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APPENDIX ONE: NCC ANESTHESIOLOGY RESIDENCY GOALS AND OBJECTIVES
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THE NATIONAL CAPITAL CONSORTIUM
ANESTHESIOLOGY RESIDENCY
PROGRAM GOALS AND OBJECTIVES
Table of Contents:
Section
Program Overview
CA 1 Year Overall Goals and Objective for Year
CA 1 Year, Goals and Objectives 1st 6 Months
CA 1 Year Goals and Objectives for 2nd 6 Months
Goals and Objectives CA 2 Year
CA 3 year Goals and Objectives
CA-1 Residents in the General Operating Room
Residents in the Post Anesthesia Care Unit
Residents in Ambulatory Surgery
CA 1 Residents in Critical Care
CA 2 Residents in Critical Care
CA 3 Residents in Critical Care
CA 1 Residents in Obstetric Anesthesia at WRNMMC
CA 2 Residents in Obstetrical Anesthesia at WRNMMC
CA 3 Residents in Obstetrical Anesthesiology at WRNMMC
Senior Residents in Obstetrical Anesthesia at WHC
CA 1 Residents in Anesthesia for Chronic Pain Medicine
CA 2 Residents in Chronic Pain Medicine
CA 3 Residents in Chronic Pain Medicine
Residents in Pre-anesthetic Evaluation
CA 1 Residents in Acute Pain Medicine at WRNMMC
CA 2 Residents in Acute Pain Medicine at WRNMMC
CA 3 Residents in Acute Pain Magement at WRNMMC
Senior Residents in Acute Pain Medicine at LRMC
CA-2 Residents in Cardiothoracic Anesthesia and Transesophageal
Echocardiography
CA-2 Residents in Cardiothoracic Anesthesia at WHC
CA 3 Residents in Cardiothoracic Anesthesia at WHC
CA 3 Residents in Cardiothoracic Anesthesia at INOVA Fairfax
CA-2 Residents in Neuroanesthesia at WRNMMC
CA 2 Residents in Neuroanesthesia at JHU
CA 3 Residents in Neuroanesthesia at WRNMMC
CA 3 Residents in Neuroanesthesia at JHU
CA 2 Residents in Pediatric Anesthesia at CNMC
CA 3 Residents in Pediatric Anesthesia at CNMC
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Table of Contents:
Section
Senior Residents in Trauma Anesthesia
Senior Residents as Clinical Teaching Chiefs
Senior Residents in Operational Anesthesia and Humanitarian Missions
Residents in the Clinical Scientist Track
CBY/PGY1 Operating Room Rotation
CBY/PGY1 Surgical Critical Care Rotation
CBY/PGY1 Acute Pain Medicine Rotation
CBY/PGY1 Internal Medicine Wards/Night Float Rotation
CBY/PGY1 Addiction Medicine Rotation
CBY/PGY1 General Surgery Rotation
CBY/PGY 1 Emergency Medicine Rotation
CBY/PGY 1 Research Rotation
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PROGRAM GOALS & OBJECTIVES
PROGRAM OVERVIEW
Anesthesiology Is an Evolving Specialty.
Beyond the operating room, the practice now encompasses ambulatory clinics, dedicated acute
pain medicine/regional anesthesia sections, intensive care units and freestanding pain centers.
Consultant anesthesiologists today must be clinically skilled, as well as savvy about
contemporary organizational management, medical leadership, legal issues, computer
applications and quality management. The curriculum at the NCC Anesthesiology Residency
incorporates hands-on training, didactics, tutorials, simulations, and problem-based learning to
meet these needs. It is designed to train anesthesiologists in all aspects of contemporary practice
and foster creativity benefitting both the anesthesiologist and the patient in a dynamic health care
environment.
Developing Competent Anesthesiologists.
The goal of anesthesiology residency training at the NCC is to become a competent physician
specializing in anesthesiology who is an asset to the Military Health Care System, the US
healthcare system and the profession. The common program objectives are:
1.
2.
3.
4.
5.
6.
7.
To develop a core competency of proficiency in the perioperative, critical care and pain
management of a wide range of patients (neonate to geriatric) in numerous anesthesia
subspecialties and in diverse settings.
To acquire medical knowledge that facilitates successful completions of parts I and II of
the American Board of Anesthesiology certification examinations.
To develop adequate the technical skill and judgment to practice anesthesia competently.
This includes performing at least the minimum number of procedures required for board
certification and demonstrating adequate skill level when performing these procedures to
the faculty.
To develop a pattern of practice-based, life-long learning facilitating the maintenance of
competency in the specialty of Anesthesiology.
To acquire communication skills facilitating interaction with patients, families and other
health professionals. This also includes developing verbal presentation skills required to
pass the oral board examination of the American Board of Anesthesiology.
To foster professionalism in all aspects of resident behavior.
To develop the skills required to function as an anesthesiologist in both the military and
civilian medical systems.
From the start, residents receive extensive exposure to diverse cases that progressively develop
their skills. Working closely with attending physicians, residents learn to perfect manual skills
and are challenged to accept increasing responsibility for a wide variety of procedures and
patients with diverse disease processes.
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These goals and objectives are broad guidelines to help residents develop into well-trained,
competent anesthesiologists. Because residency training is a diverse and complicated endeavor,
these guidelines cannot describe everything that is expected of residents.
The overall goal of our anesthesiology program is to transoform residents into knowledgeable,
competent and safe anesthesiologists. The means to that end represent a series of supervised
patient care experiences in a system of graduated responsibilities.
In their simplest form, education and development as an anesthesiologist, like any learning
experience, involves four philosophical steps in three basic domains of learning.
Growth and competence as an anesthesiology resident in the realm of patient management will
proceed through four phases. The first, and hopefully shortest phase is that of a “reporter”. In
this stage residents accurately gathers relevant patient information and communicate the
information to others. The second step is that of an “interpreter”. As residents gain experience
and knowledge of the specialty they will be able to interpret information in the context of the
current clinical situation. However, in this phase residents will be conscious that they are not
facile with the independent management of many situations or tasks. The third step is that of
“manager.” In this phase residents become consciously competent of the ability to manage
patients, critical situations and procedures. This is really the most rewarding phase of learning as
one’s confidence in skills is regularly reinforced as training progresses. It is helpful to view
failures as learning opportunities to expand understanding of the practice of the specialty. This is
the essence of practice-based learning, the development of life-long learning and the continued
maintenance of professional competency. This phase is characterized by consciously focusing
and thinking about tasks as they are performed. The final phase is that of “educator”. In this stage
residents will have the capability to effectively transfer knowledge to others. Throughout
training, residents will be exposed to new subspecialty rotations, procedures and techniques.
Transitions will occur within these stages of competency during both residency and attending
phases of one’s career. In order to practice safely, an anesthesiologist must recognize where they
are in the realm of competence at all times.
There are six core compentencies as defined by the American College of Graduate Medical
Education. They are:






Patient Care
Medical Knowledge
Interpersonal Skills and Communication
Professionalism
Practice Based Learning
Systems Based Practice
The American Board of Anesthesiology further describes these six core competencies as they
pertain to the practice of anesthesiology, see below.

Patient Care
o 1 Demonstrates patient care that is compassionate, appropriate and effective for
the treatment of health problems and the promotion of health.
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




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o 2 Respects patient privacy.
o 3 Demonstrates appropriate concern for patients and a commitment to carrying
out professional responsibilities.
o 4 Is an advocate for quality care.
o 5 Demonstrates use of a sound background in general medicine in the
management of problems relevant to the specialty of anesthesiology.
o 6 Recognizes the adequacy of preoperative preparation of patients for anesthesia
and surgery, and recommends appropriate steps when preparation is inadequate.
o 7 Selects anesthetic and adjuvant drugs and techniques for rational, appropriate,
patient-centered and cost-effective anesthetic management.
o 8 Recognizes and responds appropriately to significant changes in the
anesthetic course.
o 9 Provides appropriate post-anesthetic care.
o 10 Provides appropriate consultative support for patients who are critically ill.
o 11 Evaluates, diagnoses, and selects appropriate therapy for acute and chronic
pain disorders
Medical Knowledge
o 1 Possesses an appropriate fund of medical knowledge.
o 2 Is appropriately self-confident; recognizes gaps in knowledge and expertise.
o 3 Demonstrates medical knowledge about established and evolving biomedical,
clinical, and cognate sciences, as well as the application of this knowledge to
patient care.
Interpersonal Skills and Communication
o 1 Demonstrates effective interpersonal and communication skills that result in the
effective exchange of information and collaboration with patients, their families
and other healthcare professionals.
o 2 Is adaptable and flexible.
o 3 Is careful and thorough.
Professionalism
o 1 Demonstrates a commitment to carrying out professional responsibilities.
o 2 Adheres to ethical principles.
o 3 Demonstrates sensitivity to a diverse patient population.
Practice Based Learning
o 1 Demonstrates learning and improvement that involves the investigation and
evaluation of care for patients, the appraisal and assimilation of scientific
evidence and improvements in patient care.
o 2 Is committed to practice-based learning and improvement.
o 3 Possesses business skills important for effective practice management.
o 4 Is complete, accurate and timely in record keeping
Systems Based Practice
o 1 Demonstrates an understanding of the healthcare system and the ability to
effectively call on system resources to provide optimal patient care.
o 2 Demonstrates an awareness of and responsiveness to the larger context and
system of health care.
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It is the hope of residency leadership that these guidelines will assist residents in accruing the
knowledge, skill, and ability required to safely practice anesthesiology.
With each additional year in the anesthesiology program, residents will be provided challenges
that develop and challenge their skills to become more independent, while at the same
timeprovide immediate back-up as the situation demands. Patients presenting for surgery and
anesthesia often present with life-threatening conditions, require potentially dangerous
treatments, or develop life-threatening complications during surgery. Knowing one’s
limitations and when to call for help is an essential trait for the safe practice of anesthesiology.
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PROGRAM GOALS & OBJECTIVES
PGY 2/CA-1 YEAR
Introduction
The resident completing the first six months of clinical anesthesia training should establish
standards and habits that facilitate the assimilation of basic science, clinical science and clinical
skills necessary for completion of residency training in anesthesiology. Mastery of clinical skills
is expected to be rudimentary. The focus is on establishment of standards of professional
performance.
Basic Anesthesia Training
The majority of the first 12 months are defined as "Basic Anesthesia Training". This is shown on
the rotation schedule as general OR (GOR). The goal of these months is to provide the resident
with adequate clinical material to learn the fundamentals of anesthesiology. Scheduling during
these months is designed to give the resident a chance to acquire skill and confidence in the
conduct of uncomplicated anesthetics. Because surgical scheduling is not always consistent with
curriculum design, the resident is often required to participate, in some fashion, in cases beyond
the resident’s skill level. Training in recognized sub-disciplines of anesthesia occurs mainly in
the CA-2 and 3 year; however three distinct subspecialty rotations are introduced in the CA-1
year because they serve as the foundation for further development. These are described briefly
below.
Subspecialty Anesthesia and "Specialty Months"
The CA-1 resident is usually scheduled to complete formal subspecialty rotations in Critical
Care, Obstetrics, Regional Anesthesia, Acute and Chronic Pain Management, Pre-operative
Evaluation Clinic, and the Post Anesthesia Care Unit. Each of these rotations has goals that help
achieve the broader objectives of the CA-1 year. The overall goals and objectives for these
rotations are summarized in the Rotation Goals and Objectives. Although WRB does not have a
dedicated ambulatory anesthesia unit, it is recognized as a distinct “subspecialty" of
anesthesiology because it does form the basis for most contemporary anesthesiology practices.
The practice of ambulatory anesthesia occurs on a daily basis for most of the CA-1 and the nonsubspecialty months of the CA-2 year. Hence, it is presented as a discrete track to formalize the
resident's knowledge and skill base although it is not practiced in a continuum.
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Overall Goals and Objectives for
First 6 Months of PGY 2/CA 1 Year
Patient Care
Goals:
The goal at the end of the first 6 months is to learn the fundamentals of intraoperative care
fostering the preoperative assessment, preparation and medication, intraoperative management,
and post-surgical care of patients with uncomplicated medical conditions presenting for
anesthesia and surgery.
Cognitive patient care objectives:
1.
2.
3.
4.
5.
6.
7.
8.
Demonstrate the ability to perform an accurate pre-anesthetic history and physical exam.
Demonstrate the ability to counsel healthy (ASA Class I and II) patients on the risks and
benefits of general and regional anesthesia.
Show judgment in the selection of preoperative laboratory studies for healthy surgical
candidates.
Manage ASA physical status I patients under supervision with minimal assistance for
uncomplicated surgery, including induction, maintenance, emergence, and transport to
the post anesthesia care unit.
Accurately estimate fluid (blood/colloid/crystalloid) requirements in routine cases.
Identify basic intraoperative problems (e.g. hyper/hypotension, hypoxia, hypercapnia, t
dysrhythmias, wheezing, increased/decreased airway pressures, oliguria, anuria, acidosis,
laryngospasm, etc), formulate differential diagnoses and develop treatment plans.
Recognize key anatomic landmarks, indications/contraindications, and potential
complications of regional blocks (spinal, epidural, brachial plexus, interscalene,
intravenous regional, caudal, and peripheral nerve blocks).
Manage acute post-operative pain (patient controlled analgesia, continuous infusions of
epidural opioids and/or local anesthetics).
Technical/procedural patient care objectives:
1.
Set- up for a case in reasonable time (15 minutes - machine check, drugs, airway
equipment).
2.
Ventilate lungs via mask and intubate the trachea of patients with easy to moderately
difficult airways.
3.
Insert a laryngeal mask airway without assistance.
4.
Place peripheral intravenous and arterial catheters with minimal assistance.
5.
Perform basic regional blocks on suitable patients under supervision with minimal
assistance.
6.
Keep legible and accurate intra-, pre- and post-operative records.
7.
Operate basic monitors and pressure transducers and trouble-shoot simple technical
malfunctions.
8.
Assemble and calibrate transducers without assistance.
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Medical Knowledge
Goals:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Understand the theory and practical applications of anesthesia machines and standard
ASA monitors (pulse oximetry, capnography, circuits, oscillometric blood pressure cuffs,
oxygen monitors, temperature devices, and electrocardiogram).
Understand the theory and practice of neuromuscular blockade (commonly used
relaxants, monitoring sites, train-of-four monitoring, DBS, tetanus, and reversal).
Understand the application of physics to anesthesia (gas laws, vaporization,
thermodynamics, mechanics and electromagnetic radiation [e.g. MRI]).
Understand the concepts of "MAC" and the basic principles of uptake and distribution of
inhalation anesthetics.
Understand the basic pharmacokinetics and pharmacodynamics of opioids, muscle
relaxants and hypnotics.
Understand the basic alterations in cardiac, respiratory, and neurologic function resulting
from both general and regional anesthesia.
Understand the use of routine vasoactive drugs (e.g. phenylephrine, ephedrine, atropine).
Understand the indications for commonly used anesthetic drugs.
Understand the indications and major hemodynamic and respiratory effects of routine
anesthetic agents (e.g. inhalational, induction, benzodiazepines, opioids, ketorolac, etc.).
Understand comprehensive examination and classification of the airway.
Understand key preoperative findings in the history, physical examination , and
laboratory work.
Understand the scope of practice for preoperative, intraoperative and post-operative care.
Understand the role of the anesthesiologist as a consultant.
Understand the role of the certified registered nurse anesthetist (CRNA), PACU nurse,
operating room nurse, respiratory therapist, laboratory services and radiology services as
they pertain to the practice of anesthesiology.
Understand application of "universal precautions" and aseptic technique.
Objectives:
1.
Demonstrate an understanding of monitoring equipment including being able to explain
limitations to the monitor and situations when the monitor may be inaccurate.
2.
Use neuromuscular blockade effectively in clinical practice.
3.
Modify the use of anesthetics based on relevant physics and chemical
principles.
4.
Use the basic principles of uptake and distribution of inhalation anesthetics in clinical
practice.
5.
Make clinical decisions based on basic pharmacokinetics and pharmacodynamics
of opioids, muscle relaxants and hypnotics.
6.
Make clinical decisions based on alterations in cardiac, respiratory, and neurologic
function resulting from both general and regional anesthesia.
7.
Use of routine vasoactive drugs (e.g. phenylephrine, ephedrine, atropine) in a rationale
manner.
8.
Comprehensively examine and classify a patient’s airway.
9.
Reliably maintain "universal precautions" and aseptic technique.
10.
Maintain Basic Life support certification.
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11.
Maintain Advanced Cardiac Life Support certification.
Practice Based Learning
Goal:
The goal for residents at this point in training is to begin to develop lifelong learning skills,
including reading about unfamiliar patient care situations, and be encouraged to formulate
questions when unclear how to integrate knowledge into clinical practice.
Objectives:
1. Learn from clinical experiences and direct teaching and begin to understand the techniques
of scientific investigation, including basic statistical analysis.
2. Effectively use information technology for patient care and education.
3. Demonstrate the ability to efficiently impart information to colleagues and students.
Interpersonal Skills and Communication
Goals:
Residents will begin to develop communication skills with patients and other health care
professionals, including: interviewing patients in a manner conducive to patient participation;
developing good listening skills; learning to explain anesthetic options and procedures, including
risks in an appropriate manner; and learning to effectively impart information both verbally and in
writing.
Objectives:
1.
Communicate effectively with patients, other residents and staff physicians.
2.
Deliver concise (< 5 minutes), organized case presentation to staff that includes important
pre-anesthetic concerns.
3.
Formulate and describe in detail a plan for anesthetic management of ASA physical
status 1-3 patients, including anticipated problems and their solutions.
Professionalism
Goal:
At this point in residency trainees will demonstrate a professional attitude toward their work
including; placing the best interests of the patient over self-interest; exhibiting compassion;
respecting the opinions, beliefs and values of patients and colleagues; involving patients in their
medical care, and honoring the patient’s wishes.
Objectives:
1. Ethically manage informed consent, patient confidentiality and business practices and to
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promote trust and demonstrate commitment to excellence and professional development.
2. Begin to lead and managing intraoperative resources including nurses, anesthesia
technicians, and ancillary personnel.
Systems Based Practice
Goal:
Provide anesthetic care that respects and integrates the care provided by other physicians involved
with the patient; work as a team member and understand the anesthesiologist's role in the broad
context of the delivery of health care.
Objectives:
1. Demonstrate patient advocacy.
2. Understand quality improvement programs and the need for control of health care costs
without compromising care.
3. Report and managing of intra-operative adverse outcomes and develop patient advocacy
skills.
4. Demonstrate the ability to facilitate transitions of care.
Measurements of Progress
Satisfactory completion of this phase of training will be assessed by demonstrating proficiency in
the following general competencies (Patient Care and Management, Knowledge of Anesthesia,
Anesthesia Technical Skills, Practice-based learning and improvement, Communication skills,
Professionalism, Systems Based Practice) using the following departmental indicators;

Performance on both written and oral examinations

Aggregate scores of resident daily performance evaluations

Performance on subspecialty rotations

Evaluation of performance by the Clinical Competency Committee using the
essential attributes as outlined by the American Board of Anesthesiology
Successful completion of this phase of the residency program will be recorded by the Clinical
Competence Committee and forwarded to the Program Director for endorsement. The Program
Director, Associate Program Director, and Chairman of the Clinical Competence Committee will
counsel residents when performance does not meet expectations.
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Overall Goals and Objectives for
Months 7-12 of PGY 2/CA 1 Year
Patient Care
Goal:
Assignments will be designed to give residents a graduated experience with assignment to patients
of increasing complexity as their skills and knowledge base broaden. Independent thought and
action will develop during the year and independent action will be encouraged when residents are
completely comfortable that the problem lies within their realm of experience or expertise. The
goal at the end of the first 12 months is to be proficient in the basic management of common
problems in the subspecialties listed above (preoperative assessment, post anesthesia care, pain
management) and be proficient in the management of preoperative assessment, preoperative
preparation and medication, and the intraoperative and post-surgical care of patients with
uncomplicated medical conditions presenting for anesthesia and surgery.
Objectives:
1.
Demonstrate skill and judgment in the pre-anesthetic assessment.
2.
Demonstrate satisfactory skill in the assessment of the pediatric and adult airway.
3.
Manage, under supervision, patients with difficult airways who are undergoing elective
surgery.
4.
Perform difficult airway management, under supervision, with reasonable skill (rapid
sequence vs. awake intubation) in the operating room and the intensive care unit.
5.
Manage ASA physical status 1 & 2 patients for regional or general anesthesia under
supervision without assistance.
6.
Manage ASA physical status 3 patients for uncomplicated surgery under supervision with
assistance.
7.
Initiate and manage labor pain management under supervision and without assistance
(labor epidural, intrathecal narcotics, breakthrough pain).
8.
Initiate management of trauma cases and other emergencies in proper sequence under
supervision (airway, intravenous access, monitoring).
9.
Manage cesarean section by general or regional anesthesia under supervision with
assistance.
10.
Manage patients in the post anesthesia care unit under supervision with assistance as
required (assure adequacy of airway and/or adjust ventilation; manage pain, hemodynamics
and fluids; and determine readiness for discharge),
11.
Develop and implement a rational plan for tracheal intubation of patients in the intensive
care unit under supervision.
12.
Demonstrate an understanding of post-operative pain management techniques (epidural,
PCA pump, side effect therapy, breakthrough pain therapy, emergency therapy).
13.
Demonstrate satisfactory skill and judgment in the management of routine post-anesthetic
care.
14.
Insert central and arterial catheters with minimal assistance under supervision.
15.
Insert a pulmonary artery catheter under supervision.
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17.
18.
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Perform spinal and lumbar epidural anesthesia without assistance for most patients.
Perform fiberoptic or awake tracheal intubation with assistance under supervision.
Implement post-operative pain management techniques.
Medical Knowledge
Goals:
The goal for residents at the completion of PGY 2/CA 3 year is to have a base of medical
knowledge to understand how to care for patients undergoing common place procedures requiring
anesthesia or with common disease problems.
1.
Understand the role of the physician-anesthesiologist in the various anesthesia
subspecialties cited above.
2.
Understand the pharmacology of the commonly used anesthetic agents and adjuncts in
the various subspecialties cited above.
3.
Understand the physiology of significant cardiovascular events (compression of vena
cava by surgeons, hypovolemia, hypervolemia, pulmonary embolism, ischemia, myocardial
depression).
4.
Acquire advanced clinical knowledge of the physiology of anesthesia in the healthy
patient regarding:
a. cardiovascular alterations of general, spinal, epidural anesthesia.
b. respiratory alterations of all forms of anesthesia.
c. renal, cognitive, and neuromotor physiology of anesthesia.
d. the physiology of positioning under general anesthesia.
e. the physiology of recovery from general and regional anesthesia.
5.
Understand the common complications of anesthesia and surgery.
6.
Understand the logistic and medical challenges of anesthesia in the ambulatory surgical
environment.
7.
Understand the topographic and regional anatomy pertinent to the practice of
anesthesiology.
8.
Understand basic aspects of neuroanesthesia (management of increased intracranial
pressure for craniotomy, venous air embolism), vascular anesthesia (changes with aortic cross
clamp), and orthopedic anesthesia (fat and other pulmonary emboli).
9.
Understand choice of regional versus general anesthesia.
10.
Understand the need for selective invasive monitoring.
11.
Understand basics of obstetric anesthesia (physiologic changes of pregnancy, techniques
for cesarean section, special precautions to prevent fetal compromise).
12.
Understand and apply information obtained from a pulmonary artery catheter.
Objectives:
1.
Demonstrate an understanding of clinically relevant pharmacology.
2.
Demonstrate an understanding of the physiologic changes caused by of
anesthesthetics in the healthy patients.
3.
Demonstrate an understanding of the common complications of anesthesia and surgery.
4.
Use a basic understanding of neuroanatomy to implement regional
anesthesia.
5.
Demonstrate a basic understanding of neuroanesthesia (management of increased
intracranial pressure for craniotomy, venous air embolism), vascular anesthesia (changes with
National Capital Consortium Anesthesiology Residency
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aortic cross clamp), and orthopedic anesthesia (fat and other pulmonary emboli).
7.
Be able to verbalize the benefit of regional versus general anesthesia for a given patient.
8.
Be able to verbalize the indications for selective invasive monitoring.
9.
Describe the physiologic changes of pregnancy, techniques for cesarean section, and
special precautions to prevent fetal compromise.
10.
Use information obtained from a pulmonary artery catheter in a therapeutic manner.
Communication Skills
Goal:
The overall goal for residents at this point in time from an interpersonal communication standpoint
is to cogently discuss management plans with patients, anesthesiology staff or surgeons.
Objectives:
1.
Verbalize to patients concerns related to anesthesia care.
2.
Defend choices of monitoring.
3.
Defend choices of anesthetic technique and drugs and discuss other options.
4.
Recognize when the patient is not ready for surgery and develop optimization strategies.
5.
Participate actively in teaching medical students.
6.
Review literature and participate in discussions for "Journal Club" and “Morbidity and
Mortality Conferences.”
Professionalism
Goal:
Residents will continue to demonstrate a professional attitude toward their work to include;
placing the best interests of the patient over self-interest; exhibiting compassion; respecting the
opinions, beliefs and values of patients and colleagues; involving patients in their medical care
and honoring their wishes.
Objectives:
1. Residents will ethically manage informed consent, patient confidentiality and business
practices.
2. Residents will demonstrate a commitment to excellence and professional development.
3. Residents will be expected to lead and manage intraoperative resources including junior
residents, nurses, anesthesia technicians, and ancillary personnel.
Systems Based Practice
Goal:
Residents will provide anesthetic care that respects and integrates the care provided by other
physicians involved with the patient to include working as a team member and understanding the
anesthesiologist's role in the broad context of the delivery of health care.
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Objectives:
1. Residents will demonstrate patient advocacy.
2. Residents will have participated in quality improvement programs
3. Residents will have been involved in reporting and managing intra-operative adverse
outcomes.
Measurements of Progress
Satisfactory completion of this phase of training will be assessed by demonstrating proficiency in
the following general competencies (Patient Care and Management, Knowledge of Anesthesia,
Anesthesia Technical Skills, Practice-based learning and improvement, Communication skills,
Professionalism, Systems Based Practice) using the following departmental indicators:

