The assistance of third-year medical students (MS3) may be an easy, inexpensive, educational method to decrease physical and emotional stress among first-year medical students (MS1) on the first day of gross anatomy dissection. In the academic years 2000-2001 and 2001-2002, a questionnaire on the emotional and physical reactions on the first day of dissection was distributed to 84 MS1 at Mayo Medical School (Rochester, MN); 74 (88%) responded. Student perceptions were assessed on a 5-point Likert scale. The 42 second-year medical students (MS2) whose first academic year was 1999-2000 were used as a control group, because they had not had assistance from MS3. MS2 completed the same questionnaire (59% response rate). Data were collected from MS1 on the day of their first gross anatomy dissection. The most frequent reactions were headache, disgust, grief or sadness, and feeling light-headed. Significant differences (alpha < 0.05) were found with use of the chi(2) test to compare the emotional and physical reactions of MS1 and MS2. MS1 had significantly fewer physical reactions (64% vs. 88%), reporting lower levels of anxiety (23% vs. 48%), headache (14% vs. 36%), disgust (9% vs. 20%), feeling light-headed (11% vs. 24%), and reaction to the smell of the cadaver and laboratory (8% vs. 52%). MS1 commented that having MS3 at the dissection table was extremely helpful. They relied less on their peers and felt they learned more efficiently about the dissection techniques and anatomical structures. Using MS3 as assistants is one method to reduce fear and anxiety on the first day of gross anatomy dissection.

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To the Editor,During the dissection phase of an orthotopic liver transplant, a 63 yr old man developed widespread ST depression and cardiovascular collapse. Transesophageal echocardiography (TEE) revealed air in both ventricles associated with new onset biventricular dilation and dysfunction. The surgeons found a failed staple line placed inadvertently across a transjugular intrahepatic portosystemic shunt (TIPS), which was now splinting the right hepatic vein open. Control of air entrainment was achieved with caval clamping. Trendelenberg positioning was employed to prevent air entering the right ventricular outflow tract. Following resuscitation, a full echocardiographic examination was undertaken. Air was seen extending into the aortic root but was not demonstrated in the coronary circulation. Patent foramen ovale (PFO) was not demonstrated on colour Doppler. A plausible explanation for this paradoxical air embolism is intrapulmonary shunting. Intrapulmonary shunt recruitment is thought to occur by a pressure dependent baffle mechanism 1 exacerbated in this case by increased pulmonary artery pressures from air embolus.Potentially catastrophic hemodynamic changes occur frequently during orthotopic liver transplantation (OLT) and require rapid and accurate diagnosis. During the dissection phase, hepatic manipulation causes intermittent obstruction to venous return. The anhepatic phase involves clamping the portal vein and inferior vena cava, both of which cause a significant reduction in venous return. Reperfusion syndrome ([30% decrease in mean arterial pressure for at least 1 min) is seen in 42% of patients. 2 Associated physiologic changes include increased pulmonary pressures, right ventricular dysfunction, bradycardia, acidosis, and hypothermia. Given the multiple causes of hypotension and hemodynamic instability during OLT, the assessment of cardiac preload and function is easily justified. 3 In comparison with a pulmonary artery catheter, TEE has the distinct advantage of being a relatively non-invasive procedure. TEE allows direct visualization of the heart, permitting monitoring of volume status, contractility, and overall function. In addition, TEE provides valuable information when less common complications occur, such as large pleural effusions, tension pneumothorax, or pulmonary embolism. TEE is especially helpful in the management of disorders such as acute pulmonary hypertensive crisis, intracardiac clot formation, and hypertrophic cardiomyopathy. 4 The initial fear of rupturing esophageal varices is an exceedingly uncommon complication and has not yet been reported despite widespread intra-operative use. 5 We would like to raise four points: (1) baseline TEE for OLT should seek to specifically identify trans-pulmonary shunts; (2) liver transplant candidates may be at increased risk of paradoxical embolism even if they do not have a PFO or severe hepatopulmonary syndrome; (3) one should note the presence of a TIPS that may contribute to life threatening air emboli during liver dissection; and (4)...

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