani Shankar K, Moseley H, Kumar Y and Delph Y. Capnometry and anesthesia. A Review Article. Canadian J Anaesth 1992;39:617-32.
5. Moseley H, Bhavani Shankar K, Kumar AY. Anaesthesia without nitrous oxide. Postgraduate Doctor 1992;8(5):168-72.
6. Bhavani Shankar K, Kumar AY, Moseley H, Hallsworth R. Terminology and the current limitations of time capnography. A brief review. Journal Clin Monit 1995;11(3):175-182
7. Bhavani Shankar K, Moseley H, Mushlin PS, Hallsworth R, Fakoory M, Walrond ER. Anesthesia in Barbados. Canadian J Anesth 1997;44:559-68.
8. Bhavani Shankar K, Steinbrook RA. Anesthetic considerations for minimally invasive surgery. In: Brooks DC, editor. Current Review of Minimally Invasive Surgery, Third edition. 1999. Current Medicine, Inc. Philadelphia: 28-40.
9. Bhavani Shankar K. Anesthesia for cesarean section. In Problems in Anesthesia. Ed: Bader A, Datta S. 1999;11:3:333-43.
10. Shay DC, Bhavani-Shankar K, Datta S. Laparoscopic surgery during pregnancy. Anesthesiol Clin North America 2001 Mar;19(1):57-67.
11. Srinivasa V, Gilbertson LI, Bhavani-Shankar K. Thromboelastography: where is it and where is it heading? Int Anesthesiol Clin 2001;39(1):35-49.
12. Farraghar R, Bhavani Shankar K. Obstetric Anesthesia. In: Wylie and Churchil Davidson: Text Book of Anesthesia. United Kingdom: Accepted for publication (2002).
13. Bhavani Shankar K, Lee-Paritz A. Anesthesia for pregnant obese parturients. In: Anesthesia for High Risk Pregnancy. Editor: Datta S. Accepted for publication (2002).