Performance on both written and oral examinations

Aggregate scores of resident daily performance evaluations

Performance on subspecialty rotations

Evaluation of performance by the Clinical Competency Committee using the
essential attributes as outlined by the American Board of Anesthesiology
Successful completion of this phase of the residency program will be recorded by the Clinical
Competence Committee and forwarded to the Program Director for endorsement. The Program
Director, Associate Program Director, and Chairman of the Clinical Competence Committee will
counsel residents when performance does not meet expectations.
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OVERALL GOALS & OBJECTIVES
FOR CA-2 YEAR
Introduction
The second year of the three-year clinical anesthesia continuum is designed to present the resident
with cases of increasing complexity. The year is almost completely divided into rotations that
represent sub-disciplines of anesthesiology. The purposes of the subspecialty rotations are to focus
the resident's reading and clinical training on both the theoretical and basic science material of
these areas. In addition to the subspecialty rotations listed in the CA-1 goals and objectives,
residents will participate in subspecialty rotations in cardiac, neurosurgical, and pediatric surgery
in addition to a varied number of months of advanced clinical anesthesia. Each resident will be
given priority assignment during these months to ensure adequate exposure to these sub
disciplines. The goals and objectives described here are the benchmark of progress for promotion
to the CA-3 year. The resident is expected to frequently review these goals and objectives. When
assigned to a discrete subspecialty, residents are expected to review the goals and objectives for
that rotation before, during, and after the assigned month. The knowledge base and skill level
attained should facilitate progression to the most sophisticated and challenging cases.
Patient Care
Goal:
The goal at the end of the first 24 months of residency is to be proficient in the basic management
of common problems in the subspecialties listed above (Cardiac, thoracic, and neurological
surgery) and be proficient in the management of preoperative assessment, preoperative
preparation and medication, and the intraoperative and post-surgical care of patients with
complicated medical conditions presenting for anesthesia and surgery. Assignments in the
subspecialty rotations are designed to give residents a concentrated experience. Independent
thought and action will continue to develop over the course of the year and independent action is
encouraged when the problem lies within their realm of experience or expertise.
Objectives for PGY 3/CA 2 year:
1.
Perform a complete history, physical examination, and basic anesthetic plan on a wide
variety of patients including neonates, infants, adults, and geriatric patients.
2.
Explain the changes in physiology associated with aging, prematurity, and pregnancy.
3.
Be able to defend differences in anesthetic approaches for each class of patient.
4.
Manage medical diseases in surgical patients (pulmonary, cardiovascular, hepatorenal,
endocrine, hematologic).
5.
Manage routine pediatric, vascular, thoracic, and neurosurgical cases under supervision
with assistance.
6.
Manage common chronic pain syndromes under supervision with assistance.
7.
Manage routine and complicated airways.
8.
Manage intrathecal, epidural, and conduction nerve blocks.
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9.
Manage all forms of monitored anesthesia care and remote care.
10.
Manage cardiac and respiratory insufficiency in the operating room.
11.
Manage routine post-anesthetic complications, including airway compromise,
hypotension, hypertension, hypothermia, residual neuromotor block, and delirium.
12.
Manage routine and emergent anesthetics for vaginal delivery and cesarean section.
13.
Manage critical care patients with ARDS, pulmonary aspiration, neuromuscular diseases,
asthma, and pulmonary edema.
14.
Perform spinal and lumbar epidural anesthesia in patients with extremes of body habitus.
15.
Insert peripheral intravenous catheters in pediatric patients < 2 yrs.
16.
Perform a variety of basic and intermediate regional blocks.
17.
Insert a pulmonary artery catheter with minimal assistance.
18.
Insert pediatric central catheters with assistance, under supervision.
Medical Knowledge
Goal:
The goal for PGY 3/CA 2 residents is to acquire adequate medical knowledge to understand
complex patient care involving multidisciplinary subspecialty care. Residents will care for patients
undergoing complex surgical procedures and/or with advanced disease states and their medical
knowledge must be sufficient to intellectually understand the complexities involved.
Objectives:
1.
Understand the physiology and anesthetic concerns associated with pediatric anesthesia.
2.
Understand obstetric syndromes and their anesthetic implications.
3.
Understand routine open heart procedures, including pre-bypass, bypass, and separation
from cardiopulmonary bypass.
4.
Understand the physiology and pharmacology of neuroanesthesia.
5.
Understand in depth the pharmacology of a variety of vasoactive and anesthetic drugs.
6.
Understand the anatomy of an anesthesia system, including:
a.
The design and function of anesthesia breathing systems, anesthesia vaporizers,
physiologic monitors, ventilators, and gas delivery systems.
b.
The physical properties of gases, vaporization, fluid flow and mechanics,
electricity, magnetism, and electromagnetic radiation as applied to the OR.
c.
The standards for waste gas elimination, line isolation systems, and compressed
gas cylinders.
7.
Understand and articulate the anesthetic requirements for the staffing of operating rooms,
PACU, and ambulatory surgical suites.
8.
Understand the theoretical and practical elements of resuscitation of the neonate, infant,
adult, geriatric, and trauma patient.
9.
Understand the physiology and pharmacology of the neuromuscular junction.
10.
Understand the physiology and pharmacology of fetal placental blood flow and transfer.
11.
Understand the physiology and pharmacology of pulmonary blood flow and ventilation.
12.
Understand the physiology and pharmacology of renal regulation of body fluids.
13.
Understand the pathophysiology of burns.
14.
Understand the pathophysiology of cardiac and respiratory failure.
15.
Understand the pathophysiology of liver disease.
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16.
17.
pain.
18.
19.
20.
PAGE 19
Understand the pathophysiology of malignant hyperthermia.
Understand the theory of pain receptors, complex regional pain syndromes, and chronic
Understand the mechanism of action of general and local anesthetics.
Understand methods of statistical analysis of scientific and quality of care data.
Understand ethical and legal elements of the profession of anesthesiology.
Communication Skills
Goal:
The overall goal for interpersonal communication by the completion of PGY 3/CA 2 year is to be
able to cogently discuss management plans with patients, attending anesthesiologists and surgeons
for ASA physical status 4 patients.
Objectives:
1.
Demonstrate sufficient knowledge and defend clinical decisions on oral board style
examinations.
2.
Lecture to faculty and residents at teaching conferences.
3.
Actively teach medical students.
4.
Effectively communicate both verbally and in writing with consultants regarding issues
such as:
a. Assessment of cardiac risk factors for anesthesia and surgery.
b. Assessment of pulmonary risk factors for anesthesia and surgery.
Professionalism
Goal:
The overall goal for residents during PGY 3/CA 2 year is to continue to develop a professional
attitude toward their work including: placing the best interests of the patient over self-interest;
exhibiting compassion; respecting the opinions, beliefs and values of patients and colleagues;
involving patients in their medical care and honoring the patient’s wishes. During this year the
residents will face far greater challenges from a professionalism standpoint since they will
rotate at 3 hospitals they have not worked at before. They will confront new settings, different
patient populations, and new team members.
Objectives:
1. Ethically manage informed consent and adequately evaluate and educate patients in new
settings with a varied patient population. Residents will encounter patients of far more
diverse backgrounds than during CA 1 year (spent at WRNMMC where patients have
similar backgrounds as are all fully insured) as they will rotate at civilian tertiary
referral centers serving very varied patient populations. Interacting with this patient
population will require residents to exhibit a high degree of professionalism.
2. Demonstrate a commitment to excellence and professional development. Residents will
be expected to lead and manage intraoperative resources including CRNAs, junior
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residents, nurses, anesthesia technicians, and ancillary personnel.
Systems Based Practice
Goal:
Residents will provide anesthetic care that respects and integrates the care provided by other
health care providers involved with the patient.
Objectives:
1. Work as a team member on multidisciplinary teams involving subspecialty team
members.
2. Understand the anesthesiologist's role in the broad context of the delivery of health care
including patient advocacy, quality improvement programs and control of health care costs
without compromising care.
3. Be involved in reporting and managing intra-operative adverse outcomes and develop
patient advocacy skills.
Measurements of Progress
Satisfactory completion of this phase of training will be assessed by demonstrating proficiency in
the following general competencies (Patient Care and Management, Knowledge of Anesthesia,
Anesthesia Technical Skills, Practice-based Learning and Improvement, Communication Skills,
Professionalism, Systems Based Practice) using the following departmental indicators:

Performance on both written and oral examinations.

Aggregate scores of resident daily performance evaluations.

Performance on subspecialty rotations.

Evaluation of performance by the Clinical Competency Committee using the
essential attributes as outlined by the American Board of Anesthesiology.
During this year, the resident will be measured through the systems established for the CA-1
resident. However, greater emphasis will be placed on successful integration and articulated
anesthetic plans. Therefore, the resident's performance in subspecialty rotations, case
conferences and oral examinations will serve as substantive determinants of successful progress
toward the CA-3 year. Successful completion of this phase of the residency program will be
recorded by the Clinical Competence Committee and forwarded to the Program Director for
endorsement. The Program Director, Associate Program Director, and Chairman of the Clinical
Competence Committee will counsel residents when performance does not meet expectations.
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PROGRAM GOALS & OBJECTIVES CA-3 YEAR
Introduction
The CA-3 year offers great flexibility in its goal of providing residents with extensive experience
caring for the most critically ill patients. The CA-3 year is a distinctly different experience from
that of the CA-1 and 2 years. Advanced rotations are available throughout the spectrum of
subspecialties, and experience can be gained in techniques such as transesophageal
echocardiography. During the CA-3 year residents are expected to hone their clinical skills and
progress in management and leadership responsibilities in preparation for becoming a consultant
anesthesiologist. The goal is for residents to handle progressively more responsibility to prepare
them to practice independently as a consultant anesthesiologist.
All residents are provided the opportunity to attain progressively more complex and advanced
training experiences with increasing responsibility and greater exposure to seriously ill patients
compared to the CA-1 and 2 years. Clinical assignments in the CA-3 year will include the more
difficult or complex anesthetic procedures and care of the most seriously ill patients. The CA 3
year will include a “cap stone” type of experience with a rotation at either the National
Institutes of Health or at INOVA Fairfax in their cardiac anesthesia section. Both insitiutions
are high volume, quartenary referral centers for patients undergoing advanced surgical
procedures with very complex pathology. An example is the large number of patients with
syndromes enrolled in complex multidisciplinary treatment programs at NIH or the very
complex care provided by the INVOA Fairfax cardiac section for heart and lung transplants.
The resident must complete an academic assignment by the completion of their CA-3 year.
Academic projects may include special training assignments, preparation and publication of
review articles, book chapters, manuals for teaching or clinical practice, or similar academic
activities. A faculty supervisor must direct each project. The academic project requirement may
occur prior to the CA-3 year.
The Program Director and Associate Program Directors, in collaboration with the resident, will
design the resident’s CA-3 year of training, ensuring conformance to the American Board of
Anesthesiology’s requirements. In general, residents may choose either the Advanced Clinical
Track or a research track. In either track, the goals and objectives of these tracks are described
separately.
In addition, CA 3 residents have the opportunity to participate on international medical
missions.
Patient Care
Goal:
The final year is designed to hone patient care skills. Residents are expected to be able to
care for patients of all levels of ASA physician status undergoing all types of procedures.
Objectives:
1.
Manage independently, with staff availability, all ASA physical status patients with
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multisystem diseases for complex elective and emergency surgery, acute and chronic pain,
and recovery room care.
2.
Demonstrate sound judgment and decision making.
3.
Demonstrate the ability to apply basic science principles to clinical problems.
4.
Demonstrate the ability to adapt to rapidly changing clinical conditions.
5.
Demonstrate the ability to supervise and mentor medical students, junior residents and
CRNAs.
Medical Knowledge
Goal:
Understand principles of all major subspecialties (ambulatory, cardiac, critical care, endocrine,
neurosurgical, obstetrics, pediatrics, acute and chronic pain, thoracic, trauma, vascular),
including addressing important articles in recent medical literature. Demonstrate mastery of
common problems in anesthesia and care for patients undergoing common procedures.
Objectives:
1.
2.
3.
4.
Provide safe and rationale anesthesia care.
Provide safe, efficient and appropriate care for patients undergoing general anesthesia.
Provide safe, efficient and appropriate care for patients undergoing regional anesthesia.
Provide safe, efficient and appropriate care for all types of patients undergoing anesthesia to
include: pediatric, obstetrical, vascular, thoracic, trauma, cardiac surgery patients and other
patients requiring anesthesia care.
5. Perform as a consultant in anesthesiology.
6. Perform as a consultant in pain management.
Interpersonal Skills and Communication
Goal:
The interpersonal skills and communication goal for residents by the completion of training is to be
able to educate and consult with all patients and other health care providers in relation to the
practice of anesthesiology.
Objectives:
1.
2.
3.
4.
Demonstrate the ability to organize and express both verbal and written thoughts clearly.
Perform with high proficiency on oral examinations.
Lecture to faculty and residents at teaching conferences.
Actively teach medical students.
Professionalism
Goal:
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By the completion of training residents must have demonstrated consistent professional behavior
in multiple areas of operation across all subspecialties of anesthesiology. Residents must have
shown that they have internalized the value of professionalism and must consistently avoid
unprofessionalism which is detrimental to the therapeutic team approach to patient care.
Objectives:
1. Demonstrate a professional attitude to their work including. Residents must consistently
place the best interests of the patient over self-interest; exhibiting compassion; respect the
opinions, beliefs and values of patients and colleagues; involve patients in their medical
care and honor the patient’s wishes.
2. Demonstrate consistent ethical management of informed consent, consistent respect for
patient confidentiality and an in depth understanding of business practices.
3. Demonstrate a consistent commitment to excellence and professional development.
Residents must have shown they consistently lead and manage intraoperative resources
including CRNAs, junior residents, nurses, anesthesia technicians, and ancillary personnel.
4. Residents must have shown active participation in teaching fellow residents and medical
students and the ability to continue to do so after training.
5. Residents must have demonstrated the qualities and attributes fundamental to a consultant
anesthesiologist according to the requirements of the American Board of Anesthesiology.
Systems Based Practice
Goal:
Residents must consistently provide anesthetic care that respects and integrates the care provided
by other physicians involved with the patient; work as a team member and understand the
anesthesiologist's role in the broad context of the delivery of health care, including patient
advocacy, quality improvement programs and control of health care costs without compromising
care.
Objectives:
1. Residents must have been involved in reporting and managing intra-operative adverse
outcomes. They must have the ability to participate in institutional Quality Improvement
programs after graduation.
2. Residents must consistently show an understanding of their role in the larger health care
delivery system and the ability to do so after graduation when in independent practice.
3. Residents must have demonstrated patient advocacy skills.
4. Residents must have an understanding of advanced topics in the management of an
Anesthesiology Department such as scheduling and creation of standard operating
procedures.
Measurements of Progress
Satisfactory completion of this phase of training will be assessed by demonstrating proficiency in
the following general competencies (Patient Care and Management, Knowledge of Anesthesia,
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Anesthesia Technical Skills, Practice-based learning and improvement, Communication skills,
Professionalism, Systems Based Practice) using the following departmental indicators;

Performance on both written and oral examinations.

Aggregate scores of resident daily performance evaluations.

Performance on subspecialty rotations.

Evaluation of performance by the Clinical Competency Committee using the
essential attributes as outlined by the American Board of Anesthesiology.
Successful completion of this phase of the residency program will be recorded by the Clinical
Competence Committee and forwarded to the Program Director for endorsement. The Program
Director, Associate Program Director, and Chairman of the Clinical Competence Committee will
counsel residents when performance does not meet expectations.
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PROGRAM GOALS AND OBJECTIVES FOR
CA-1 RESIDENTS IN THE GENERAL OPERATING ROOM
I. ROTATION DEFINITION:
The General Operating Room (GOR) rotation is planned and intended to provide the new CA-1
with a basic, broad introduction to the practice of anesthesiology. The knowledge to be gained,
both clinical and cognitive, is in the realm of the basics of anesthesia. Teaching will be divided
broadly into three areas: pre-anesthetic assessment, intraoperative anesthesia management, and
post-anesthesia care. To fulfill the goals and objectives the resident will be assigned to
Preoperative Evaluation Clinic for anesthesia assessment instruction and to appropriate surgical
patients. The majority of the CA-1 year will be spent performing routine cases of minimal to
moderate difficulty in non-subspecialty areas such as general surgery, plastic and reconstructive
surgery, ophthalmology, orthopedics, urology, otolaryngology and gynecology.
II. GOALS AND OBJECTIVES
The goals of this rotation for beginning CA-1 residents are to provide a broad perspective of
anesthesia, such that the resident should acquire a basic understanding of pre-anesthetic,
intraoperative and post-anesthetic issues, and to prepare residents to advance into further basic
anesthesia rotations where they will be expected to function with lesser supervision. This will
provide residents with experiences in a wide range of surgical procedures requiring general,
regional and monitored anesthesia care. Emphasis will be placed on the clinical aspects of
managing general anesthesia with mask, the laryngeal mask airway or endotracheal tube, and
basic regional anesthetic techniques, especially spinal and epidural anesthesia. The resident will
be expected to evaluate, induce and maintain anesthesia (MAC, regional or general anesthesia by
mask, ET tube or LMA) for various surgical procedures in the above areas, including abdominal
surgery, the full spectrum of orthopedic surgical procedures, and minor to intermediate difficulty
peripheral surgery. The resident should specifically develop an understanding of the effects of
aging in the practice of anesthesia. The resident should be able to plan for and implement
appropriate monitoring, fluid management and post-operative pain management strategies.
While managing these anesthetics, the resident will have to manage difficult and abnormal
airways. The curriculum includes a discussion of “The ASA Difficult Airway Algorithm” and its
application to clinical situations. Alternative methods for securing the airway, such as awake
and/or fiberoptic intubation will be practiced. Emphasis will be placed on formulating a plan of
action before managing the difficult airway. The resident will discuss emergency techniques
such as transtracheal jet ventilation and cricothyrotomy. The resident is expected to review
airway anatomy and physiology.
Patient Care
Goal:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health.
1.
Provide a preoperative patient assessment, and suggest appropriate perioperative
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interventions to ensure patient safety and reduce risk, based on findings and preexisting patient
conditions.
2.
Formulate an anesthetic plan, emphasizing the different needs of the inpatient and
ambulatory patient and integrating general, neuraxial, and peripheral regional anesthesia
techniques to provide optimum patient outcome and satisfaction.
3.
Provide peripheral and/or neuraxial blocks, sedation or general anesthesia in a competent
and safe manner, providing continuity of care in the operating room, and, when possible, in the
PACU or same-day surgery unit.
Objectives:
Preoperative Assessment and Preparation
1.
Perform preoperative assessments, utilizing appropriate consultations, to prepare patients
for surgery.
2.
Prescribe appropriate preoperative medications for patients receiving steroids, TPN, and
with diabetes.
Airway Management
1.
Manage airways of normal to moderate difficulty utilizing face masks, laryngeal mask
airways, oral airways, and endotracheal tubes.
2.
Intubate patients with a minimum 95% success rate and perform a rapid sequence
intubation in patients with supervision.
3.
Perform elective fiberoptic intubation on patients with normal airways under general
anesthesia.
4.
Perform awake intubations with assistance.
Anesthesia Equipment and Monitoring
1.
Perform a checkout of the anesthesia machine and related equipment.
2.
Assemble and organize appropriate equipment for general, regional or MAC anesthesia
for patients undergoing surgical procedures with the potential for minimal to moderate blood
loss.
3.
Determine and apply standard monitoring for patients, explaining and responding
appropriately to changes in the monitored parameters.
4.
Obtain and maintain venous access.
5.
Apply appropriate monitoring devices and describe the risks and benefits of invasive
monitoring.
6.
Assemble equipment necessary for placement of arterial and central venous pressure
lines.
7.
Insert arterial lines when indicated.
8.
Prepare and position a patient for central line placement (IJ or SC) while developing the
skills required for placement of central lines via either route.
9.
Organize equipment and drugs to facilitate safe and timely room turnovers.
General Anesthesia
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Goals and Objectives
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1.
Induce and maintain general anesthesia in ASA I and II patients with moderate staff
direction, and in ASA III and IV patients with staff involvement as needed for major intraabdominal and other surgical procedures.
2.
Conduct general anesthetics with inhalational, balanced and TIVA techniques.
Regional Anesthesia Techniques
1.
Initiate spinal or epidural anesthetics and manage the patient intra-operatively.
2.
Perform regional anesthesia to the upper extremity, correctly selecting equipment and
medications.
Sedation Techniques
1.
Manage deep sedation for prolonged surgical procedures.
Intraoperative Management
1.
2.
3.
4.
5.
6.
7.
8.
Maintain normal levels of O2 or CO2 through proper management of ventilation.
Assist in properly positioning patients.
Accurately complete the anesthetic record.
Demonstrate communication and teamwork in the operating room.
Select, modify and prepare the appropriate endotracheal tubes for laser surgery.
Appropriately manage intraoperative fluid and transfusion therapy.
Modify the anesthetic gas mixture to minimize the risk of fire in airway laser procedures.
Perform jet ventilation for laser cases performed without an endotracheal tube.
Post-operative Management
1.
Safely conduct the patient to PACU and communicate the patient‟s condition to
personnel responsible for post-operative care of the patient.
2.
Prevent or treat post-operative nausea and vomiting with appropriate doses of
antiemetics.
3.
Institute appropriate post-operative analgesia for surgical patients.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
1.
Understand new theories of anesthetic management and how they will affect the future of
anesthesia care.
2.
List important considerations for surgical procedures, and how anesthetics can be tailored
to meet these requirements.
3.
Describe the use of multimodal analgesia, in particular the use of TIVA and regional
blocks, and how this technique contributes favorably to the goals of anesthesia.
4.
Discuss complications of anesthesia that can lead to unplanned admissions, and strategies
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to avoid or treat these complications.
Objectives:
Preoperative Assessment and Preparation
1.
Describe the ASA classification and preparation of an ASA I - III patient for surgery.
2.
Describe appropriate pre-anesthetic medication for this ASA I or III patient.
3.
Discuss methods of preparing patients with IDDM for anesthesia.
4.
Describe implications of patients on steroids undergoing anesthesia.
5.
Discuss the appropriate evaluation and management of patients with hypertension,
coronary artery disease or pulmonary disease presenting for surgery.
6.
Explain the pathophysiology of altered renal function in patients.
7.
Assess and categorize patient’s airways into the appropriate classification.
Airway Management
1.
Recognize indications for rapid sequence or awake intubations and discuss the methods
of each.
2.
Describe the innervation of the upper airway, larynx and trachea.
3.
Describe topical anesthesia of the airway for awake intubation.
4.
Summarize the “ASA Difficult Airway Management Algorithm.”
5.
Plan an induction technique for a difficult airway and an alternative plan for managing a
"cannot ventilate-cannot intubate scenario."
6.
Review the anatomy of the cricothyroid membrane.
7.
Describe needle cricothyrotomy.
8.
Compare the pressure required for transtracheal ventilation in adults and children using a
jet ventilator.
Anesthesia Equipment and Monitoring
1.
List and describe the safety features found on modern anesthesia machines.
2.
Describe the function and use of the components of an anesthesia machine, including
flow meters, vaporizers, and gas sources.
3.
List and describe the components of an adult circle system and anesthetic ventilator,
identifying appropriate settings for an adult patient.
4.
Identify the data available from noninvasive monitoring and the complications that can be
identified from such monitoring.
5.
List the “Standards for Basic Anesthetic Monitoring.”
6.
Identify the indications (patient conditions and surgical procedures) for invasive
monitoring, particularly arterial line and central venous line placement.
7.
Describe the relative anatomy, techniques for placement and complications of CVP lines.
8.
Describe the relative anatomy, techniques for placement and complications of arterial
lines.
Anesthetics and Adjuncts
1.
Describe the basic pharmacology of commonly used inhalation anesthetics, local
anesthetics, muscle relaxants, and intravenous agents.
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2.
Discuss cost-benefit analysis of various narcotics, muscle relaxants and intravenous
drugs.
3.
Describe the basic pharmacology of local anesthetics, including the properties
determining onset, duration, potency and toxicity.
4.
Describe the basic pharmacology of commonly used vasopressors, antimuscarinics,
neuromuscular blocking agent antagonists, and B-blockers.
Regional Anesthesia Techniques
1.
Plan and select equipment and local anesthetic agents for basic regional anesthetic
procedures; select and defend these choices for surgical procedures based on duration, location
and severity of illness of the patient.
2.
Describe the anatomy pertinent to the performance of spinal, epidural or axillary block.
3.
Describe the pharmacology and clinical use of common local anesthetics for spinal and
epidural anesthesia.
4.
Describe physiological effects and treatment of side effects related to spinal and epidural
anesthesia.
Sedation Techniques
1.
Discuss safe management of minimal, moderate and deep sedation.
Intraoperative Management
1.
List the purposes of an anesthesia record and discuss its use.
2.
Describe physiologic effects of hypothermia and discuss methods of prevention in the
operating room.
3.
Describe patient injuries related to anesthesia and methods of prevention.
4.
Describe proper patient positioning and prevention of injuries in the supine, lateral and
lithotomy positions.
5.
Discuss the following implications of lasers used in procedures:
a.
Review the risks of laser energy.
b.
Apply safety principles applicable to laser airway surgery.
c.
List the advantages and disadvantages of different endotracheal tubes as they
pertain to laser surgery.
d.
Formulate a safe anesthetic plan for airway laser surgery.
e.
Summarize a plan of action for management of airway fires.
6.
Plan the anesthetic management, including patient monitoring, for fiberoptic and rigid
bronchoscopy.
7.
Explain the principles of venturi jet ventilation during laser airway surgery via a rigid
bronchoscope or laryngoscope.
8.
Discuss apneic oxygenation and the subsequent rate of rise of PaCO2 during its use.
9.
Discuss complications common during orthopedic surgery as pertaining to pneumatic
tourniquets, fat embolism, methylmethacrylate, and etiology of deep venous thrombosis.
10.
Discuss risks of anesthesia practice pertaining to anesthesiologists.
11.
Describe the perioperative fluid management for an ASA I or II adult undergoing
abdominal and peripheral surgeries with minor to moderate blood loss.
12.
List the indications for and complications of blood transfusions.
13.
Describe the elements of autologous blood programs, including pre-operative autologous
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pre-donation, acute normovolemic hemodilution, and cell salvage.
14.
Describe the physiologic changes and complications associated with laparoscopic
surgical procedures.
Post-operative Management
1.
List common problems in the PACU.
2.
Compare and contrast post-operative pain control strategies, including patient controlled
analgesia (PCA) with different opioids, subarachnoid opioids, epidural analgesia, continuous
peripheral nerve catheters, intraarticular local anesthetic and opioid injections, and non-steroidal
anti-inflammatory drugs (NSAIDS).
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
Discuss with patients the utility and advantages, as well as potential disadvantages, of the
different forms of anesthesia and analgesia for appropriate cases.
2.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
3.
Articulate the anesthetic plan to the attending anesthesiologist and explain the rationale
for the plan.
4.
Conduct post-operative visits for inpatients to evaluate patient satisfaction and determine
the incidence of undesirable effects of the anesthetic.
5.
The resident must be sensitive to patient concerns about awareness and pain.
Professionalism
Goal:
Residents must demonstrate a commitment to fulfilling professional responsibilities, adherence
to ethical principles, and sensitivity to a diverse patient population.
Objective:
1.
Interact with staff anesthesiologists, CRNAs, PACU nurses, and operating room staff in a
manner that reflects interpersonal respect, integrity and commitment to excellence in patient care.
2.
Manage interpersonal conflict with dignity and in a manner that avoids offensive
behavior and reflects emotional maturity.
3.
Protect patient confidentiality.
4.
Maintain a respectable appearance.
5.
Consult the surgical team and attending anesthesiologist when questions arise as to the
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appropriateness of an anesthetic technique or about the nature of the planned procedure, fostering
an atmosphere of collegiality, facilitating the development of a plan which best serves the interest
of the patient.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care, evaluate scientific evidence,
and assimilate both to improve their patient care practices.
Objectives:
1.
Review the success of every anesthetic case performed and, should problems occur, use
appropriate resources to address those problems to improve the quality of care.
2.
Keep an accurate case log to document clinical experiences.
3.
On a daily basis evaluate the shortcomings, complications and patient satisfaction of their
anesthetic care. Discuss these observations with staff and rotation directors to develop a plan for
improving the quality of anesthetic care provided.
4.
Participate in simulated oral board scenarios, drawing upon knowledge gained from
clinical experience and the readings, and communicate safe pre-, intra- and post-operative
management of all forms of anesthesia and their potential complications in complex situations.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Analyze those factors that may optimize PACU throughput.
2.
Assess causes of failure to achieve PACU discharge in less than 60 minutes, modifying
care to improve their success in this area.
3.
Evaluate patient feedback to facilitate identification of problems in anesthesia care and
creation of potential solutions to improve both patient care and patient satisfaction.
4.
Develop an understanding of the use of Anesthesia Coding guidelines as a measure of
productivity
III. REQUIRED READING
1.
Clinical Anesthesiology, 4th edition, G. Edward Morgan, Maged S. Mikhail, Michael J.
Murray Ed. McGraw Hill, 2005.
IV. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and will be based on the review of evaluations from the faculty.
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Goals and Objectives
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ROTATION EVALUATION
At the completion of the rotation, the residents will evaluate the training experiences. The
evaluation will include their assessment of:

Educational experience.

Caseload diversity and volume.

Strengths and weaknesses of the rotation.
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Goals and Objectives
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PROGRAM GOALS AND OBJECTIVES FOR
RESIDENTS IN THE POST ANESTHESIA CARE UNIT
I.
ROTATION DEFINITION
The PACU experience consists of a one month rotation spent caring for post-operative patients in
the PACU. All patients who have received general anesthesia, regional anesthesia, or monitored
anesthesia care (MAC) should receive appropriate post-anesthesia management. The importance
of an anesthesiologist’s involvement in the admission, post-operative assessment, management
and discharge from the PACU cannot be overemphasized. Any patient transported to the PACU
will be accompanied by a member of the anesthesiology service who is knowledgeable about the
patient's condition. The patient will receive appropriate monitoring, support and treatment in the
PACU. A physician capable of managing complications and providing advanced cardiac life
support shall be available to patients in the PACU.
II.
GOALS AND OBJECTIVES
The goal of the PACU rotation is to provide the anesthesiology resident with a firm framework of
knowledge and skills necessary to recognize, diagnose and treat complications that may occur in
the immediate post-operative period while patients recover from the effects of surgery and
anesthesia. This rotation is designed to provide the resident with a comprehensive introduction to
the various aspects of post-operative care in the PACU. A brief description of the clinical
material to be taught will be divided into four major areas. The first area is admission criteria; the
second area is pain management; the third is discharge criteria; and the fourth is the management
of all types of medical and/or post-surgical complications that may arise in the PACU. These
complications may involve the cardiac, pulmonary, renal, metabolic, musculoskeletal and
neurological systems, or other miscellaneous complications that could have resulted from
problems in the operating room. The resident will be expected to become knowledgeable with
post-operative pain medications, resuscitative medications and other miscellaneous medications.
The resident will also become familiar with reading and interpreting EKGs and data from
invasive line monitoring including arterial lines, central lines, and Swan- Ganz catheters. The
resident will learn to obtain appropriate consultation and to work with
consultants in a collegial manner. A reading list will be provided at the beginning of the rotation
to provide further exposure to common PACU problems and interventions.
Patient Care
Goals:
Residents must provide patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health.
Objectives:
1. Provide appropriate assessments of problems that occur with PACU patients and
suggest appropriate perioperative interventions to ensure patient safety and reduce
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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risk, based on the clinical scenario and preexisting patient conditions.
2. Manage post-operative pain, emphasizing the needs of the ambulatory patient and
integrating the general, neuraxial and/or peripheral regional anesthesia techniques
used in the operating room to provide optimum patient outcome and satisfaction.
Objectives:
1.
Treat patients with post-operative hypertension.
2.
Diagnose cardiac dysrhythmias and prescribe the appropriate treatment.
3.
Institute ACLS and BLS protocols to resuscitate patients.
4.
Diagnose aspiration pneumonitis and institute appropriate therapy.
5.
Assess and manage volume status.
6.
Follow-up on post-operative chest x-rays obtained in the PACU, recognizing and treating
complications such as pneumothorax and hemothorax, including insertion of a chest tube under
supervision in an emergency situation.
7.
Perform airway management as required, including mask ventilation and endotracheal
intubation in both conscious and unconscious patients.
8.
Institute breathing treatments for asthmatics and prescribe epinephrine for upper airway
obstruction, when appropriate.
9.
Manage the treatment of hypothermia or hyperthermia in adult and pediatric patients.
10.
Treat the four different classifications of shock: hypovolemic, cardiogenic, septic, and
neurogenic shock.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
1.
Understand the discharge criteria for ambulatory surgical patients and describe how
PACU pain medication regimens may be designed to meet these requirements.
2.
Understand the use of multimodal analgesia, in particular the use of peripheral blocks,
and how this technique contributes favorably to the goals of ambulatory anesthesia.
3.
Understand complications of peripheral blocks, their presentation in the PACU
and management strategies.
4.
Understand complications of general anesthesia which may lead to unplanned
admissions, and strategies to avoid or treat these complications.
5.
Recognize when post-operative pain exceeds that expected for a surgical procedure and
may require surgical intervention.
Objectives:
1.
2.
3.
4.
Discuss the various modalities for management of acute post-operative pain.
Discuss perioperative fluid assessment and management.
Discuss the evaluation, assessment and treatment of hypotension and hypertension.
Discuss the evaluation and treatment of airway complications.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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5.
Discuss differential diagnosis and management of the patient with delayed emergence
from anesthesia.
6.
Discuss the differential diagnosis and management of the patient with prolonged
weakness from neuromuscular blockade.
7.
Discuss the ASPAN guidelines for nursing staff support within the PACU.
8.
Understand and discuss issues relating to cardiac dysfunction, including:
a.
The definition and treatment of shock and the pathophysiology of cardiogenic,
hypovolemic, septic, and neurogenic shock.
b.
Myocardial ischemia, infarction and arrhythmias.
9.
Understand and discuss issues relating to pulmonary dysfunction, including:
a.
Inadequate respiratory drive.
b.
Increases in airway resistance.
c.
Decreases in compliance.
d.
Problems with neuromuscular disease.
e.
Increases in dead space ventilation.
f.
Increases in carbon dioxide.
g.
Increases in V/Q mismatch.
h.
Causes and treatment of pulmonary aspiration.
10.
Understand and discuss issues relating to renal dysfunction, including:
a.
The causes of decreased urine output and identification of pre-renal, renal, or
post-renal dysfunction.
b.
The complications of renal failure.
11.
Understand and discuss issues relating to metabolic dysfunction , including:
a.
The diagnosis of acid base imbalances and definitions of and differences between
anion gap and non-anion gap acidosis.
b.
Glucose metabolism, diabetes, and acute diabetic acidosis.
c.
Electrolyte problems including those related to sodium, potassium, and chloride.
d.
The adverse effects of electrolyte changes on cardiac conduction.
12.
Understand and discuss miscellaneous problems, including:
a.
The causes and treatment of nausea and vomiting.
b.
Eye injury in the operating room.
c.
Positioning injury in the operating room.
d.
Airway trauma in the operating room.
e.
The use and complications of invasive lines.
f.
The diagnosis and management of airway obstruction.
13.
Understand and discuss issues relating to temperature dysfunction , including:
a.
Diagnosis and treatment of patients with malignant hyperthermia.
b.
The diagnosis and treatment of hypothermia.
14.
Understand and discuss discharge evaluation criteria , including:
a.
Aldrete Score for in-house patients.
b.
Cognitive/Motor Criteria for Outpatients.
Interpersonal Skills and Communication
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Goals and Objectives
JUL 2016
PAGE 36
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families and professional
associates.
Objectives:
1.
Communicate effectively and demonstrate caring and respectful behaviors when
interacting with patients and their families.
2.
Create and sustain a positive patient/family relationship.
3.
Work closely with the PACU nurses to provide optimum patient care.
4.
Work effectively with others as a member or leader of a health care team or other
professional group.
5.
Receive accurate report from the OR team concerning patients medical conditions and
perioperative course.
6.
Accurately document any medically significant patient interactions.
7.
Deliver accurate reports when transferring patient care to either the anesthesia team on
call or the ICU, including PACU keep patients.
8.
Recognize situations requiring consultation with the attending anesthesiologist.
Professionalism
Goal:
Residents must demonstrate a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient population.
Objective:
1.
Demonstrate respect, compassion, and integrity when interacting with patients.
2.
Demonstrate a commitment to patient confidentiality and HIPAA guidelines.
3.
Demonstrate sensitivity and responsiveness to patients‟ culture, age, gender, and
disabilities.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices, appraise and
assimilate scientific evidence, and improve their delivery of patient care.
Objectives:
1.
2.
3.
Use information technology to support patient care decisions and patient education.
Obtain and read current journal articles related to PACU topics.
Apply knowledge they have gained in the PACU to the general practice of anesthesia.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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4.
Facilitate the learning of students and other health care professionals.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of health care and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals.
2.
Understand how efficient management of the PACU enhances flow of patients through the
OR and can impact OR productivity.
3.
Understand PACU staffing ratios and shift scheduling to mange personnel costs.
4.
Practice cost-effective health care and resource allocation that does not compromise quality
of care.
5.
Work with health care professionals, including those from other disciplines, to provide
patient-focused care.
III.
REQUIRED READING
1.
The Post-anesthesia Care Unit, Chapter 85, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
2.
Distributed articles
IV.
EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and the following criteria:
1.
Completion of a minimum of two weeks of PACU experience by each resident.
2.
Satisfactory staff evaluations for their month in the PACU. These will be based on
discussions between staff and resident, focusing on patient care, knowledge, practice- based
learning, and interpersonal and communication skills.
3.
Evaluations by PACU nurses, highlighting interpersonal and communication skill,
professionalism, and system based practice.
4
Residents will be required to give a twenty minute lecture to the PACU staff on an
anesthesia-related topic of post-operative care.
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V.
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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Goals and Objectives
JUL 2016
PAGE 39
PROGRAM GOALS AND OBJECTIVES FOR
RESIDENTS IN AMBULATORY SURGERY
I. ROTATION DEFINITION
The Ambulatory Surgery curriculum at the National Capital Consortium is designed to introduce
residents to basic concepts in assessment and management of outpatients for surgical procedures.
This is achieved during daily rotations in an outpatient preoperative evaluation clinic (typically
12-20 patients daily) and performance of anesthetics for outpatients during a three year residency.
Residents are expected to master anesthetic principles and techniques and understand current
controversies as they relate to ambulatory surgery.
II. GOALS AND OBJECTIVES
The overall goal of this curriculum is to introduce the resident to the concept of anesthesia for
ambulatory surgery, emphasizing the different management strategies and challenges as
compared with in-patient surgery. These primarily will involve rapid preoperative assessment,
different ambulatory anesthesia techniques, and ensuring appropriate discharge to home on the
same day of surgery.
Patient Care
Goal:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Provide a preoperative patient assessment and suggest appropriate perioperative
interventions to ensure patient safety and reduce risk, based on findings and preexisting patient
conditions.
2.
Elaborate an anesthetic plan, emphasizing the different needs of the ambulatory patient
and integrating general, neuraxial, intravenous, and peripheral regional anesthesia techniques to
provide optimum patient outcome and satisfaction.
3.
Provide peripheral blocks, neuraxial blocks, sedation or general anesthesia in a competent
and safe manner, providing continuity of care in the operating room, and, when possible, in the
PACU or same-day surgery unit.
Objective:
Preoperative Evaluation
1.
Perform a rapid preoperative evaluation on healthy ASA I and ASA II class patients,
noting when the surgery is not appropriate for this patient in the ambulatory setting.
General Anesthesia
1.
Perform inhalational anesthesia with short-acting agents and awaken the patient quickly
and comfortably.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 40
2.
Perform total intravenous anesthesia with propofol and short-acting narcotics.
3.
Manage inhalation induction in children.
4.
Administer short-acting muscle relaxants including appropriate reversal.
5.
Provide safe airway management with face masks, laryngeal mask airways, and
endotracheal tubes.
Regional Anesthesia
1.
2.
Perform peripheral nerve blocks.
Perform spinal, caudal, and epidural blocks.
Monitored Anesthesia Care Sedation Techniques
1.
2.
Perform MAC with appropriate intravenous agents administered by bolus.
Perform MAC with appropriate intravenous agents administered via continuous infusion.
Post-operative Management
1.
Manage patients in the PACU and treat post-operative pain, emesis and any other
complications.
2.
Discharge patients from facility via Phase II recovery.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Understand new theories of anesthetic management and their impact upon the future of
anesthesia care.
2.
List important anesthetic implications of surgical procedures, and prescribe anesthetics to
meet these requirements.
3.
Describe the use of multimodal analgesia, in particular TIVA and regional blocks, and its
favorable impact upon the goals of anesthesia.
4.
Discuss anesthetic complications and their management.
5.
Discuss the prevention and management of anesthetic complications that may lead to
unplanned admissions.
Objectives:
Preoperative Evaluation
1.
Identify the key aspects of history and physical examination relevant to patients
undergoing surgery in the ambulatory setting.
2.
Understand the advantages and disadvantages of various preoperative evaluation
methods, including clinic appointments, telephone interviews, and screening
questionnaires.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
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3.
Outline a rational and cost-effective plan for preoperative laboratory testing in an
ambulatory surgical population and defend these choices with data.
4.
Develop a plan for the effective management of diabetic patients for outpatient surgical
procedures.
5.
List and discuss the pathophysiological changes and anesthetic implications of reactive
airway disease, morbid obesity, and advanced age.
6.
Know the current status regarding anesthesia in ex-premature infants, especially with
regards to pulmonary disease and post-operative apnea.
7.
Select patients for ambulatory anesthesia, assessing the severity of co-morbid conditions
such as diabetes, reactive airway disease, morbid obesity, advanced age, prematurity, children
with recent upper respiratory tract infections, family history of malignant hyperthermia, sickle
cell disease, mentally handicapped patients, congenital diseases, malignancy, and patients with
other, uncommon diseases.
8.
Discuss preoperative preparation including:
a.
NPO guidelines and the differences between adults and children.
b.
Use of antacids and H2 receptor antagonists.
c.
Prophylactic antiemetic therapy.
d.
Premedication with anxiolytics, sedatives, and opioids.
e.
Pediatric premedications and the pros and cons of parenteral presence during
induction of anesthesia.
Anesthetic Management
1.
Discuss the appropriate use of premedication in the ambulatory setting, including
antacids, H2 receptor antagonists, antiemetics, anxiolytics, and opioids. List the indications,
contraindications, appropriate application of various pediatric premedication regimens.
2.
Demonstrate knowledge of anesthesia monitors and equipment, including oscillometry,
EKG, pulse oximetry, capnography, gas analyzers, temperature monitors, and automated record
keeping devices.
3.
Be prepared to discuss the pharmacologic characteristics and physiologic effects of
intravenous agents, including barbiturates, benzodiazepines, propofol, etomidate, ketamine,
opioids, and available antagonists.
4.
Discuss the pharmacologic characteristics, physiologic effects, indications and
contraindications of the available inhalational anesthetics in the ambulatory surgery setting.
5.
Know the mechanism of action, mode of clearance, and indications and contraindications
for ultra-short, short, and intermediate duration muscle relaxants in the ambulatory surgery
setting.
6.
Discuss the relative advantages and disadvantages of different airway maintenance
techniques including the face mask, laryngeal mask airway, and endotracheal intubation.
7.
Demonstrate understanding of the sedation techniques and considerations inherent in
monitored anesthesia care.
8.
Demonstrate understanding of the special anesthetic requirements for laser surgery, MRI,
radiation therapy, electroconvulsive therapy, lithotripsy, and endoscopy.
Regional Anesthesia Techniques
1.
List the indications and contraindications for regional anesthetic techniques in the
ambulatory setting, including appropriate selection of local anesthetic agents.
2.
Discuss the advantages and disadvantages of neuraxial blocks with various local
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
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anesthetics in the ambulatory setting.
Monitored Anesthesia Care (MAC) Sedation Techniques
1.
Explain the need and technique for psychological preparation of the patient for monitored
anesthesia care.
2.
Discuss the pharmacokinetics and pharmacodynamics of IV bolus techniques.
3.
Demonstrate an understanding of the indications, contraindications, and various
techniques for providing monitored anesthesia care.
4.
Discuss the appropriate use of continuous IV techniques (e.g. propofol, remifentanil,
etc.).
Post-operative Management
1.
Understand the bypass and discharge criteria and common post-operative complications
present in Phase I (PACU) and Phase 2 recovery.
2.
Describe appropriate post-operative management of a patient during Phase I recovery
(PACU) including:
a.
b.
c.
3.
Discuss pertinent issues during Phase II recovery including:
a.
b.
4
Monitoring in the PACU.
Pain management.
Emesis management.
Discharge criteria for ambulatory surgical patients.
The use of post-operative patient education instructions in the facility.
Describe the post-operative follow-up of patients in the ambulatory setting.
Interpersonal Skills and Communication
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates. Residents are expected to:
1.
Discuss with patients both the advantages as well as potential disadvantages of the
different forms of anesthesia and analgesia appropriate for the surgical procedure.
2.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
3.
Articulate the anesthetic plan to the attending anesthesiologist and explain its rationale.
4.
Conduct post-operative visits for inpatients to evaluate patient satisfaction and determine
the incidence of undesirable effects of the anesthetic.
5.
Demonstrate sensitivity to patient concerns about awareness and pain.
Professionalism
Residents must demonstrate a commitment to their professional responsibilities, adherence to
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 43
ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
1.
Interact with staff anesthesiologists, CRNAs, PACU nurses, and operating room staff in a
manner that reflects interpersonal respect, integrity and commitment to excellence in patient care.
2.
Manage interpersonal conflict with dignity and in a manner that avoids offensive
behavior and reflects emotional maturity.
3.
Protect patient confidentiality.
4.
Maintain a respectable appearance.
5.
Consult the surgical team and attending anesthesiologist when questions arise as to the
appropriateness of an anesthetic technique or about the nature of the planned procedure,
fostering an atmosphere of collegiality and allowing the development of a plan which best serves
the interest of the patient.
Practice Based Learning
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care. Residents are expected to:
1.
Review the success of every anesthetic case performed, and if problems occur use
appropriate resources to address those problems and improve the quality of care.
2.
Keeps an accurate case log documenting their clinical experiences.
3.
On a daily basis, gather information on the shortcomings, complications and patient
satisfaction with perioperative care. Discuss these observations with staff and rotation
directors to develop a plan for improving the quality of care.
Systems Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value. Residents are expected to:
1.
For each anesthetic case performed, analyze those factors that may optimize PACU
throughput.
2.
Assess causes of failure to achieve PACU discharge in less than 60 minutes, modifying
patient care plans to improve success in this area.
3.
Evaluate patient feedback data, identifying problems in anesthesia care and creating
potential solutions that enhance patient satisfaction and facilitate more effective care.
4.
Develop an understanding of the use of Anesthesia Coding guidelines as a measure of
productivity
III. REQUIRED READING
1.
Preoperative Evaluation, Chapter 34, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
2.
Ambulatory Outpatient Anesthesia, Chapter 78, Anesthesia, 7th edition, Ronald Miller
Ed. Churchill Livingston, 2010.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 44
3.
The Post-anesthesia Care Unit, Chapter 71, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
IV. EVALUATION
Because ambulatory surgery is not a distinct rotation, evaluation of this aspect of their
development as an anesthesiologist will be ongoing throughout the residency.
V. ROTATION EVALUATION
Because ambulatory surgery is not a distinct rotation, residents will evaluate it as part of the
general OR and advanced clinical anesthesia rotations.
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Goals and Objectives
JUL 2016
PAGE 45
PROGRAM GOALS AND OBJECTIVES FOR
CA-1 RESIDENTS IN CRITICAL CARE
I. ROTATION DEFINITION
The Critical Care rotation at the National Capital Consortium is designed to introduce residents to
basic concepts in assessment and management in the ICU. This rotation is at the Walter Reed
National Military Medical Center. The critical care medicine rotation at WRB provides an
intensive introduction to the current practice of Critical Care Medicine in a referral medical
center. The Surgical Intensive Care Unit is both a pre and post-surgical care unit with an average
census of twelve to fifteen patients. Patients with a broad spectrum of pathology and
pathophysiology are treated here. Advanced physiologic monitoring techniques, mechanical
ventilation, nutritional support, clinical evaluation, and decision making are stressed during the
rotation. Residents assume graduated responsibility for patient care under the supervision of
credentialed critical care attending physicians. The successful completion of the PGY 2/CA 1
rotation should produce a physician familiar with basic aspects of ICU care.
The importance of having an anesthesiologist involved in the assessment and management of the
critically ill surgical patient has long been recognized. Indeed, the perioperative management
skills demonstrated by anesthesiologists lead to their initial involvement in the formulation and
directorship of early surgical intensive care units (SICUs). Recently, with the increasing amount
of fellowship training in this important area and the arrival of other physicians involved in the
delivery of critical care medicine, the role of the anesthesiologist in the SICU directorship has
diminished as multidisciplinary critical care medicine teams have evolved. Today, most SICUs
are under the directorship of board certified critical care specialists who trained from the base
specialties of anesthesiology, internal medicine, and surgery and have demonstrated both the
interest and expertise in the management of the critically ill patient. With the arrival at many
medical centers of dedicated trained critical care specialists, most departments of anesthesia have
relinquished the responsibility for SICU management to these specialists as the benefits of
having specific physicians dedicated to the delivery of such care is becoming more evident.
The need for anesthesiologists to acquire and to maintain their critical care expertise has never
diminished. The anesthesiologist's responsibilities in the operating room and recovery areas
demand an in-depth knowledge of such diverse topics as mechanical ventilation and weaning,
cardiovascular pharmacology, electrophysiology of the heart, metabolic response to stress, and
the pathophysiology of multi-system organ failure. In recognition of this, the Residency Review
Committee for Anesthesiology mandates that a minimum of four months training within the
environment of the intensive care unit (ICU) be provided as a portion of the core curriculum to
each resident in anesthesiology.
II. GOALS AND OBJECTIVES
The basic goals of the PGY 2/CA 1 rotation in critical care medicine are to provide the
anesthesiology resident with a framework of knowledge and skills to provide a rational basis to
care of the critically ill patient. The resident physician will rotate through the SICU under the
direction of the Chief, Critical Care Medicine Service. Teaching responsibilities and the delivery
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 46
of the core curriculum didactic lecture series will be provided by the designated attending ICU
Staff Physician and Critical Care Medicine Fellow under the guidelines of the Chief, Anesthesia
& Operative Service and the Chief, Critical Care Service.
A broad perspective of Critical Care Medicine will be provided so that the anesthesiology
residents may achieve a basic understanding of:
1.
The assessment and management of critically ill patients, including post-operative and
severely injured patients.
2.
The use of life support equipment.
3.
The use of vasoactive drugs.
4.
The role of teamwork in the critical care setting.
5.
The socioeconomic, ethical, and legal issues related to critical care.
6.
The unique ethical and moral questions that arise in dealing with critically ill and dying
patients and their families.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Acquire skill for optimal care of the severely injured and critically ill patient.
2.
Communicate effectively with and demonstrate caring and respectful behaviors when
interacting with patients and their families.
3.
Gather essential and accurate information about their patients.
4.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
5.
Develop and carry out patient management plans.
6.
Counsel and educate patients and their families.
Objectives:
1.
2.
3.
Perform complete histories and physicals on critically ill patients.
Coordinate the care of patients including admission, evaluation, and management
Perform the following procedures:
a.
Arterial line placement (radial, femoral).
b.
Insertion of a pulmonary artery catheter.
c.
Endotracheal intubation.
d.
Insertion of subclavian or jugular venous catheters.
4.
Develop communication skills with patients and family members, colleagues, nursing
staff, respiratory therapists, administrative staff, and other support personnel.
5.
Develop proficiency in the delivery of life support activities, including basic and
advanced cardiac life support guidelines as currently recommended by the American Heart
Association.
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Goals and Objectives
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Integrated Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Understand new theories and principles of intensive care medicine and their impact upon
the future of ICU care.
2.
List important considerations for surgical procedures, and how ICU care can be tailored
to meet these requirements.
3.
Describe the use of multimodal analgesia and sedation, in particular the use of TIVA, in
the ICU.
4.
Understand the theory and practice of advanced ventilatory management in the ICU.
Objectives:
The PGY 2/CA 1 resident should gain a basic understanding of the following areas:
Pulmonary
1.
Pulmonary Assessment
a.
History.
b.
Physical Examination.
c.
X-ray interpretation.
d.
Pulmonary Function Testing.
e.
ABG interpretation.
f.
Pulse oximetry/capnography technology.
g.
Bronchoscopy.
2.
Respiratory Insufficiency secondary to:
a.
Central Apnea.
b.
Airway Obstruction.
c.
Chronic Obstructive Pulmonary Disease.
d.
Pneumonia.
e.
Adult Respiratory Distress Syndrome.
f.
Pneumo/hemo thorax.
g.
Bronchopleural fistulae.
3
Respiratory Therapy
a.
Physical Therapy.
b.
Chest physiotherapy.
c.
Postural drainage.
d.
Fiberoptic bronchoscopy.
e.
Oxygen therapy.
f.
CPAP.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 48
4.
Mechanical ventilation
a.
CMV.
b.
IMV.
c.
SIMV.
d.
Assist Control.
e.
Pressure cycled and volume cycled ventilators.
f.
Pressure support.
g.
PEEP.
h.
Pressure release ventilation.
i.
Inverse ratio ventilation.
5.
Pharmacologic therapy
a.
Bronchodilators (β agonists, methyl xanthines, anticholinergics).
b.
Mucolytics (N-acetylcysteine).
c.
Antibiotics.
Cardiovascular
1.
Assessment
a.
Physical examination.
b.
EKG interpretation.
c.
Echocardiography interpretation.
d.
Stress testing (adenosine/dipyrimidamole thallium testing).
e.
Nuclear medicine studies.
2.
Pathology
a.
Dysrhythmia recognition and treatment.
b.
Ischemia detection, recognition and treatment.
c.
Management of hypo and hypertension.
d.
DVT/PE prophylaxis, detection and treatment.
e.
Congestive Heart Failure.
f.
Low cardiac output states.
g.
Pericardial tamponade.
h.
Aortic aneurysm.
2.
Techniques
a.
Peripheral intravenous cannulation.
b.
Central venous cannulation (IJ, EJ, subclavian, femoral).
c.
Arterial cannulation (radial, brachial, axillary, dorsalis pedis, femoral, etc.).
d.
Cardiac pacing (transvenous, transcutaneous).
3.
Pharmacology
a.
Antidysrhythmics.
b.
Vasopressors (ephedrine, isoproterenol, metaraminol, dopamine, dobutamine,
epinephrine, norepinephrine, digoxin, inodilators, phenylephrine, methoxamine, etc.).
c.
Antihypertensives (nicardipine, sodium nitroprusside, nitroglycerin, hydralazine,
phentolamine, labetalol, propranolol, metoprolol, esmolol, etc.).
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 49
Central Nervous System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Determinants of cerebral oxygen consumption, blood flow and intracranial pressure.
Management of closed head trauma.
Acute care of CVA patients.
Barbiturate-induced coma.
Pre and post-operative care of intracranial aneurysm patients.
Complications of stereotaxic and open neurosurgical procedures.
Glasgow neurologic rating scale.
SIADH.
Acute drug overdose.
Diagnosis of brain death.
Endocrine
1.
2.
3.
4.
5.
6.
Diabetes mellitus (DKA, hyperosmolar coma).
Diabetes insipidus.
Pheochromocytoma.
Addisonian crisis.
Malignant hyperthermia susceptibility.
Thyrotoxicosis.
Fluid, Electrolytes, Nutrition
1.
2.
3.
4.
Enteral nutritional formulae.
Parenteral nutritional formulae.
Determination of respiratory quotient (RQ).
Electrolyte disturbances (pathophysiology and therapy).
Integument
1.
2.
3.
4.
Histology.
Preservation of integrity.
Therapy for disruption of the integument.
Temperature regulation.
Hematologic
1.
2.
3.
4.
Appropriate use of blood and blood products.
Coagulopathies (pathology and therapy).
Disseminated intravascular coagulation (DIC)
Hemolysis (etiologies and therapy).
Renal
1.
2.
3.
4.
Causes, phases and prevention of acute renal failure (ARF).
Indications for renal dialysis.
Diuretics (thiazides, loop, osmotic etc.)
Complications of transurethral resection of the prostate (TURP).
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 50
Analgesia
1.
2.
3.
4.
5.
Regional and neuraxial.
PCA.
IV/IM/transcutaneous opioids.
NSAIDS.
Other (tricyclic antidepressants [TCAs], carbamazepine, etc.).
Ethics
1.
2.
3.
4.
Physician-patient relationships.
Team approach to patient care.
Care of dying patients and their family.
Rational allocation of scarce and expensive resources.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
Take part in discussions with patients and family members the advantages and potential
disadvantages of the different treatment options.
2.
Demonstrate sensitivity to patient concerns about awareness, disability and pain.
3.
Create and sustain a therapeutic and ethically sound relationship with patients.
4.
Use effective listening skills and elicit and provide information using effective nonverbal,
explanatory, questioning, and writing skills.
5.
Efficiently and accurately present patient data on rounds.
6.
Write complete and legible notes in chart.
7.
Effectively relate information to consultants.
8.
Effectively relate information to patients’ families in lay terms, including end of life
discussions.
9.
Work effectively with others as a member or leader of a health care team or other
professional group.
10.
Effectively communicate with nursing, therapists and social workers.
11.
Facilitate the education of medical students and junior residents which is lead by senior
residents and faculty.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 51
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession;
and, a commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
3.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to their patients‟
health problems.
2.
Obtain and use information about severely ill patients and the larger population from
which their patients are drawn.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Use information technology to manage information, access on-line medical information,
and support their education.
5.
Facilitate the learning of students and other health care professionals.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
2.
Understand how medical practice and delivery systems differ, including methods of
controlling health care costs and allocating resources.
3.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and understand how these activities affect system performance.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 52
III. REQUIRED READING
1.
The ICU Book, 3nd edition, Paul Marino, Williams & Wilkins, 2007.
2.
Distributed articles.
IV. EVALUATION
Final evaluation will be based upon clinical performance. Completion of an ICU rotation in the
PGY 2/CA 1 year requires performance at the level of interpreter or greater.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 53
PROGRAM GOALS AND OBJECTIVES
PGY 3/CA-2 RESIDENTS IN CRITICAL CARE
I. ROTATION DEFINITION
The Critical Care rotation at the National Capital Consortium for PGY 3/CA 2 residents is
designed to foster mastery of basic concepts in assessment and management in the ICU. This
rotation is at the Walter Reed National Military Medical Center. The Surgical Intensive Care Unit
is both a pre and post-surgical care unit with an average census of twelve to fifteen patients.
Patients with a broad spectrum of pathology and pathophysiology are treated here. Advanced
physiologic monitoring techniques, mechanical ventilation, nutritional support, clinical
evaluation, and decision making are stressed during the rotation. Residents assume graduated
responsibility for patient care under the supervision of credentialed critical care attending
physicians. The PGY 3/CA 2 is expected to show a higher degree of familiarity with critical care
and to show mastery, not just basic understanding, of the principles of critical care (e.g.
ventilator management, the decision between invasive and non-invasive ventilation, use of basic
vasoactive medications). This is demonstrated through the addition of supervision of interns and
junior residents, which PGY 2/CA 1 residents are not expected to show. The most important
distinction between a critical care rotation as a PGY 2/CA 1 and PGY 3/CA 2 is in the level of
performance expected by completion. PGY 3/CA 2s must perform at the level of a manger in
order to gain credit for the rotation.
II. GOALS AND OBJECTIVES
The goals of the PGY 3/CA 2 rotation in critical care medicine is to foster in the anesthesiology
resident a thorough understanding of basic knowledge and skills to provide a rational basis to care
of the critically ill patient. The major distinction between rotations as a PGY 2/CA 1 and PGY
3/CA 2 is the expectation that PGY 3/CA 2s will demonstrate mastery of basic principles through
teaching junior residents and interns. The resident physician will rotate through the SICU under
the direction of the Chief, Critical Care Medicine Service. Teaching responsibilities and the
delivery of the core curriculum didactic lecture series will be provided by the designated attending
ICU Staff Physician and Critical Care Medicine Fellow under the guidelines of the Chief,
Anesthesia & Operative Service and the Chief, Critical Care Service.
A broad perspective of Critical Care Medicine will be provided so that the anesthesiology
PGY 3/CA 2 residents may achieve a thorough understanding of:
1.
The assessment and management of critically ill patients, including post-operative and
severely injured patients.
2.
The use of life support equipment.
3.
The use of vasoactive drugs.
4.
The role of teamwork in the critical care setting.
5.
The socioeconomic, ethical, and legal issues related to critical care.
6.
The unique ethical and moral questions that arise in dealing with critically ill and dying
patients and their families.
III. CORE COMPETENCY PROFICIENCY
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 54
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Acquire skill for optimal care of the severely injured and critically ill patient.
2.
Communicate effectively with and demonstrate caring and respectful behaviors when
interacting with patients and their families.
3.
Gather essential and accurate information about their patients.
4.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
5.
Develop and carry out patient management plans.
6.
Counsel and educate patients and their families.
Objectives:
1.
2.
3.
Perform complete histories and physicals on critically ill patients.
Coordinate the care of patients including admission, evaluation, and management
Perform the following procedures:
a.
Arterial line placement (radial, femoral).
b.
Insertion of a pulmonary artery catheter.
c.
Endotracheal intubation.
d.
Insertion of subclavian or jugular venous catheters.
4.
Develop communication skills with patients and family members, colleagues, nursing
staff, respiratory therapists, administrative staff, and other support personnel.
5.
Develop proficiency in the delivery of life support activities, including basic and
advanced cardiac life support guidelines as currently recommended by the American Heart
Association.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Understand new theories and principles of intensive care medicine and their impact upon
the future of ICU care.
2.
List important considerations for surgical procedures, and how ICU care can be tailored
to meet these requirements.
3.
Describe the use of multimodal analgesia and sedation, in particular the use of TIVA, in
the ICU.
4.
Master the theory and practice of advanced ventilatory management in the ICU.
Objectives:
The PGY 3/CA 2 resident should have an in depth understanding of the following areas:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 55
Pulmonary
1.
Pulmonary Assessment
a.
History.
b.
Physical Examination.
c.
X-ray interpretation.
d.
Pulmonary Function Testing.
e.
ABG interpretation.
f.
Pulse oximetry/capnography technology.
g.
Bronchoscopy.
2.
Respiratory Insufficiency secondary to:
a.
Central Apnea.
b.
Airway Obstruction.
c.
Chronic Obstructive Pulmonary Disease.
d.
Pneumonia.
e.
Adult Respiratory Distress Syndrome.
f.
Pneumo/hemo thorax.
g.
Bronchopleural fistulae.
3
Respiratory Therapy
a.
Physical Therapy.
b.
Chest physiotherapy.
c.
Postural drainage.
d.
Fiberoptic bronchoscopy.
e.
Oxygen therapy.
f.
CPAP.
4.
Mechanical ventilation
a.
CMV.
b.
IMV.
c.
SIMV.
d.
Assist Control.
e.
Pressure cycled and volume cycled ventilators.
f.
Pressure support.
g.
PEEP.
h.
Pressure release ventilation.
i.
Inverse ratio ventilation.
5.
Pharmacologic therapy
a.
Bronchodilators (β agonists, methyl xanthines, anticholinergics).
b.
Mucolytics (N-acetylcysteine).
c.
Antibiotics.
Cardiovascular
1.
Assessment
a.
Physical examination.
b.
EKG interpretation.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 56
c.
d.
e.
Echocardiography interpretation.
Stress testing (adenosine/dipyrimidamole thallium testing).
Nuclear medicine studies.
2.
Pathology
a.
Dysrhythmia recognition and treatment.
b.
Ischemia detection, recognition and treatment.
c.
Management of hypo and hypertension.
d.
DVT/PE prophylaxis, detection and treatment.
e.
Congestive Heart Failure.
f.
Low cardiac output states.
g.
Pericardial tamponade.
h.
Aortic aneurysm.
2.
Techniques
a.
Peripheral intravenous cannulation.
b.
Central venous cannulation (IJ, EJ, subclavian, femoral).
c.
Arterial cannulation (radial, brachial, axillary, dorsalis pedis, femoral, etc.).
d.
Cardiac pacing (transvenous, transcutaneous).
3.
Pharmacology
a.
Antidysrhythmics.
b.
Vasopressors (ephedrine, isoproterenol, metaraminol, dopamine, dobutamine,
epinephrine, norepinephrine, digoxin, inodilators, phenylephrine, methoxamine, etc.).
c.
Antihypertensives (nicardipine, sodium nitroprusside, nitroglycerin, hydralazine,
phentolamine, labetalol, propranolol, metoprolol, esmolol, etc.).
Central Nervous System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Determinants of cerebral oxygen consumption, blood flow and intracranial pressure.
Management of closed head trauma.
Acute care of CVA patients.
Barbiturate-induced coma.
Pre and post-operative care of intracranial aneurysm patients.
Complications of stereotaxic and open neurosurgical procedures.
Glasgow neurologic rating scale.
SIADH.
Acute drug overdose.
Diagnosis of brain death.
Endocrine
1.
2.
3.
4.
5.
6.
Diabetes mellitus (DKA, hyperosmolar coma).
Diabetes insipidus.
Pheochromocytoma.
Addisonian crisis.
Malignant hyperthermia susceptibility.
Thyrotoxicosis.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 57
Fluid, Electrolytes, Nutrition
1.
2.
3.
4.
Enteral nutritional formulae.
Parenteral nutritional formulae.
Determination of respiratory quotient (RQ).
Electrolyte disturbances (pathophysiology and therapy).
Integument
1.
2.
3.
4.
Histology.
Preservation of integrity.
Therapy for disruption of the integument.
Temperature regulation.
Hematologic
1.
2.
3.
4.
Appropriate use of blood and blood products.
Coagulopathies (pathology and therapy).
Disseminated intravascular coagulation (DIC)
Hemolysis (etiologies and therapy).
Renal
1.
2.
3.
4.
Causes, phases and prevention of acute renal failure (ARF).
Indications for renal dialysis.
Diuretics (thiazides, loop, osmotic etc.)
Complications of transurethral resection of the prostate (TURP).
Analgesia
1.
2.
3.
4.
5.
Regional and neuraxial.
PCA.
IV/IM/transcutaneous opioids.
NSAIDS.
Other (tricyclic antidepressants [TCAs], carbamazepine, etc.).
Ethics
1.
2.
3.
4.
Physician-patient relationships.
Team approach to patient care.
Care of dying patients and their family.
Rational allocation of scarce and expensive resources.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 58
associates. Residents are expected to:
1.
Lead a discussion (not just participate) with patients and family members the advantages
and potential disadvantages of the different treatment options.
2.
Demonstrate sensitivity to patient concerns about awareness, disability and pain.
3.
Create and sustain a therapeutic and ethically sound relationship with patients.
4.
Use effective listening skills and elicit and provide information using effective nonverbal,
explanatory, questioning, and writing skills.
5.
Efficiently and accurately present patient data on rounds.
6.
Write complete and legible notes in chart.
7.
Effectively relate information to consultants.
8.
Effectively relate information to patients’ families in lay terms, including end of life
discussions.
9.
Work effectively with others as a member or leader of a health care team or other
professional group.
10.
Effectively communicate with nursing, therapists and social workers.
11.
Teach medical students and junior residents.
Professionalism
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession;
and, a commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
3.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Practice Based Learning
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care. Residents are expected to:
1.
Locate, appraise, and assimilate evidence from scientific studies related to their patients’
health problems.
2.
Obtain and use information about severely ill patients and the larger population from
which their patients are drawn.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Use information technology to manage information, access on-line medical information,
and support their education.
5.
Teach students and other health care professionals.
Systems Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 59
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value. Residents are expected to:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
2.
Understand how medical practice and delivery systems differ, including methods of
controlling health care costs and allocating resources.
3.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and understand how these activities affect system performance.
III. REQUIRED READING
1.
The ICU Book, 3nd edition, Paul Marino, Williams & Wilkins, 2007.
2.
Distributed articles.
IV. EVALUATION
Final evaluation will be based upon clinical performance. Completion of the PGY 3/CA 2 rotation
in critical care requires performance at the manager level or greater. Residents must also posess a
mastery of basic principles of critical care.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 60
PROGRAM GOALS AND OBJECTIVES
PGY 4/CA-3 RESIDENTS IN CRITICAL CARE
I. ROTATION DEFINITION
The Critical Care rotation at the National Capital Consortium is designed to introduce residents to
basic concepts in assessment and management in the ICU. This rotation is at the Walter Reed
National Military Medical Center. The critical care medicine rotation at WRB provides an
intensive introduction to the current practice of Critical Care Medicine in a referral medical
center. The Surgical Intensive Care Unit is both a pre and post-surgical care unit with an average
census of twelve to fifteen patients. Patients with a broad spectrum of pathology and
pathophysiology are treated here. Advanced physiologic monitoring techniques, mechanical
ventilation, nutritional support, clinical evaluation, and decision making are stressed during the
rotation. Residents assume graduated responsibility for patient care under the supervision of
credentialed critical care attending physicians. The PGY 4/CA 3 is expected to show a higher
degree of familiarity with critical care and to show mastery of advanced principles of critical
care (e.g. indications for hemodialysis, nutrition, adherence to ACCC guidelines for survival of
sepsis, antibiotic rotations, etc.). PGY 4/CA 3s must show at least the capability to perform at the
level of an educator in order to gain credit for the rotation in addition to consistent performance
at the manager level. In addition PGY 4/CA 3s are expected to show an advanced understanding
of systems based practice and will create work schedules and interface with key hospital
managers such as the anesthesia floor runner/medical monitor and the hospital bed manager.
II. GOALS AND OBJECTIVES
The goals of the PGY 4/CA 3 rotation in critical care medicine are to provide 1) a leadership and
management experience for the senior resident and 2) to allow for mastery of advanced concepts
in critical care. The resident physician will rotate through the SICU under the direction of the
Chief, Critical Care Medicine Service. Teaching responsibilities and the delivery of the core
curriculum didactic lecture series will be provided by the designated attending ICU Staff Physician
and Critical Care Medicine Fellow under the guidelines of the Chief, Anesthesia
& Operative Service and the Chief, Critical Care Service.
A broad perspective of Critical Care Medicine will be provided so that the anesthesiology
residents may achieve an in depth understanding of:
1.
The assessment and management of critically ill patients, including post-operative and
severely injured patients.
2.
The use of life support equipment.
3.
The use of vasoactive drugs.
4.
The role of teamwork in the critical care setting.
5.
The socioeconomic, ethical, and legal issues related to critical care.
6.
The unique ethical and moral questions that arise in dealing with critically ill and dying
patients and their families.
Patient Care
Goals:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 61
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Acquire skill for optimal care of the severely injured and critically ill patient.
2.
Communicate effectively with and demonstrate caring and respectful behaviors when
interacting with patients and their families.
3.
Gather essential and accurate information about their patients.
4.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
5.
Develop and carry out patient management plans.
6.
Counsel and educate patients and their families.
Objectives:
1.
2.
3.
Perform complete histories and physicals on critically ill patients.
Coordinate the care of patients including admission, evaluation, and management
Perform the following procedures:
a.
Arterial line placement (radial, femoral).
b.
Insertion of a pulmonary artery catheter.
c.
Endotracheal intubation.
d.
Insertion of subclavian or jugular venous catheters.
4.
Develop communication skills with patients and family members, colleagues, nursing
staff, respiratory therapists, administrative staff, and other support personnel.
5.
Develop proficiency in the delivery of life support activities, including basic and
advanced cardiac life support guidelines as currently recommended by the American Heart
Association.
Medical Knowledge
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Understand new theories and principles of intensive care medicine and their impact upon
the future of ICU care.
2.
List important considerations for surgical procedures, and how ICU care can be tailored
to meet these requirements.
3.
Describe the use of multimodal analgesia and sedation, in particular the use of TIVA, in
the ICU.
4.
Master the theory and practice of advanced ventilatory management in the ICU and teach
this to junior residents and medical students.
Objectives:
The senior resident should demonstrate mastery of the following areas:
Pulmonary
1.
Pulmonary Assessment
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 62
a.
b.
c.
d.
e.
f.
g.
History.
Physical Examination.
X-ray interpretation.
Pulmonary Function Testing.
ABG interpretation.
Pulse oximetry/capnography technology.
Bronchoscopy.
2.
Respiratory Insufficiency secondary to:
a.
Central Apnea.
b.
Airway Obstruction.
c.
Chronic Obstructive Pulmonary Disease.
d.
Pneumonia.
e.
Adult Respiratory Distress Syndrome.
f.
Pneumo/hemo thorax.
g.
Bronchopleural fistulae.
3
Respiratory Therapy
a.
Physical Therapy.
b.
Chest physiotherapy.
c.
Postural drainage.
d.
Fiberoptic bronchoscopy.
e.
Oxygen therapy.
f.
CPAP.
4.
Mechanical ventilation
a.
CMV.
b.
IMV.
c.
SIMV.
d.
Assist Control.
e.
Pressure cycled and volume cycled ventilators.
f.
Pressure support.
g.
PEEP.
h.
Pressure release ventilation.
i.
Inverse ratio ventilation.
5.
Pharmacologic therapy
a.
Bronchodilators (β agonists, methyl xanthines, anticholinergics).
b.
Mucolytics (N-acetylcysteine).
c.
Antibiotics.
Cardiovascular
1.
Assessment
a.
Physical examination.
b.
EKG interpretation.
c.
Echocardiography interpretation.
d.
Stress testing (adenosine/dipyrimidamole thallium testing).
e.
Nuclear medicine studies.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 63
2.
Pathology
a.
Dysrhythmia recognition and treatment.
b.
Ischemia detection, recognition and treatment.
c.
Management of hypo and hypertension.
d.
DVT/PE prophylaxis, detection and treatment.
e.
Congestive Heart Failure.
f.
Low cardiac output states.
g.
Pericardial tamponade.
h.
Aortic aneurysm.
2.
Techniques
a.
Peripheral intravenous cannulation.
b.
Central venous cannulation (IJ, EJ, subclavian, femoral).
c.
Arterial cannulation (radial, brachial, axillary, dorsalis pedis, femoral, etc.).
d.
Cardiac pacing (transvenous, transcutaneous).
3.
Pharmacology
a.
Antidysrhythmics.
b.
Vasopressors (ephedrine, isoproterenol, metaraminol, dopamine, dobutamine,
epinephrine, norepinephrine, digoxin, inodilators, phenylephrine, methoxamine, etc.).
c.
Antihypertensives (nicardipine, sodium nitroprusside, nitroglycerin, hydralazine,
phentolamine, labetalol, propranolol, metoprolol, esmolol, etc.).
Central Nervous System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Determinants of cerebral oxygen consumption, blood flow and intracranial pressure.
Management of closed head trauma.
Acute care of CVA patients.
Barbiturate-induced coma.
Pre and post-operative care of intracranial aneurysm patients.
Complications of stereotaxic and open neurosurgical procedures.
Glasgow neurologic rating scale.
SIADH.
Acute drug overdose.
Diagnosis of brain death.
Endocrine
1.
2.
3.
4.
5.
6.
Diabetes mellitus (DKA, hyperosmolar coma).
Diabetes insipidus.
Pheochromocytoma.
Addisonian crisis.
Malignant hyperthermia susceptibility.
Thyrotoxicosis.
Fluid, Electrolytes, Nutrition
1.
Enteral nutritional formulae.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 64
2.
3.
4.
Parenteral nutritional formulae.
Determination of respiratory quotient (RQ).
Electrolyte disturbances (pathophysiology and therapy).
Integument
1.
2.
3.
4.
Histology.
Preservation of integrity.
Therapy for disruption of the integument.
Temperature regulation.
Hematologic
1.
2.
3.
4.
Appropriate use of blood and blood products.
Coagulopathies (pathology and therapy).
Disseminated intravascular coagulation (DIC)
Hemolysis (etiologies and therapy).
Renal
1.
2.
3.
4.
Causes, phases and prevention of acute renal failure (ARF).
Indications for renal dialysis.
Diuretics (thiazides, loop, osmotic etc.)
Complications of transurethral resection of the prostate (TURP).
Analgesia
1.
2.
3.
4.
5.
Regional and neuraxial.
PCA.
IV/IM/transcutaneous opioids.
NSAIDS.
Other (tricyclic antidepressants [TCAs], carbamazepine, etc.).
Ethics
1.
2.
3.
4.
Physician-patient relationships.
Team approach to patient care.
Care of dying patients and their family.
Rational allocation of scarce and expensive resources.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 65
Objectives:
1.
Discuss with patients and family members the advantages and potential disadvantages of
the different treatment options.
2.
Demonstrate sensitivity to patient concerns about awareness, disability and pain.
3.
Create and sustain a therapeutic and ethically sound relationship with patients.
4.
Use effective listening skills and elicit and provide information using effective nonverbal,
explanatory, questioning, and writing skills.
5.
Efficiently and accurately present patient data on rounds.
6.
Write complete and legible notes in chart.
7.
Effectively relate information to consultants.
8.
Effectively relate information to patients‟ families in lay terms, including end of life
discussions.
9.
Work effectively with others as a member or leader of a health care team or other
professional group.
10.
Effectively communicate with nursing, therapists and social workers.
11.
Teach PGY 3/CA 2 and PGY 2/CA 1 residents to teach medical students and other junior
residents.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession;
and, a commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
3.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to their patients’
health problems.
2.
Obtain and use information about severely ill patients and the larger population from
which their patients are drawn.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 66
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Use information technology to manage information, access on-line medical information,
and support their education.
5.
Facilitate the learning of students and other health care professionals.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
2.
Understand how medical practice and delivery systems differ, including methods of
controlling health care costs and allocating resources.
3.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and understand how these activities affect system performance.
6.
Create the work and call schedule for the rotating residents.
7.
Work with the hospital bed manager and anesthesia floor runner to ensure best
utilization of ICU resources.
IV. REQUIRED READING
1.
The ICU Book, 3nd edition, Paul Marino, Williams & Wilkins, 2007.
2.
Distributed articles.
V. EVALUATION
Final evaluation will be based upon clinical performance. PGY 4/CA 3 residents must show at least
the capability to perform at the educator level and consistently perform at the manager level.
VIII. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 67
PROGRAM GOALS AND OBJECTIVES FOR
PGY 2/CA-1 RESIDENTS IN OBSTETRIC ANESTHESIA
I. ROTATION DEFINITION
This PGY 2/CA-1 level rotation is provided as a two month block at the Walter Reed National
Military Medical Center. The purpose of this rotation is to provide the resident with a basic
understanding of maternal and fetal/neonatal physiology, the impact of anesthesia upon
uncomplicated labor and vaginal delivery, and the delivery of anesthesia for cesarean section. In
addition, the resident will develop skills in determining the appropriateness for regional
anesthesia blocks (epidurals and spinal blocks), their placement, maintenance, and management
of their potential complications. At the conclusion of the rotation, the resident will be expected to
develop an anesthetic management plan for all routine and emergency obstetric deliveries with
minimal staff consultation.
II. GOALS AND OBJECTIVES
Obstetric anesthesia presents one of the most challenging and rewarding clinical anesthesia arenas.
The anesthesiologist must be organized and ever vigilant because of the urgent nature of the
birthing process and altered physiology of the mother. A calm posture must be acquired in
managing the patient through the preoperative, intraoperative and post-operative course. An
intense period of training is designed so that each resident will acquire the judgment and technical
skills needed for obstetrical anesthesia. The goal is to expose the resident to many of the common
problems in obstetrics, building a sound foundation for future, independent management. All
residents rotating through the service will gain an understanding of the basic principles of
managing the perinatal anesthetic needs of the parturient. Residents will develop competence in
pre-anesthetic assessment and planning, anesthetic management, prevention and management of
complications, and post-anesthetic care for the parturient in a community hospital.
Patient Care
Goals:
Residents must provide patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health. Residents are expected to:
1.
Acquire skills for optimal care of the routine and high risk parturient.
2.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
3.
Interact effectively with patients and their families in the peripartum period while
demonstrating respect and care for individuals.
4.
Formulate an anesthetic plan based on the individual patient’s medical history and
expected peripartum course.
5.
Demonstrate flexibility as the expected peripartum course changes.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 68
6.
Perform competently all regional and general anesthetic techniques essential to the
practice of OB anesthesiology.
7.
Work together with other members of the interdisciplinary health care team to optimize
patient care while acknowledging the occasional stressful aspects of OB patient care.
Objectives:
1.
Manage all common forms of anesthesia and analgesia in the broad spectrum of
parturients encountered in the community hospital setting.
2.
Evaluate, diagnose, and implement treatment of common postpartum complications
including PDPH, persistent neurologic deficits, and side effects from epidural narcotics.
3.
Select and apply appropriate monitoring to the given clinical situation in the parturient.
4.
Interact with health personnel as the leader of the anesthetic and resuscitative care team
in the delivery suite.
5.
Assign APGAR scores for newborns and implement resuscitative efforts based on scores
assigned.
6.
Provide neonatal resuscitation as needed, assuming the parturient does not need
immediate attention.
Integrated Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of OB
anesthesiology.
2.
Demonstrate a sound knowledge base concerning anatomy, maternal, and maternofetal physiology under both normal and pathological states and their relationships to regional
and general anesthesia.
3.
Demonstrate how specific disease states affect the anesthetic management of OB
patients.
Objectives:
Anesthesia and Maternal Fetal Physiology
1.
Discuss in detail the physiologic changes that accompany pregnancy and their anesthetic
implications.
2.
Describe the pathophysiology of common clinical conditions associated with high risk
pregnancy (e.g., cardiac, neurosurgical, neuromuscular, immunologic and coagulation
disorders).
3.
Discuss the pathophysiology of obesity in pregnancy, including management and impact
upon the neonate.
4.
Discuss the pathophysiology of diabetes in pregnancy, including management and impact
upon the neonate.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 69
5.
Discuss local anesthetic toxicity and the parturient.
6.
Understand the effects of commonly used medications and anesthetic agents on the
infant/fetus.
7.
Describe the effects of anesthetic agents and regional anesthesia on uterine blood flow,
uterine activity and labor.
8.
Describe the pathophysiology and management of pregnancy induced hypertension
(PIH).
9.
Describe basic principles and rationale of fetal assessment including stress and non-stress
tests, biophysical profile and fetal monitoring.
10.
Understand the anesthetic and obstetric implications of abnormal fetal presentations,
multiple births and preterm labor.
Anesthesia for Labor and Delivery
1.
Discuss and list advantages and disadvantages of analgesic methods for labor including
epidural, inhalational, pudendal and IV sedation.
2.
Understand the indications and contraindications for various test dosing strategies during
epidural anesthesia.
3.
Understand the different options for infusions during laboring epidural anesthesia.
4.
Interpret fetal heart tracings and describe the etiology and treatment of the various fetal
heart rate tracing abnormalities.
5.
Discuss the pharmacodynamics of common non-anesthetic medications used in obstetrics
and their interactions with anesthetics including oxytocin, ergot preparations, magnesium,
terbutaline, indomethacin, prostaglandins and steroids.
6.
Discuss the pharmacokinetics and pharmacodynamics of local anesthetics including
toxicity and appropriate selection for the spectrum of clinical indications.
Anesthesia for Cesarean Section
1.
Understand the ACOG guidelines for emergency cesarean section, and prescribe
appropriate anesthetic plans.
2.
Discuss analgesia and anesthesia for cesarean section including epidural, spinal, general
and local anesthesia.
3.
Understand the maternal and fetal ramifications of regional versus general anesthetic
techniques.
4.
Understand the options for post-operative analgesia utilizing PCA, intrathecal, and
epidural narcotics.
5.
Identify and describe the management of the difficult airway in the parturient
Anesthetic Complications
1.
Identify and describe the management of amniotic fluid embolus (AFE).
2.
Identify and describe the management of post-dural puncture headache.
3.
Discuss the implications and describe the management of non-obstetric surgery in
pregnancy.
4.
Identify, develop a differential diagnosis, and describe the management of abnormal
bleeding in the perinatal period.
5.
Describe the factors placing the parturient at risk for aspiration pneumonitis and
acceptable guidelines for prophylaxis.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
6.
PAGE 70
Describe the etiology, diagnosis and treatment of postpartum neurologic deficits.
Neonatal Resuscitation
1.
Describe basic principles and sequence of neonatal evaluation and resuscitation.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the advantages as well as potential
disadvantages of the different treatment options.
2.
Create and sustain a therapeutic and ethically sound relationship with peripartum patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
2.
Demonstrate respect, compassion, integrity, and a responsiveness to the needs of patients
and society that supersedes self-interest.
3.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and
disabilities.
4.
Demonstrate accountability to patients, colleagues and the institution.
5.
Demonstrate a commitment to excellence and ongoing professional development.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 71
1.
Locate, appraise, evaluate and assimilate evidence from scientific and clinical studies
related to OB anesthesiology practice. This includes, but is not limited to, the directed readings
in the Core Curriculum. In selected cases, it is appropriate to pursue additional scientific
evidence in a reference text or in an electronic on-line search.
2.
Assist in the teaching of medical students rotating through the OB anesthesia service.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Apply information technology to manage information, access on-line medical
information, and support their education.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and providers to assess, coordinate, and improve health
care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Obstetric Anesthesia, 3rd edition, David H. Chestnut Ed. Elsevier Mosby, 2004.
IV. EVALUATION
Successful completion of this rotation will be based on review of written evaluations by the OB
anesthesia faculty and results of the written examination. A PGY 2/CA 1 resident must be deemed
to perform consistently at the interpreter level or higher by the time of the summative evaluation
for the rotation to be able to receive credit for the rotation in OB anesthesia.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 72
PROGRAM GOALS AND OBJECTIVES FOR
PGY 3/CA 2 RESIDENTS IN OBSTETRIC ANESTHESIA
AT WRNMMC
I. ROTATION DEFINITION
This PGY 3/CA 2 level rotation is a one month block at the Walter Reed National Military
Medical Center. The purpose of this rotation is to provide the resident with a basic understanding
of maternal and fetal/neonatal physiology, the impact of anesthesia upon uncomplicated labor and
vaginal delivery, and the delivery of anesthesia for cesarean section. In addition, the resident will
develop skills in determining the appropriateness for regional anesthesia blocks (epidurals and
spinal blocks), their placement, maintenance, and management of their potential complications.
At the conclusion of the rotation, the resident will be expected to develop an anesthetic
management plan for all routine and emergency obstetric deliveries. PGY 3/CA 2 residents are
expected to show greater autonomy and to also serve as educators for PGY 2/CA 1s.
II. GOALS AND OBJECTIVES
PGY 3/CA 2 residents rotating through the OB anesthesiology service are expected to show
mastery of principles of managing the perinatal anesthetic needs of the parturient. Residents will
develop competence in pre-anesthetic assessment and planning, anesthetic management,
prevention and management of complications, and post-anesthetic care for the parturient in a
community hospital.
Patient Care
Goals:
Residents must provide patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health. Residents are expected to:
1.
Acquire skills for optimal care of the routine and high risk parturient.
2.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
3.
Interact effectively with patients and their families in the peripartum period while
demonstrating respect and care for individuals.
4.
Formulate an anesthetic plan based on the individual patient’s medical history and
expected peripartum course.
5.
Demonstrate flexibility as the expected peripartum course changes.
6.
Perform competently all regional and general anesthetic techniques essential to the
practice of OB anesthesiology.
7.
Work together with other members of the interdisciplinary health care team to optimize
patient care while acknowledging the occasional stressful aspects of OB patient care.
Objectives:
1.
Manage all common forms of anesthesia and analgesia in the broad spectrum of
parturients encountered in the community hospital setting.
2.
Evaluate, diagnose, and implement treatment of common postpartum complications
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 73
including PDPH, persistent neurologic deficits, and side effects from epidural narcotics.
3.
Select and apply appropriate monitoring to the given clinical situation in the parturient.
4.
Interact with health personnel as the leader of the anesthetic and resuscitative care team
in the delivery suite.
5.
Assign APGAR scores for newborns and implement resuscitative efforts based on scores
assigned.
6.
Provide neonatal resuscitation as needed, assuming the parturient does not need
immediate attention.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of OB
anesthesiology.
2.
Demonstrate a sound knowledge base concerning anatomy, maternal, and maternofetal physiology under both normal and pathological states and their relationships to regional
and general anesthesia.
3.
Demonstrate how specific disease states affect the anesthetic management of OB
patients.
4.
Understand historical controversies and recent developments in OB anesthesiology
Objectives:
Anesthesia and Maternal Fetal Physiology
1.
Discuss in detail the physiologic changes that accompany pregnancy and their anesthetic
implications.
2.
Describe the pathophysiology of common clinical conditions associated with high risk
pregnancy (e.g., cardiac, neurosurgical, neuromuscular, immunologic and coagulation
disorders).
3.
Discuss the pathophysiology of obesity in pregnancy, including management and impact
upon the neonate.
4.
Discuss the pathophysiology of diabetes in pregnancy, including management and impact
upon the neonate.
5.
Discuss local anesthetic toxicity and the parturient.
6.
Understand the effects of commonly used medications and anesthetic agents on the
infant/fetus.
7.
Describe the effects of anesthetic agents and regional anesthesia on uterine blood flow,
uterine activity and labor.
8.
Describe the pathophysiology and management of pregnancy induced hypertension
(PIH).
9.
Describe basic principles and rationale of fetal assessment including stress and non-stress
tests, biophysical profile and fetal monitoring.
10.
Understand the anesthetic and obstetric implications of abnormal fetal presentations,
multiple births and preterm labor.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 74
Anesthesia for Labor and Delivery
1.
Discuss and list advantages and disadvantages of analgesic methods for labor including
epidural, inhalational, pudendal and IV sedation.
2.
Understand the indications and contraindications for various test dosing strategies during
epidural anesthesia.
3.
Understand the different options for infusions during laboring epidural anesthesia.
4.
Interpret fetal heart tracings and describe the etiology and treatment of the various fetal
heart rate tracing abnormalities.
5.
Discuss the pharmacodynamics of common non-anesthetic medications used in obstetrics
and their interactions with anesthetics including oxytocin, ergot preparations, magnesium,
terbutaline, indomethacin, prostaglandins and steroids.
6.
Discuss the pharmacokinetics and pharmacodynamics of local anesthetics including
toxicity and appropriate selection for the spectrum of clinical indications.
Anesthesia for Cesarean Section
1.
Understand the ACOG guidelines for emergency cesarean section, and prescribe
appropriate anesthetic plans.
2.
Discuss analgesia and anesthesia for cesarean section including epidural, spinal, general
and local anesthesia.
3.
Understand the maternal and fetal ramifications of regional versus general anesthetic
techniques.
4.
Understand the options for post-operative analgesia utilizing PCA, intrathecal, and
epidural narcotics.
5.
Identify and describe the management of the difficult airway in the parturient
Anesthetic Complications
1.
Identify and describe the management of amniotic fluid embolus (AFE).
2.
Identify and describe the management of post-dural puncture headache.
3.
Discuss the implications and describe the management of non-obstetric surgery in
pregnancy.
4.
Identify, develop a differential diagnosis, and describe the management of abnormal
bleeding in the perinatal period.
5.
Describe the factors placing the parturient at risk for aspiration pneumonitis and
acceptable guidelines for prophylaxis.
6.
Describe the etiology, diagnosis and treatment of postpartum neurologic deficits.
Neonatal Resuscitation
1.
Describe basic principles and sequence of neonatal evaluation and resuscitation.
Interpersonal/Communication Skills
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 75
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the advantages as well as potential
disadvantages of the different treatment options.
2.
Create and sustain a therapeutic and ethically sound relationship with peripartum patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
2.
Demonstrate respect, compassion, integrity, and a responsiveness to the needs of patients
and society that supersedes self-interest.
3.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
4.
Demonstrate accountability to patients, colleagues and the institution.
5.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, evaluate and assimilate evidence from scientific and clinical studies
related to OB anesthesiology practice. This includes, but is not limited to, the directed readings
in the Core Curriculum. In selected cases, it is appropriate to pursue additional scientific
evidence in a reference text or in an electronic on-line search.
2.
Assist in the teaching of medical students rotating through the OB anesthesia service.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Apply information technology to manage information, access on-line medical
information, and support their education.
Systems Based Practice
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 76
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and providers to assess, coordinate, and improve health
care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Obstetric Anesthesia, 3rd edition, David H. Chestnut Ed. Elsevier Mosby, 2004.
IV. EVALUATION
Successful completion of this rotation will be based on review of written evaluations by the OB
anesthesia faculty and results of the written examination. For a PGY 3/CA 2 resident to gain credit
for a month of OB anesthesia they must be judged to be operating on the manager level
consistently. They must show an ability to operate with autonomy with supervision available (as
opposed to constantly present) and they must show an ability to facilitate the learning of junior
residents.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 77
PROGRAM GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN OBSTETRIC ANESTHESIA
at WRNMMC
I. ROTATION DEFINITION
This PGY 4/CA 3 level rotation is a one month block at Walter Reed National Military Medical
Center. The purpose of this rotation is to provide the resident with the opportunity to show
mastery of maternal and fetal/neonatal physiology, the impact of anesthesia upon uncomplicated
labor and vaginal delivery, the delivery of anesthesia for cesarean section and the ability to
manage work schedules for other residents. In addition, the resident will determine the
appropriateness for regional anesthesia blocks (epidurals and spinal blocks), their placement,
maintenance, and management of their potential complications. At the conclusion of the rotation,
the resident will be expected to develop an anesthetic management plan for all routine and
emergency obstetric deliveries with minimal staff consultation.
II. GOALS AND PRIMARY AREA OF KNOWLEDGE
PGY 4/CA 3 residents rotating through the OB anesthesiology service are expected to show
mastery of advanced concepts (severe pre-eclampsia, twin gestations, co-morbid maternal disease
states, etc.) of managing the perinatal anesthetic needs of the parturient. Residents will develop
competence in pre-anesthetic assessment and planning, anesthetic management, prevention and
management of complications, and post-anesthetic care for the parturient in a community hospital.
PGY 4/CA 3 residents are expected to show the ability to function as educators and to function
as leaders during the rotation.
Patient Care
Goals:
Residents must provide patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health. Residents are expected to:
1.
Acquire skills for optimal care of the routine and high risk parturient.
2.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
3.
Interact effectively with patients and their families in the peripartum period while
demonstrating respect and care for individuals.
4.
Formulate an anesthetic plan based on the individual patient’s medical history and
expected peripartum course.
5.
Demonstrate flexibility as the expected peripartum course changes.
6.
Perform competently all regional and general anesthetic techniques essential to the
practice of OB anesthesiology.
7.
Work together with other members of the interdisciplinary health care team to optimize
patient care while acknowledging the occasional stressful aspects of OB patient care.
Objectives:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 78
1.
Manage all common forms of anesthesia and analgesia in the broad spectrum of
parturients encountered in the community hospital setting.
2.
Evaluate, diagnose, and implement treatment of common postpartum complications
including PDPH, persistent neurologic deficits, and side effects from epidural narcotics.
3.
Select and apply appropriate monitoring to the given clinical situation in the parturient.
4.
Interact with health personnel as the leader of the anesthetic and resuscitative care team
in the delivery suite.
5.
Assign APGAR scores for newborns and implement resuscitative efforts based on scores
assigned.
6.
Provide neonatal resuscitation as needed, assuming the parturient does not need
immediate attention.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of OB
anesthesiology.
2.
Demonstrate a sound knowledge base concerning anatomy, maternal, and maternofetal physiology under both normal and pathological states and their relationships to regional
and general anesthesia.
3.
Demonstrate how specific disease states affect the anesthetic management of OB
patients.
4.
Understand historical controversies and recent developments in OB anesthesiology.
Objectives:
Anesthesia and Maternal Fetal Physiology
1.
Discuss in detail the physiologic changes that accompany pregnancy and their anesthetic
implications.
2.
Describe the pathophysiology of common clinical conditions associated with high risk
pregnancy (e.g., cardiac, neurosurgical, neuromuscular, immunologic and coagulation
disorders).
3.
Discuss the pathophysiology of obesity in pregnancy, including management and impact
upon the neonate.
4.
Discuss the pathophysiology of diabetes in pregnancy, including management and impact
upon the neonate.
5.
Discuss local anesthetic toxicity and the parturient.
6.
Understand the effects of commonly used medications and anesthetic agents on the
infant/fetus.
7.
Describe the effects of anesthetic agents and regional anesthesia on uterine blood flow,
uterine activity and labor.
8.
Describe the pathophysiology and management of pregnancy induced hypertension
(PIH).
9.
Describe basic principles and rationale of fetal assessment including stress and non-stress
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 79
tests, biophysical profile and fetal monitoring.
10.
Understand the anesthetic and obstetric implications of abnormal fetal presentations,
multiple births and preterm labor.
Anesthesia for Labor and Delivery
1.
Discuss and list advantages and disadvantages of analgesic methods for labor including
epidural, inhalational, pudendal and IV sedation.
2.
Understand the indications and contraindications for various test dosing strategies during
epidural anesthesia.
3.
Understand the different options for infusions during laboring epidural anesthesia.
4.
Interpret fetal heart tracings and describe the etiology and treatment of the various fetal
heart rate tracing abnormalities.
5.
Discuss the pharmacodynamics of common non-anesthetic medications used in obstetrics
and their interactions with anesthetics including oxytocin, ergot preparations, magnesium,
terbutaline, indomethacin, prostaglandins and steroids.
6.
Discuss the pharmacokinetics and pharmacodynamics of local anesthetics including
toxicity and appropriate selection for the spectrum of clinical indications.
Anesthesia for Cesarean Section
1.
Understand the ACOG guidelines for emergency cesarean section, and prescribe
appropriate anesthetic plans.
2.
Discuss analgesia and anesthesia for cesarean section including epidural, spinal, general
and local anesthesia.
3.
Understand the maternal and fetal ramifications of regional versus general anesthetic
techniques.
4.
Understand the options for post-operative analgesia utilizing PCA, intrathecal, and
epidural narcotics.
5.
Identify and describe the management of the difficult airway in the parturient
Anesthetic Complications
1.
Identify and describe the management of amniotic fluid embolus (AFE).
2.
Identify and describe the management of post-dural puncture headache.
3.
Discuss the implications and describe the management of non-obstetric surgery in
pregnancy.
4.
Identify, develop a differential diagnosis, and describe the management of abnormal
bleeding in the perinatal period.
5.
Describe the factors placing the parturient at risk for aspiration pneumonitis and
acceptable guidelines for prophylaxis.
6.
Describe the etiology, diagnosis and treatment of postpartum neurologic deficits.
Neonatal Resuscitation
1.
Describe basic principles and sequence of neonatal evaluation and resuscitation.
Interpersonal Skills and Communication
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 80
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the advantages as well as potential
disadvantages of the different treatment options.
2.
Create and sustain a therapeutic and ethically sound relationship with peripartum patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
2.
Demonstrate respect, compassion, integrity, and a responsiveness to the needs of patients
and society that supersedes self-interest.
3.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
4.
Demonstrate accountability to patients, colleagues and the institution.
5.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, evaluate and assimilate evidence from scientific and clinical studies
related to OB anesthesiology practice. This includes, but is not limited to, the directed readings
in the Core Curriculum. In selected cases, it is appropriate to pursue additional scientific
evidence in a reference text or in an electronic on-line search.
2.
Assist in the teaching of medical students rotating through the OB anesthesia service.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 81
4.
Apply information technology to manage information, access on-line medical
information, and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and providers to assess, coordinate, and improve health
care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Obstetric Anesthesia, 3rd edition, David H. Chestnut Ed. Elsevier Mosby, 2004.
IV. EVALUATION
Successful completion of this rotation will be based on review of written evaluations by the OB
anesthesia faculty and results of the written examination. For a PGY 4/CA 3 resident to gain credit
for a month of OB anesthesia they must at least be judged to be able to operate on the educator
level and must function at the level of a manager consistently.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 82
PROGRAM GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN OBSTETRIC ANESTHESIA
at Washington Hospital Center
I. ROTATION DEFINITION
This PGY 4/CA 3 level rotation is a one month block at Washington Hospital Center. The
purpose of this rotation is to provide the resident with the opportunity to show mastery of
maternal and fetal/neonatal physiology, the impact of anesthesia upon uncomplicated labor and
vaginal delivery, and the delivery of anesthesia for cesarean section. It is distinct from rotations
at Walter Reed due to the higher volume of high risk obstetrical patients. Patients at Walter
Reed nearly universally receive significant prenatal care whereas Washington Hospital Center
serves civilian patients with varied and sometimes inadequate access to prenatal care. It is a
unique rotation and a chance to see parturients with extremes of pathology due to both the
population served and the immediate proximity to the Children’s National Medical Center, where
many patients with adequate access to prenatal care are referred to when known fetal abnormalities
are identified through prenatal testing.
II. GOALS AND PRIMARY AREA OF KNOWLEDGE
PGY 4/CA 3 residents rotating through the OB anesthesiology service are expected to show
mastery of principles of managing the perinatal anesthetic needs of the parturient. Residents will
develop competence in pre-anesthetic assessment and planning, anesthetic management,
prevention and management of complications, and post-anesthetic care for the parturient in a
community hospital. PGY 4/CA 3 residents are expected to show the ability to function as
educators during the rotation.
Patient Care
Goals:
Residents must provide patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health. Residents are expected to:
1.
Acquire skills for optimal care of the routine and high risk parturient.
2.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
3.
Interact effectively with patients and their families in the peripartum period while
demonstrating respect and care for individuals.
4.
Formulate an anesthetic plan based on the individual patient‟s medical history and
expected peripartum course.
5.
Demonstrate flexibility as the expected peripartum course changes.
6.
Perform competently all regional and general anesthetic techniques essential to the
practice of OB anesthesiology.
7.
Work together with other members of the interdisciplinary health care team to optimize
patient care while acknowledging the occasional stressful aspects of OB patient care.
Objectives:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 83
1.
Manage all common forms of anesthesia and analgesia in the broad spectrum of
parturients encountered in the community hospital setting.
2.
Evaluate, diagnose, and implement treatment of common postpartum complications
including PDPH, persistent neurologic deficits, and side effects from epidural narcotics.
3.
Select and apply appropriate monitoring to the given clinical situation in the parturient.
4.
Interact with health personnel as the leader of the anesthetic and resuscitative care team
in the delivery suite.
5.
Assign APGAR scores for newborns and implement resuscitative efforts based on scores
assigned.
6.
Provide neonatal resuscitation as needed, assuming the parturient does not need
immediate attention.
Integrated Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of OB
anesthesiology.
2.
Demonstrate a sound knowledge base concerning anatomy, maternal, and maternofetal physiology under both normal and pathological states and their relationships to regional
and general anesthesia.
3.
Demonstrate how specific disease states affect the anesthetic management of OB
patients.
4.
Understand historical controversies and recent developments in OB anesthesiology.
5.
Effects of maternal drug use on anesthetic care.
6.
Understand the interaction between anesthetics and fetal abnormalities.
Objectives:
Anesthesia and Maternal Fetal Physiology
1.
Discuss in detail the physiologic changes that accompany pregnancy and their anesthetic
implications.
2.
Describe the pathophysiology of common clinical conditions associated with high risk
pregnancy (e.g., cardiac, neurosurgical, neuromuscular, immunologic and coagulation
disorders).
3.
Discuss the pathophysiology of obesity in pregnancy, including management and impact
upon the neonate.
4.
Discuss the pathophysiology of diabetes in pregnancy, including management and impact
upon the neonate.
5.
Discuss local anesthetic toxicity and the parturient.
6.
Understand the effects of commonly used medications and anesthetic agents on the
infant/fetus.
7.
Describe the effects of anesthetic agents and regional anesthesia on uterine blood flow,
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 84
uterine activity and labor.
8.
Describe the pathophysiology and management of pregnancy induced hypertension
(PIH).
9.
Describe basic principles and rationale of fetal assessment including stress and non-stress
tests, biophysical profile and fetal monitoring.
10.
Understand the anesthetic and obstetric implications of abnormal fetal presentations,
multiple births and preterm labor.
Anesthesia for Labor and Delivery
1.
Discuss and list advantages and disadvantages of analgesic methods for labor including
epidural, inhalational, pudendal and IV sedation.
2.
Understand the indications and contraindications for various test dosing strategies during
epidural anesthesia.
3.
Understand the different options for infusions during laboring epidural anesthesia.
4.
Interpret fetal heart tracings and describe the etiology and treatment of the various fetal
heart rate tracing abnormalities.
5.
Discuss the pharmacodynamics of common non-anesthetic medications used in obstetrics
and their interactions with anesthetics including oxytocin, ergot preparations, magnesium,
terbutaline, indomethacin, prostaglandins and steroids.
6.
Discuss the pharmacokinetics and pharmacodynamics of local anesthetics including
toxicity and appropriate selection for the spectrum of clinical indications.
Anesthesia for Cesarean Section
1.
Understand the ACOG guidelines for emergency cesarean section, and prescribe
appropriate anesthetic plans.
2.
Discuss analgesia and anesthesia for cesarean section including epidural, spinal, general
and local anesthesia.
3.
Understand the maternal and fetal ramifications of regional versus general anesthetic
techniques.
4.
Understand the options for post-operative analgesia utilizing PCA, intrathecal, and
epidural narcotics.
5.
Identify and describe the management of the difficult airway in the parturient
Anesthetic Complications
1.
Identify and describe the management of amniotic fluid embolus (AFE).
2.
Identify and describe the management of post-dural puncture headache.
3.
Discuss the implications and describe the management of non-obstetric surgery in
pregnancy.
4.
Identify, develop a differential diagnosis, and describe the management of abnormal
bleeding in the perinatal period.
5.
Describe the factors placing the parturient at risk for aspiration pneumonitis and
acceptable guidelines for prophylaxis.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 85
6.
Describe the etiology, diagnosis and treatment of postpartum neurologic deficits.
Neonatal Resuscitation
1.
Describe basic principles and sequence of neonatal evaluation and resuscitation.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the advantages as well as potential
disadvantages of the different treatment options.
2.
Create and sustain a therapeutic and ethically sound relationship with peripartum patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
2.
Demonstrate respect, compassion, integrity, and a responsiveness to the needs of patients
and society that supersedes self-interest.
3.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
4.
Demonstrate accountability to patients, colleagues and the institution.
5.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 86
Objectives:
1.
Locate, appraise, evaluate and assimilate evidence from scientific and clinical studies
related to OB anesthesiology practice. This includes, but is not limited to, the directed readings
in the Core Curriculum. In selected cases, it is appropriate to pursue additional scientific
evidence in a reference text or in an electronic on-line search.
2.
Assist in the teaching of medical students rotating through the OB anesthesia service.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Apply information technology to manage information, access on-line medical
information, and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and providers to assess, coordinate, and improve health
care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Obstetric Anesthesia, 3rd edition, David H. Chestnut Ed. Elsevier Mosby, 2004.
IV. EVALUATION
Successful completion of this rotation will be based on review of written evaluations by the OB
anesthesia faculty and results of the written examination. For a PGY 4/CA 3 resident to gain credit
for a month of OB anesthesia during a rotation at Washington Hospital Center they must be
judged to be able to operate on the manager level. This is the same level expected of PGY 3/CA 2s,
but this evaluation is in the setting of caring for a higher number of patients with advanced
maternal-fetal disease states.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016



PAGE 87
Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 88
GOALS AND OBJECTIVES FOR
PGY 2/CA 1 RESIDENTS REQUIRED ROTATION
IN CHRONIC PAIN MEDICINE
I. ROTATION DEFINITION
Each PGY 2/CA 1 resident spends one month on a Chronic Pain Medicine rotation at the Walter
Reed National Military Medical Center. The National Capital Consortium also sponsors an
ACGME accredited Pain Management Fellowship. The Pain Medicine Clinic has over 5,000
patient encounters annually. The scope of practice is broad, including all aspects of chronic pain
management. In the Pain Medicine Clinic, the resident is responsible for the initial and follow-up
assessments of the chronic pain patients. They are expected to perform an intake history and
physical examination followed by presentation of the patient to one of the pain medicine staff
physicians. If a procedure is indicated, on that or a later date, the resident will prepare the patient
for the procedure. All procedures are performed in the presence of a staff physician. PGY 2/CA 1
residents are expected to attain competency in basic pain procedures such as epidural steroid
injections from an intra-laminar approach, facet joint blocks, trigger point injections and joint
injections. Senior residents who choose an elective in pain medicine are expected to develop a
basic understanding and familiarity with complex procedures such as radiofrequency ablations,
discography, major sympathetic blocks and intradiscal electrothermal therapy. Senior residents are
expected to understand the rationale for placing intrathecal pumps and spinal cord stimulators.
There are two to three faculty present at the Walter Reed Clinic and there is one present daily at
the Naval National Medical Center Pain Clinic. The faculty is expected to participate directly in
the care of every patient. They are also to be present through the entirety of every procedure in the
clinic.
II. GOALS AND OBJECTIVES
The primary goal is to provide education, training and experience in the subspecialty of pain
medicine in an atmosphere of mutual respect between instructor and resident that stimulates and
prepares the resident to apply acquired knowledge and skills independently. This rotation will
strive to provide an environment that promotes the acquisition of the knowledge, skills, clinical
judgment, and attitudes essential to the practice of chronic pain medicine.
In addition to clinical skills, this rotation will emphasize interpersonal skills, effective
communication, and professionalism. This program will work toward ensuring that its residents
assume responsibility and act responsibly and with integrity; demonstrate a commitment to
excellence and ethical principles of clinical care (including confidentiality of patient information,
informed consent, and business practices); demonstrate respect and regard for the needs of patients
and society that supersedes self-interest; and work effectively as a member of a health- care team
or other professional group. Furthermore, residents are expected to create and sustain a therapeutic
relationship with patients; engage in active listening, provide information using appropriate
language, ask clear questions, provide an opportunity for input and questions, and demonstrate
sensitivity and responsiveness to cultural differences, including awareness of their and their
patients’ cultural perspectives.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 89
Residents will be integrated into the entire process of evaluating and treating patients with acute
and chronic pain. They will evaluate new patients, interacting with the referring physician, take
histories, perform physical examinations, laboratory and radiograph review and interpretation,
diagnosis, treatment plan formulation, invasive procedures, and referral to other specialists as
appropriate. They will be expected to follow-up with patients they treat to gain an appreciation
and understanding of the outcomes and consequences of treatment plans. They will participate in
all phases of managing a hospital and clinic based pain practice to gain insight and experiences
in business practices.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Perform an appropriate evaluation; including history, physical exam and laboratory
studies as needed.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
expected clinical course.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care and enhance quality of life.
Objectives:
1.
2.
3.
4.
Conduct a full history and physical examination.
Perform translaminar epidural steroid injections using fluoroscopy.
Perform diagnostic and therapeutic lumbar facet procedures.
Perform trigger point injections.
Integrated Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of chronic pain
medicine.
2.
Demonstrate a sound knowledge base concerning anatomy, physiology, and
pharmacology.
3.
Demonstrate how specific physical and psychological states affect the management of
chronic pain patients.
4.
Understand recent developments in pain medicine.
Objectives:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 90
The goal is to provide a broad understanding of chronic pain problems. Knowledge to be gained
includes the basics of evaluation and management of chronic pain patients.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Discuss the principles and indications of diagnostic testing.
List the indications for diagnostic testing.
Describe mechanisms of chronic pain.
Discuss chronic regional pain syndrome (CRPS).
Discuss sickle cell disease related pain.
Explain etiologies and treatment of mechanical lower back pain.
Describe myofascial pain syndrome and its treatment.
Compare and contrast diagnostic and therapeutic neural blockade.
Describe post-herpetic neuralgia and its management.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the advantages as well as potential
disadvantages of the different treatment options.
2.
Create and sustain a therapeutic and ethically sound relationship with patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism:
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession;
and a commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
3.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and
disabilities.
4.
Demonstrate accountability to patients, colleagues and institution.
5.
Demonstrate a commitment to excellence and ongoing professional development.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 91
Practice Based Learning
Goals:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to their patients‟
health problems.
2.
Assist in the teaching of medical students rotating through the pain clinic.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies of diagnostic and therapeutic effectiveness.
4.
Apply information technology to patient information, access on-line medical information,
and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care while learning how these activities affect system performance.
III. REQUIRED READING
1.
Essentials of Pain Medicine, Benzon & Raja, 3rd Ed, 2011.
2.
Raj’s Practical Management of Pain, 4th edition. Honorio Benzon, James P. Rathmell,
Christopher L. Wu, Dennis C. Turk, Charles E. Argoff. Mosby 2008.
3.
Bonica’s Management of Pain, 4th edition. Scott M. Fishman, Jane C. Ballantyne, James
P. Rathmell, Eds. Lippincott Williams & Wilkins 2009.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 92
IV. EVALUATION
Final evaluation will be based upon clinical performance, a written evaluation and quality of
academic presentation. PGY 2/CA 1s must be determined to operate the the interpreter level to gain
credit for the rotation.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 93
GOALS AND OBJECTIVES FOR
PGY 3/CA 2 RESIDENTS ELECTIVE
IN CHRONIC PAIN MEDICINE
I. ROTATION DEFINITION
Senior residents may choose an elective in Pain Medicine at WRNMMC. Senior residents who
choose an elective in pain medicine are expected to demonstrate proficiency in basic pain
procedures (see PGY 2/CA 1 objectives) and develop a mastery of basic pain management
principles and procedures and a basic understanding and familiarity with complex procedures such
as radiofrequency ablations, discography, major sympathetic blocks and intradiscal electrothermal
therapy. The faculty is expected to participate directly in the care of every patient. They are also to
be present through the entirety of every procedure in the clinic.
II. GOALS AND OBJECTIVES
The primary goal is to provide a greater depth of education, training and experience in the
subspecialty of pain medicine than gain on the previous required rotation. PGY 3/CA 2 residents
must demonstrate a mastery of basic aspects of pain management and a basic understanding of
complex pain management strategies and procedures. This rotation will strive to provide an
environment that promotes the acquisition of the knowledge, skills, clinical judgment, and attitudes
essential to the practice of chronic pain medicine.
In addition to clinical skills, this rotation will emphasize interpersonal skills, effective communication,
and professionalism. This program will work toward ensuring that its residents assume responsibility
and act responsibly and with integrity; demonstrate a commitment to excellence and ethical principles
of clinical care (including confidentiality of patient information, informed consent, and business
practices); demonstrate respect and regard for the needs of patients and society that supersedes selfinterest; and work effectively as a member of a health- care team or other professional group.
Furthermore, residents are expected to create and sustain a therapeutic relationship with patients;
engage in active listening, provide information using appropriate language, ask clear questions,
provide an opportunity for input and questions, and demonstrate sensitivity and responsiveness to
cultural differences, including awareness of their and their patients’ cultural perspectives.
Residents will be integrated into the entire process of evaluating and treating patients with acute and
chronic pain. They will evaluate new patients, interacting with the referring physician, take histories,
perform physical examinations, laboratory and radiograph review and interpretation, diagnosis,
treatment plan formulation, invasive procedures, and referral to other specialists as appropriate. They
will be expected to follow-up with patients they treat to gain an appreciation and understanding of the
outcomes and consequences of treatment plans. They will participate in all phases of managing a
hospital and clinic based pain practice to gain insight and experiences in business practices.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health. Residents are expected to:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 94
1.
Perform an appropriate evaluation; including history, physical exam and laboratory
studies as needed.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
expected clinical course.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care and enhance quality of life.
Objectives:
1.
2.
3.
4.
5.
6.
7.
Conduct a full history and physical examination.
Perform translaminar epidural steroid injections using fluoroscopy.
Perform diagnostic and therapeutic lumbar facet procedures.
Perform trigger point injections.
Perform transformainal epidural steroid injections
Perform neuroablative procedures of the posterior rami for facet arthropathy
Perform interlaminar cervical epidural steroid injections
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of chronic pain
medicine.
2.
Demonstrate a sound knowledge base concerning anatomy, physiology, and
pharmacology.
3.
Demonstrate how specific physical and psychological states affect the management of
chronic pain patients.
4.
Understand recent developments in pain medicine.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
9.
7.
8.
Discuss the principles and indications of diagnostic testing.
List the indications for diagnostic testing.
Describe mechanisms of chronic pain.
Discuss chronic regional pain syndrome (CRPS).
Discuss sickle cell disease related pain.
Explain etiologies and treatment of mechanical lower back pain.
Describe myofascial pain syndrome and its treatment.
Compare and contrast diagnostic and therapeutic neural blockade.
Describe post-herpetic neuralgia and its management.
Discuss neuroablative strategies
Discuss indications and techniques for cervical epidural steroid injections
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 95
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the advantages as well as potential
disadvantages of the different treatment options.
2.
Create and sustain a therapeutic and ethically sound relationship with patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism:
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and
society that supersedes self-interest; accountability to patients, society, and the profession; and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
3.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and
disabilities.
4.
Demonstrate accountability to patients, colleagues and institution.
5.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to their patients‟
health problems.
2.
Assist in the teaching of medical students rotating through the pain clinic.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies of diagnostic and therapeutic effectiveness.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 96
4.
Apply information technology to patient information, access on-line medical information, and
support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care while learning how these activities affect system performance.
III. REQUIRED READING
1.
Essentials of Pain Medicine, Benzon & Raja, 3rd Ed, 2011.
2.
Raj’s Practical Management of Pain, 4th edition. Honorio Benzon, James P. Rathmell,
Christopher L. Wu, Dennis C. Turk, Charles E. Argoff. Mosby 2008.
3.
Bonica’s Management of Pain, 4th edition. Scott M. Fishman, Jane C. Ballantyne, James
P. Rathmell, Eds. Lippincott Williams & Wilkins 2009.
IV. EVALUATION
Final evaluation will be based upon clinical performance, a written evaluation and quality of academic
presentation. PGY 3/CA 2s must at least be determined to operate the manager level to gain credit for
an elective rotation in Chronic Pain Medicine.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 97
GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS ELECTIVE
IN CHRONIC PAIN MEDICINE
I. ROTATION DEFINITION
Senior residents may choose an elective in Pain Medicine at WRNMMC. Senior residents who
choose an elective in pain medicine in the 4th post graduate year are expected to demonstrate
mastery in basic pain procedures, an indepth understanding of complex procedures such as
radiofrequency ablations, discography, major sympathetic blocks and intradiscal electrothermal
therapy and must gain a basic understanding of the most complex pain procedures (implantable spinal
pumps and spinal cord stimulators. The faculty is expected to participate directly in the care of every
patient. They are also to be present through the entirety of every procedure in the clinic.
II. GOALS AND OBJECTIVES
The primary goal is to provide a greater depth of education, training and experience in the
subspecialty of pain medicine than gain on the previous required rotation. Senior residents must
demonstrate a mastery of basic aspects of pain management, a thorough understanding of complex
but common issues and a basic understanding of the most complex and uncommon pain
management strategies and procedures. The goal of a rotation through the pain clinic in the PGY 4
year is to develop the anesthesiology resident into a consultant in pain medicine with an
understanding of the indications and complications of the most invasive procedures. The resident
should then be able to handle basic to intermediate pain procedures and cases and know when to
refer to a pain fellowship trained physician for further options in care for a patient. This rotation
will strive to provide an environment that promotes the acquisition of the knowledge, skills, clinical
judgment, and attitudes essential to the practice of chronic pain medicine.
In addition to clinical skills, this rotation will emphasize interpersonal skills, effective communication,
and professionalism. This program will work toward ensuring that its residents assume responsibility
and act responsibly and with integrity; demonstrate a commitment to excellence and ethical principles
of clinical care (including confidentiality of patient information, informed consent, and business
practices); demonstrate respect and regard for the needs of patients and society that supersedes selfinterest; and work effectively as a member of a health- care team or other professional group.
Furthermore, residents are expected to create and sustain a therapeutic relationship with patients;
engage in active listening, provide information using appropriate language, ask clear questions,
provide an opportunity for input and questions, and demonstrate sensitivity and responsiveness to
cultural differences, including awareness of their and their patients’ cultural perspectives.
Residents will be integrated into the entire process of evaluating and treating patients with acute and
chronic pain. They will evaluate new patients, interacting with the referring physician, take histories,
perform physical examinations, laboratory and radiograph review and interpretation, diagnosis,
treatment plan formulation, invasive procedures, and referral to other specialists as appropriate. They
will be expected to follow-up with patients they treat to gain an appreciation and understanding of the
outcomes and consequences of treatment plans. They will participate in all phases of managing a
hospital and clinic based pain practice to gain insight and experiences in business practices.
Patient Care
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 98
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health. Residents are expected to:
1.
Perform an appropriate evaluation; including history, physical exam and laboratory
studies as needed.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
expected clinical course.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care and enhance quality of life.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Conduct a full history and physical examination.
Perform translaminar epidural steroid injections using fluoroscopy.
Perform diagnostic and therapeutic lumbar facet procedures.
Perform trigger point injections.
Perform transformainal epidural steroid injections
Perform neuroablative procedures of the posterior rami for facet arthropathy
Perform interlaminar cervical epidural steroid injections
Perform discography
Perform intradiscal electrotherapy (IDET)
Integrated Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of chronic pain
medicine.
2.
Demonstrate a sound knowledge base concerning anatomy, physiology, and
pharmacology.
3.
Demonstrate how specific physical and psychological states affect the management of
chronic pain patients.
4.
Understand recent developments in pain medicine.
Objectives:
1.
2.
3.
4.
5.
Discuss the principles and indications of diagnostic testing.
List the indications for diagnostic testing.
Describe mechanisms of chronic pain.
Discuss chronic regional pain syndrome (CRPS).
Discuss sickle cell disease related pain.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 99
6.
7.
8.
9.
7.
8.
9.
10.
11.
Explain etiologies and treatment of mechanical lower back pain.
Describe myofascial pain syndrome and its treatment.
Compare and contrast diagnostic and therapeutic neural blockade.
Describe post-herpetic neuralgia and its management.
Discuss neuroablative strategies
Discuss indications and techniques for cervical epidural steroid injections
Discuss discogentic pain
Discuss the risks and benefits of discography
Discuss the risks and benefits of IDET
Interpersonal/Communication Skills
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the advantages as well as potential
disadvantages of the different treatment options.
2.
Create and sustain a therapeutic and ethically sound relationship with patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism:
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and
society that supersedes self-interest; accountability to patients, society, and the profession; and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices.
3.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
4.
Demonstrate accountability to patients, colleagues and institution.
5.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Goal:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 100
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to their patients‟
health problems.
2.
Assist in the teaching of medical students rotating through the pain clinic.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies of diagnostic and therapeutic effectiveness.
4.
Apply information technology to patient information, access on-line medical information, and
support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care while learning how these activities affect system performance.
IV. REQUIRED READING
1.
Essentials of Pain Medicine, Benzon & Raja, 3rd Ed, 2011.
2.
Raj’s Practical Management of Pain, 4th edition. Honorio Benzon, James P. Rathmell,
Christopher L. Wu, Dennis C. Turk, Charles E. Argoff. Mosby 2008.
3.
Bonica’s Management of Pain, 4th edition. Scott M. Fishman, Jane C. Ballantyne, James
P. Rathmell, Eds. Lippincott Williams & Wilkins 2009.
V. EVALUATION
Final evaluation will be based upon clinical performance, a written evaluation and quality of academic
presentation. PGY 3/CA 2s or PGY 4/CA 3s must be determined to operate the manager level to gain
credit for an elective rotation in Chronic Pain Medicine.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 101
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 102
GOALS AND OBJECTIVES FOR
RESIDENTS IN PRE-ANESTHETIC EVALUATION
I. ROTATION DEFINTION
During the first year, each resident will spend one month in the Ambulatory Procedures Unit (APU)
at the Walter Reed National Military Medical Center. In the APU, the resident is responsible for the
pre-operative assessment of ambulatory patients scheduled for surgical or diagnostic procedures. For
each patient they see, they are expected to perform a focused history and physical exam, review
pertinent laboratory data, develop an anesthetic plan, and counsel the patient accordingly. Should the
patient not be ready for surgery, the resident shall request appropriate consultation(s) in cooperation
with the attending anesthesiologist and patient’s referring physician. A staff anesthesiologist is
always assigned as the APU resident supervisor.
II. GOALS AND OBJECTIVES
The main goal of this rotation is to provide education, training and experience in pre-anesthetic
evaluation in an atmosphere of mutual respect between instructor and resident so that residents will
be stimulated and prepared to apply acquired knowledge and talents independently. This rotation
will strive to provide an environment that promotes the acquisition of the knowledge, skills, clinical
judgment, and attitudes essential for thorough and efficient pre-anesthetic evaluation.
In addition to clinical skills, this rotation will emphasize interpersonal skills, effective
communication, and professionalism. This program will work toward ensuring that residents, by the
time they finish the rotation, assume responsibility and act responsibly and with integrity;
demonstrate a commitment to excellence and the ethical principles of clinical care, including
confidentiality of patient information, informed consent, and business practices; demonstrate respect
and regard for the needs of patients and society that supersedes self-interest; and work effectively as a
member of a health-care team or other professional group.
Residents will be integrated into the entire process of pre-anesthetic evaluation. They will evaluate
patients, interact with the referring physician as needed, perform focused history and physical exams,
review and interpret laboratory data, and establish an appropriate anesthetic plan in cooperation with
the patient and supervising anesthesiologist. They will participate in all phases of the clinic‟s practice
in order to gain insight and experience in business practices.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health. Residents are expected to:
1.
Provide a preoperative patient assessment and suggest appropriate perioperative
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 103
interventions to ensure patient safety and reduce risk.
2.
Communicate successfully with patients to obtain pertinent pre-operative data.
3.
Formulate an anesthetic plan based on the patient‟s medical history and the planned
surgical procedure with the goal of discharge to home after satisfactory recovery from surgery and
anesthesia.
4.
Work with other health care professionals to provide a safe, efficient, and cost-effective
arena for ambulatory surgery.
Objectives:
1.
Conduct a complete history and focused physical examination.
2.
Predict difficult intubation and formulate an anesthetic plan.
3.
Determine which patients are ready for anesthesia and surgery and which need additional
consultative evaluations
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply analytical thought processes to clinical situations.
2.
Apply supportive sciences to the practice of anesthesiology.
3.
Demonstrate a solid foundation in pharmacology and physiology.
4.
Acquire and demonstrate knowledge of disease processes and their anesthetic
implications.
Objectives:
1.
Demonstrate the knowledge and skills required to obtain a focused history and physical
examination.
2.
Demonstrate the knowledge required to determine appropriate anesthetic plans for
various surgical procedures.
3.
Demonstrate the knowledge required to determine appropriate anesthetic plans based on
co-existing disease(s).
4.
Demonstrate the knowledge required to examine the airway, predict difficult intubation,
and formulate primary and back-up plans to secure the airway.
5.
Learn and apply the ASA practice guidelines for preoperative fasting.
6.
Learn and apply the AHA/ACC guidelines for the management of the cardiac patient
undergoing non-cardiac surgery
7.
List the indications for pre-anesthetic laboratory and radiologic studies.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 104
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to the assessment
and care of pre-operative patients.
2.
Use information technology to manage medical information, access on-line medical
information and support their medical knowledge.
3.
Facilitate the learning of students and other health care professionals.
Interpersonal/Communication Skills
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Establish relationships with patients and their families that facilitate the effective retrieval of
pertinent medical and social information and the provision of information regarding anesthetic options
and risks.
2.
Work as part of a health care team, communicating with other health care professionals
involved in the care of the patient.
Professionalism
Goals:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
2.
3.
4.
Demonstrate respect, compassion, and integrity.
Demonstrate responsiveness to patient’s needs.
Demonstrate accountability to patients, colleagues, and institution.
Demonstrate a commitment to excellence and ongoing professional development.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 105
Objectives:
1.
2.
3.
Integrate the practice of anesthesiology into each patient‟s perioperative care plan.
Understand how patients are selected for ambulatory surgery.
List resource availability and their relationship to the APU.
III. REQUIRED READING
1.
American Society of Anesthesiologists. Practice guidelines for preoperative fasting and
the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy
patient undergoing elective procedures. Anesthesiology 1999;9:896-905.
2.
Fleiser LA, Beckman JA, Calkins H, et al. ACC/AHA 2007 guidelines on perioperative
cardiovascular evaluation and care for non-cardiac surgery. J Am Coll Cardiol
2007;50:159-242.
3.
Hines, RL, Marschall KE. Anesthesia and co-existing disease, 5th Edition. Churchill
Livingstone. New York; 2008.
IV. EVALUATION:
Final evaluation will be based upon clinical performance.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 106
GOALS AND OBJECTIVES FOR
CA1/PGY2 RESIDENTS IN ACUTE PAIN
MEDICINE AT WRNMMC
I. ROTATION DEFINITION
Acute Pain Medicine is an essential subsection perioperative care. It is based on the premise that
acute pain is much more than a symptom but rather collection of pathophysiologic processes that
can lead to persistent post-surgical pain. In a multidisciplinary fashion, an anesthesiologist led
acute pain medicine service utilizes a multimodal approach to perioperative pain through
interventional, pharmacologic, and other rehabilitative techniques (physical therapy, psychiatry,
etc). Such a service is extended to both surgical and non-surgical patients.
Regional anesthesia is one of the most power tools an Acute Pain Medicine service provides.
Regional anesthetic administration with local anesthetics prevents nociceptive impulses from
reaching the central nervous system before, during, and after surgical procedures. Advantages of
regional anesthesia include reduced physiologic derangements with surgery, less risk of
pulmonary aspiration (airway reflexes are not obtunded), and the provision of post-operative
analgesia. Preoperatively placed regional anesthetics reduce or prevent up-regulation of central
nervous system nociceptive signaling pathways. Perioperative regional anesthetics allow
reduction or avoidance of general anesthetics during surgery, reducing the toxicities of these
systemic medications. Neuraxial and peripheral anesthetic techniques extended into the
postoperative period reduce adverse anatomic and metabolic responses to surgery. Regional
techniques may improve surgical outcomes, including reducing wound infections and possibly
cancer recurrence. For all these reasons, anesthesiologists must be proficient in their ability to
provide regional anesthetics.
This rotation provides an introduction to acute pain medicine and the use of regional anesthetic
techniques for both in- patient and ambulatory surgery. Residents will receive an introduction
to the approach to surgical and non-surgical patients via multimodal analgesic principles.
Residents will receive considerable exposure to the unique requirements of regional anesthesia.
Residents are expected to perform at least 40 peripheral blocks during their residency. While
some patients will only need to be followed until discharge from the PACU, residents will be
expected to follow some patients throughout the duration of their inpatient rehabilitation. This
ensures adequate clinical experience to develop both the motor skills necessary to perform
regional blocks and the cognitive skills to manage patients throughout the perioperative period.
A multidisciplinary approach to acute pain and the advantages of regional anesthetic techniques in
perioperative patient care will be stressed. These include reduction of nausea and vomiting, the
rapid emergence from anesthesia in order to qualify for PACU bypass, and improved perioperative
pain control. The pharmacologic rationale for the selection of local anesthetics, the role of regional
techniques in multimodal pain management, the complications and outcomes of regional
anesthesia, and specifics of many peripheral nerve blocks (including indications, contraindications,
pertinent anatomy and complications for each technique) will be emphasized during the rotation.
In this rotation, residents will focus on developing the necessary motor skills to place peripheral
nerve blocks and learning the principles of safe regional anesthesia. CA2/PGY2 residents are
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 107
expected to develop an understanding and familiarity with basic interventional strategies for acute
pain medicine such as include femoral block, sciatic block, popliteal fossa block, brachial plexus
blocks (interscalene block, supraclavicular, infraclavicular, and axillary), intravenous regional
anesthesia, and caudal block.
II. RESIDENT RESPONSIBILITIES
Residents will be responsible for evaluating patients who are candidates for regional anesthesia or
who require consultative medical pain care. Residents will be expected to take a history and
perform a pertinent physical exam. Residents are expected, with supervision from Staff
Anesthesiologist, to plan and execute the appropriate medical, interventional or combination
therapy for each patient on the acute pain service. Residents are required to document medical
care appropriately and to follow patients while on the acute pain service looking for benefit and
complication of therapy.
Daily assignment
1.
2.
3.
4.
5.
6.
The resident will be assigned to the regional service for the day. The resident should
review the schedule for possible regional anesthesia candidates the day prior and
the morning of duty.
The resident will work closely with the regional staff anesthesiologist to coordinate
blocks. The resident may perform all scheduled OR peripheral blocks preoperatively
in the designated “regional block area.” Spinal, epidural, and combined spinalepidural blocks may be placed in the operating room, either by the regional resident
or by the OR room staff. Ultimately, the anesthesiologist supervising the anesthetic
case has final say regarding who does the block for that room.
The resident is responsible for reviewing the chart, interviewing and examining the
patient and discussing the anesthetic options with the staff anesthesiologist for each
case.
The resident will perform the block, document the procedure on the chart, follow the
patient in the operating room (noting any complications and checking for
effectiveness), follow-up with the patient in the recovery room, complete the
appropriate post-operative orders, and visit the patients post-operatively on the floor.
At the end of each day, the schedule for the following day should be reviewed by the
resident and the regional anesthesiologist.
The resident will participate in daily Acute Pain Service rounds and participate in the
management of perioperative pain and other aspects of perioperative care. Residents
will write daily notes, prescribe medications, and engage the primary admitting
surgical services in the care of operative patients.
While on the service, residents will keep a log of blocks, including the type of block, date,
indication, success or failure, and any complications. The resident should round on in-house
cases the next day after the regional procedure is performed, and follow up on any problems
identified when the APU staff calls outpatients the next day.
III. GOALS AND OBJECTIVES
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 108
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
Provide a preoperative patient assessment, and suggest appropriate perioperative
interventions to ensure patient safety and reduce risk, based on findings and
preexisting patient conditions.
Formulate an anesthetic plan, emphasizing the needs of the ambulatory patient and
integrating general, neuraxial, and peripheral regional anesthesia techniques to
provide optimum patient outcome and satisfaction.
Provide peripheral and/or neuraxial blocks, sedation or general anesthesia in a competent
and safe manner, and provide continuity of care in the operating room, and, when
possible, in the PACU or same-day surgery unit.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Preoperatively evaluate and identify patients that are candidates for regional anesthetic
procedures.
Perform brachial plexus, interscalene, intravenous regional, caudal, paravertebral, lumbar
plexus, sciatic and peripheral nerve blocks on appropriate patients under supervision
with minimal assistance and a high rate of success (>95%).
Provide regional techniques with sedation or combined with a general anesthetic in a
variety of surgical procedures.
Actively teach medical students and junior residents the pertinent anatomy and
techniques of the various regional anesthetics.
Perform upper extremity brachial plexus blocks (interscalene, supraclavicular,
infraclavicular, axillary).
Perform lower extremity plexus blocks (lumbar plexus, femoral, sciatic).
Properly plan and select equipment and local anesthetic agents for all regional anesthetic
procedures.
Provide sedation to create optimal conditions for performing a given block, as well as
patient comfort and blunting of adverse hemodynamic responses.
Demonstrate use of the peripheral nerve stimulator and ultrasound to assist in the
performance of peripheral nerve blocks.
Recognize the need for general anesthesia following an inadequate regional anesthetic
and convert to general anesthesia safely and efficiently with minimal disruption of
the planned surgery.
Recognize, evaluate and treat complications of regional blocks.
Recognize and evaluate the patient with a potential central neuraxial hematoma in a
timely and efficient manner.
Recognize and treat systemic local anesthetic toxicity.
Medical Knowledge
Goals:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 109
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
1.
2.
3.
4.
5.
List important requirements for ambulatory/inpatient surgical procedures and
how regional anesthetics can be designed to meet these requirements.
Describe the use of multimodal analgesia, in particular the use of peripheral blocks, and
its relationship to the goals of acute perioperatie pain medicine (inpatient and
ambulatory).
Discuss complications of peripheral blocks and their management.
List indications and contraindications of specific peripheral nerve blocks and their impact
upon the degree of post-operative pain expected from the planned surgery.
Describe the pharmacology (analgesic mechanisms and side effects) and utility of various
pharmacologic agents used for acute peiroperative pain and in the immediate
rehabilitative phase.
Objectives:
1.
2.
Identify indications and contraindications for regional anesthesia.
Understand and discuss the pharmacokinetics and pharmacodynamics of local anesthetics
and the differences among them.
3. Understand and discuss the benefits and risks related to the various additives used with
local anesthetic solutions.
4. Select and defend the choice of block and local anesthetic for surgical procedures,
depending on duration, location and severity of patient illness.
5. Display expert knowledge of anatomy pertinent to performing head and neck, upper and
lower extremity, plexus, sciatic, pleural, rib, spinal, epidural, and caudal anesthetic
procedures.
6. Demonstrate expert knowledge of the anatomic and physiologic differences of the
obstetric and pediatric patient population that may affect the implementation use
of a given regional technique.
7. Understand the benefits of a regional technique as it pertains to patient safety and
influence upon surgical outcome.
8. Discuss the peripheral nerve blocks of the upper and lower extremity, including
indications, contraindications, side effects, local anesthetic choice, needle type, the
use of indwelling catheters, patient positioning, monitoring and the
advantages/disadvantages of the various techniques and equipment used.
9. Discuss intravenous regional block (Bier block), including indications, side effects,
choice of local anesthetic, patient monitoring and its advantages/disadvantages.
10. Discuss peripheral nerve blocks of the head, neck and chest, including indications,
contraindications, side effects, local anesthetics, needle type, the use of
indwelling
catheters,
patient
positioning,
monitoring
and
the
advantages/disadvantages of the different techniques and equipment.
11. Discuss techniques for nerve localization; including peripheral nerve stimulation,
eliciting paresthesias, anatomic (e.g. bounce, pop, etc), and ultrasonic.
12. Discuss the mechanisms and side effects of various multimodal pharmacologic
agents used for acute perioperative pain.
Interpersonal Skills and Communication
Goals:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 110
Residents must be able to demonstrate interpersonal and communication skills that result in
effective information exchange and team-building with patients, their patient’s families, and
professional associates.
Objectives:
1.
2.
3.
4.
5.
Discuss with patients the advantages and potential disadvantages of various multimodal
analgesics including pharmacologic and regional anesthesia techniques.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
Articulate the anesthetic plan to the attending anesthesiologist and explain its
rationale.
Conduct post-operative visits for in-patients, and call-backs for ambulatory patients to
evaluate patient satisfaction and determine the incidence of undesirable effects of
the anesthetic.
The resident must be sensitive to patient concerns about awareness and
pain.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
2.
3.
4.
5.
6.
Interact with staff anesthesiologists, CRNAs, PACU nurses, floor nurses, and operating
room staff in a manner which reflects interpersonal respect, integrity and commitment
to excellence in patient care.
Manage interpersonal conflict with dignity and in a manner which avoids offensive
behavior and reflects emotional maturity.
Protect patient confidentiality.
Maintain a respectable appearance.
Consult the surgical/medical team and attending anesthesiologist when questions arise
as to the appropriateness of regional anesthesia or about the nature of the planned
procedure, fostering an atmosphere of collegiality and allowing the development of
a plan which best serves the interest of the patient.
The resident must possess sufficient judgment and maturity to abort attempting regional
anesthetics when necessary.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 111
Objectives:
1.
2.
3.
Collect and analyze post-procedure data from anesthetic cases performed.
Keep an accurate case log to document regional blocks performed, including the
following information: type of block, success of block, any complications
encountered, overall anesthetic plan, duration of block (from call-backs) and patient
satisfaction.
On a daily basis, report the information regarding block success and duration,
complications and patient satisfaction with the rotation directors, and
provide an assessment and plan for improving the quality of anesthetic care
provided.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
2.
3.
4.
For each ambulatory anesthetic case performed, analyze those factors which may
optimize the likelihood of PACU bypass, communicate these to the attending in
the anesthetic plan, and conduct the anesthetic accordingly.
Assess causes of failure to achieve planned PACU bypass in ambulatory cases, and
suggest changes to improve success.
Evaluate patient feedback data, identifying problems in anesthesia care and creating
potential solutions to enhance patient satisfaction and facilitate more effective
care.
Evaluate the cost-effectiveness of acute pain medicine/regional anesthetic care,
including block techniques, medications, and perioperative analgesia options.
IV. REQUIRED READING
1.
Local Anesthetics, Chapter 30, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
1.
Spinal, Epidural, and Caudal Anesthesia, Chapter 51, Anesthesia, 7th edition, Ronald
Miller Ed. Churchill Livingston, 2010.
2.
Nerve Blocks, Chapter 52, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
V. REFERENCE MATERIALS
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
1.
2.
3.
4.
5.
PAGE 112
Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional
Anesthesia (New York School of Regional... by Admir Hadzic (Dec 7, 2011)
Atlas of Regional Anesthesia: Expert Consult - Online and Print, 4e (Expert Consult
Title: Online + Print) by David L. Brown MD (Aug 4, 2010)
Atlas of Ultrasound-Guided Regional Anesthesia: Expert Consult - Online and Print, 2e
by Andrew T. Gray MD (Oct 8, 2012)
Ultrasound Guided Regional Anesthesia and Pain Medicine by Paul E. Bigeleisen (Nov
20, 2009)
Acute Pain Management (Cambridge Medicine) by Raymond S. Sinatra, Oscar A. de
Leon-Cassasola, Eugene R. Viscusi and Brian Ginsberg (Apr 27, 2009)
6.
Anesthesia and Analgesia – monthly sections on regional and ambulatory anesthesia.
7.
Web Sites:
www.nysora.com
www.dvcipm.org
www.usra.ca
www.neuraxiom.com
V. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and will be based on the written evaluations provided at the completion of this rotation. PGY
2/CA 1 residents must be determined to function at the level of interpreter or higher to receive
credit for a rotation in acute pain medicine. The summative monthly evaluation will be based
upon the following tools and information
1.
2.
3.
4.
5.
Resident case logs.
Tabulated QI data for the blocks and anesthetics performed by the resident.
Resident written self-assessment of their educational needs in regional anesthesia,
recommendations for changes in systems and bedside care based upon the QI data
and educational needs assessment.
Monthly evaluations by staff anesthesiologists with emphasis on punctuality, maturity,
clinical competence, rapport with patients, and fundamentals of knowledge. “On the
fly” evaluations will be used to address daily concerns.
Resident evaluations of the staff and rotation.
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 113
GOALS AND OBJECTIVES FOR
PGY 3/CA 2 RESIDENTS IN ACUTE PAIN MEDICINE
AT WRNMMC
I. ROTATION DEFINITION
This rotation provides additional training in acute pain medicine. Senior residents will master the
use of regional anesthetic techniques for both in- patient and ambulatory surgery as well as medical
management of acute pain.
In this rotation, residents will further develop the necessary motor skills to place peripheral nerve
blocks and learning the principles of safe regional anesthesia. Senior residents are expected to
demonstrate proficiency in less complicated regional anesthetic techniques such as femoral block,
sciatic block, popliteal fossa block, brachial plexus blocks (interscalene block, supraclavicular,
infraclavicular, and axillary), intravenous regional anesthesia or caudal block. PGY 3/CA 2 residents
are expected to develop an understanding for the indications and performance of paravertebral
blocks, lumbar plexus blocks, and other invasive nerve blocks. PGY 3/CA 2 residents are expected
to also demonstrate a mastery of basic medical management of acute pain strategies (e.g. opioids
and patient controlled analgesia) and also to develop an understanding of the indications and
principles of advanced medical management of pain (e.g. ketamine infusions, complex spine pain
protocols, etc.).
II. RESIDENT RESPONSIBILITIES
Residents will be responsible for evaluating patients who are candidates for regional anesthesia or
who require consultative medical pain care. Residents will be expected to take a history and perform
a pertinent physical exam. Residents are expected, with supervision from Staff Anesthesiologist, to
plan and execute the appropriate medical, interventional or combination therapy for each patient on
the acute pain service. Residents are required to document medical care appropriately and to follow
patients while on the acute pain service looking for benefit and complication of therapy.
Daily assignment
1.
The resident will be assigned to the regional service for the day. The resident should
review the schedule for possible regional anesthesia candidates the day prior and the morning of
duty.
2.
The resident will work closely with the regional staff anesthesiologist to coordinate blocks.
The resident may perform all scheduled OR peripheral blocks preoperatively in the designated
“regional block area.” Spinal, epidural, and combined spinal-epidural blocks may be placed in the
operating room, either by the regional resident or by the OR room staff. Ultimately, the
anesthesiologist supervising the anesthetic case has final say regarding who does the block for that
room.
3.
The resident is responsible for reviewing the chart, interviewing and examining the patient
and discussing the anesthetic options with the staff anesthesiologist for each case.
4.
The resident will perform the block, document the procedure on the chart, follow the patient
in the operating room (noting any complications and checking for effectiveness), follow-up with the
patient in the recovery room, complete the appropriate post-operative orders, and visit the patients
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 114
post-operatively on the floor.
5.
At the end of each day, the schedule for the following day should be reviewed by the
resident and the regional anesthesiologist.
6.
The resident will participate in daily Acute Pain Service rounds and participate in the
management of perioperative pain and other aspects of perioperative care. Residents will write daily
notes, prescribe medications, and engage the primary admitting surgical services in the care of
operative patients.
While on the service, residents will keep a log of blocks, including the type of block, date,
indication, success or failure, and any complications. The resident should round on in-house
cases the next day after the regional procedure is performed, and follow up on any problems
identified when the APU staff calls outpatients the next day.
III. GOALS AND OBJECTIVES
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health. Residents are expected to:
1.
Provide a preoperative patient assessment, and suggest appropriate perioperative
interventions to ensure patient safety and reduce risk, based on findings and preexisting patient
conditions.
2.
Formulate an anesthetic plan, emphasizing the needs of the ambulatory patient and
integrating general, neuraxial, and peripheral regional anesthesia techniques to provide optimum
patient outcome and satisfaction.
3.
Provide peripheral and/or neuraxial blocks, sedation or general anesthesia in a competent
and safe manner, and provide continuity of care in the operating room, and, when possible, in the
PACU or same-day surgery unit.
4.
Demonstrate basic leadership skills by leading team of junior residents and acute pain
nurses in daily care of acute pain patients followed by the service.
Objectives:
1.
Preoperatively evaluate and identify patients that are candidates for regional anesthetic
procedures or acute pain service consultation.
2.
Perform brachial plexus, interscalene, intravenous regional, caudal, paravertebral, lumbar
plexus, sciatic and peripheral nerve blocks on appropriate patients under supervision with minimal
assistance and a high rate of success (>95%).
3.
Provide regional techniques with sedation or combined with a general anesthetic in a
variety of surgical procedures.
4.
Actively teach medical students and junior residents the pertinent anatomy and
techniques of the various regional anesthetics.
5.
Perform upper extremity brachial plexus blocks (interscalene, supraclavicular,
infraclavicular, axillary).
6.
Perform lower extremity plexus blocks (lumbar plexus, femoral, sciatic).
7.
Properly plan and select equipment and local anesthetic agents for all regional anesthetic
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 115
procedures.
8.
Provide sedation to create optimal conditions for performing a given block, as well as
patient comfort and blunting of adverse hemodynamic responses.
9.
Demonstrate use of the peripheral nerve stimulator and ultrasound to assist in the
performance of peripheral nerve blocks.
10.
Recognize the need for general anesthesia following an inadequate regional anesthetic
and convert to general anesthesia safely and efficiently with minimal disruption of the planned
surgery.
11.
Recognize, evaluate and treat complications of regional blocks.
12.
Recognize and evaluate the patient with a potential central neuraxial hematoma in a
timely and efficient manner.
13.
Recognize and treat systemic local anesthetic toxicity.
14.
Demonstrate proficiency in developing analgesic regimens (multimodal in nature) during the
acute rehabilitative phase post surgery.
15.
Demonstrate the ability to effectively manage and acute pain team of junior residents and
acute pain nurses to provide appropriate follow up and evaluation of acute pain patients.
16.
Demonstrate familiarity with low dose ketamine infusions and other complex medical pain
management strategies
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
1.
List important requirements for ambulatory/inpatient surgical procedures and how
regional anesthetics can be designed to meet these requirements.
2.
Describe the use of multimodal analgesia, in particular the use of peripheral blocks, and its
relationship to the goals of ambulatory/inpatient anesthesia.
3.
Discuss complications of peripheral blocks and their management.
4.
List indications and contraindications of specific peripheral nerve blocks and their impact
upon the degree of post-operative pain expected from the planned surgery.
5.
Describe the requirements regarding personnel, equipment, and resources involved in an
effective acute pain medicine service.
6.
Understand relevant pharmacokinetics and pharmacodynamics of common pain
medications.
Objectives:
1.
Identify indications and contraindications for regional anesthesia.
2.
Understand and discuss the pharmacokinetics and pharmacodynamics of various multimodal
analgesics (ie anticonvulsants, NSAIDS, opioids, non-opioid adjuncts, local anesthetics) and the
differences among them.
3.
Understand and discuss the benefits and risks related to the various additives used with
local anesthetic solutions.
4.
Select and defend the choice of block and local anesthetic for surgical procedures,
depending on duration, location and severity of patient illness.
5.
Display expert knowledge of anatomy pertinent to performing head and neck, upper and
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 116
lower extremity, plexus, sciatic, pleural, rib, spinal, epidural, and caudal anesthetic
procedures.
6.
Demonstrate expert knowledge of the anatomic and physiologic differences of the
obstetric and pediatric patient population that may affect the implementation use of a given
regional technique.
7.
Understand the benefits of a regional technique as it pertains to patient safety and
influence upon surgical outcome.
8.
Discuss the peripheral nerve blocks of the upper and lower extremity, including indications,
contraindications, side effects, local anesthetic choice, needle type, the use of indwelling catheters,
patient positioning, monitoring and the advantages/disadvantages of the various techniques and
equipment used.
9.
Discuss intravenous regional block (Bier block), including indications, side effects,
choice of local anesthetic, patient monitoring and its advantages/disadvantages.
10.
Discuss peripheral nerve blocks of the head, neck and chest, including indications,
contraindications, side effects, local anesthetics, needle type, the use of indwelling catheters,
patient positioning, monitoring and the advantages/disadvantages of the different techniques
and equipment.
11.
Discuss techniques for nerve localization; including peripheral nerve stimulation,
eliciting paresthesias, anatomic (e.g. bounce, pop, etc), and ultrasonic.
12.
Discuss various techniques for pain evaluation to include pain scales and
physiologic indicators.
13.
Discuss the pharmacokinetics and pharmacodynamics of opioids and non-steroidal antiinflamatories
14.
Discuss the indications, pharmacology, and side effects of ketamine.
Interpersonal Skills and Communication
Goals:
Residents must be able to demonstrate interpersonal and communication skills that result in
effective information exchange and team-building with patients, their patient‟s families, and
professional associates.
Objectives:
1.
Discuss with patients the advantages and potential disadvantages of regional anesthesia
and analgesia.
2.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
3.
Articulate the anesthetic plan to the attending anesthesiologist and explain its rationale.
4.
Conduct post-operative visits for in-patients, and call-backs for ambulatory patients to
evaluate patient satisfaction and determine the incidence of undesirable effects of the anesthetic.
5.
The resident must be sensitive to patient concerns about awareness and pain.
6.
The senior resident must be able to participate in multidisciplinary discussions
with the patients’ primary team and other ancillary/consultant services to optimize
analgesic regimens and avoid detracting from other essential aspects of patients’ care.
Professionalism
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 117
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Interact with staff anesthesiologists, CRNAs, PACU nurses, and operating room staff in a
manner which reflects interpersonal respect, integrity and commitment to excellence in patient care.
2.
Manage interpersonal conflict with dignity and in a manner which avoids offensive
behavior and reflects emotional maturity.
3.
Protect patient confidentiality.
4.
Maintain a respectable appearance.
5.
Consult the surgical team and attending anesthesiologist when questions arise as to the
appropriateness of regional anesthesia or about the nature of the planned procedure, fostering an
atmosphere of collegiality and allowing the development of a plan which best serves the interest
of the patient.
6.
The resident must possess sufficient judgment and maturity to abort attempting regional
anesthetics when necessary.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Collect and analyze post-procedure data from anesthetic cases performed.
2.
Keep an accurate case log to document regional blocks performed, including the following
information: type of block, success of block, any complications encountered, overall anesthetic
plan, duration of block (from call-backs) and patient satisfaction.
3.
On a daily basis, report the information regarding block success and duration,
complications and patient satisfaction with the rotation directors, and provide an assessment
and plan for improving the quality of anesthetic care provided.
4.
Closely monitor the effects of pharmacologic analgesic choices during the acute
rehabilitate phase post-surgery for patients followed by the acute pain service.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 118
Objectives:
1.
For each ambulatory anesthetic case performed, analyze those factors which may
optimize the likelihood of PACU bypass, communicate these to the attending in the anesthetic
plan, and conduct the anesthetic accordingly.
2.
Assess causes of failure to achieve planned PACU bypass in ambulatory cases, and
suggest changes to improve success.
3.
Evaluate patient feedback data, identifying problems in anesthesia care and creating
potential solutions to enhance patient satisfaction and facilitate more effective care.
4.
Evaluate the cost-effectiveness of acute pain medicine care, including block techniques,
medications, and perioperative analgesia options.
III. REQUIRED READING
1.
Local Anesthetics, Chapter 30, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Spinal, Epidural, and Caudal Anesthesia, Chapter 51, Anesthesia, 7th edition, Ronald
Miller Ed. Churchill Livingston, 2010.
3.
Nerve Blocks, Chapter 52, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
IV. REFERENCE MATERIALS
1.
Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia
(New York School of Regional... by Admir Hadzic (Dec 7, 2011)
2.
Atlas of Regional Anesthesia: Expert Consult - Online and Print, 4e (Expert Consult Title:
Online + Print) by David L. Brown MD (Aug 4, 2010)
3.
Atlas of Ultrasound-Guided Regional Anesthesia: Expert Consult - Online and Print, 2e by
Andrew T. Gray MD (Oct 8, 2012)
4.
Ultrasound Guided Regional Anesthesia and Pain Medicine by Paul E. Bigeleisen (Nov 20,
2009)
Acute Pain Management (Cambridge Medicine) by Raymond S. Sinatra, Oscar A. de LeonCassasola, Eugene R. Viscusi and Brian Ginsberg (Apr 27, 2009)
5.
6.
Anesthesia and Analgesia – monthly sections on regional and ambulatory anesthesia.
7.
Web Sites:
www.nysora.com
www.dvcipm.org
www.usra.ca
www.neuraxiom.com
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 119
V. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee and
will be based on the written evaluations provided at the completion of this rotation. PGY 3/CA 2
residents must be determined to function at the level of manager or higher to receive credit for an
elective rotation in acute pain medicine. The summative monthly evaluation will be based upon
the following tools and information
1.
Resident case logs.
2.
Tabulated QI data for the blocks and anesthetics performed by the resident.
3.
Resident written self-assessment of their educational needs in regional anesthesia,
recommendations for changes in systems and bedside care based upon the QI data and
educational needs assessment.
4.
Monthly evaluations by staff anesthesiologists with emphasis on punctuality, maturity,
clinical competence, rapport with patients, and fundamentals of knowledge. “On the fly” evaluations
will be used to address daily concerns.
5.
Resident evaluations of the staff and rotation.
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 120
GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN ACUTE PAIN MEDICINE
AT WRNMMC
I. ROTATION DEFINITION
This rotation provides additional training in acute pain medicine. Senior residents will master the
use of regional anesthetic techniques for both in- patient and ambulatory surgery as well as medical
management of acute pain.
In this rotation, residents will further develop the necessary motor skills to place peripheral nerve
blocks and learning the principles of safe regional anesthesia. Senior residents are expected to
demonstrate proficiency in less complicated regional anesthetic techniques such as femoral block,
sciatic block, popliteal fossa block, brachial plexus blocks (interscalene block, supraclavicular,
infraclavicular, and axillary), intravenous regional anesthesia or caudal block. PGY 4/CA 3 residents
are expected to display mastery of paravertebral blocks, lumbar plexus blocks, and other invasive
nerve blocks. PGY 4/CA 3 residents are expected to also demonstrate mastery of basic medical
management of acute pain strategies (e.g. opioids and patient controlled analgesia) and mastery of
the indications and principles of advanced medical management of pain (e.g. ketamine infusions,
complex spine pain protocols, etc.). PGY 4/CA 3 residents must develop and demonstrate the
ability to lead an acute pain team and perform advanced regional anesthesia with supervision
available as opposed to immediately present.
II. RESIDENT RESPONSIBILITIES
Residents will be responsible for evaluating patients who are candidates for regional anesthesia or
who require consultative medical pain care. Residents will be expected to take a history and perform
a pertinent physical exam. Residents are expected, with supervision from Staff Anesthesiologist, to
plan and execute the appropriate medical, interventional or combination therapy for each patient on
the acute pain service. Residents are required to document medical care appropriately and to follow
patients while on the acute pain service looking for benefit and complication of therapy.
Daily assignment
1.
The resident will be assigned to the regional service for the day. The resident should
review the schedule for possible regional anesthesia candidates the day prior and the morning of
duty.
2.
The resident will work closely with the regional staff anesthesiologist to coordinate blocks.
The resident may perform all scheduled OR peripheral blocks preoperatively in the designated
“regional block area.” Spinal, epidural, and combined spinal-epidural blocks may be placed in the
operating room, either by the regional resident or by the OR room staff. Ultimately, the
anesthesiologist supervising the anesthetic case has final say regarding who does the block for that
room.
3.
The resident is responsible for reviewing the chart, interviewing and examining the patient
and discussing the anesthetic options with the staff anesthesiologist for each case.
4.
The resident will perform the block, document the procedure on the chart, follow the patient
in the operating room (noting any complications and checking for effectiveness), follow-up with the
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 121
patient in the recovery room, complete the appropriate post-operative orders, and visit the patients
post-operatively on the floor.
5.
At the end of each day, the schedule for the following day should be reviewed by the
resident and the regional anesthesiologist.
6.
The resident will participate in daily Acute Pain Service rounds and participate in the
management of perioperative pain and other aspects of perioperative care. Residents will write daily
notes, prescribe medications, and engage the primary admitting surgical services in the care of
operative patients.
While on the service, residents will keep a log of blocks, including the type of block, date,
indication, success or failure, and any complications. The resident should round on in-house
cases the next day after the regional procedure is performed, and follow up on any problems
identified when the APU staff calls outpatients the next day.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health. Residents are expected to:
1.
Provide a preoperative patient assessment, and suggest appropriate perioperative
interventions to ensure patient safety and reduce risk, based on findings and preexisting patient
conditions.
2.
Formulate an anesthetic plan, emphasizing the needs of the ambulatory patient and
integrating general, neuraxial, and peripheral regional anesthesia techniques to provide optimum
patient outcome and satisfaction.
3.
Provide peripheral and/or neuraxial blocks, sedation or general anesthesia in a competent
and safe manner, and provide continuity of care in the operating room, and, when possible, in the
PACU or same-day surgery unit.
4.
Demonstrate advanced leadership skills by leading team of junior residents and acute pain
nurses in daily care of acute pain patients followed by the service.
5.
Demonstrate the ability to perform regional anesthesia with supervision available.
Objectives:
1.
Preoperatively evaluate and identify patients that are candidates for regional anesthetic
procedures or acute pain service consultation.
2.
Perform brachial plexus, interscalene, intravenous regional, caudal, paravertebral, lumbar
plexus, sciatic and peripheral nerve blocks on appropriate patients with supervision available.
3.
Provide regional techniques with sedation or combined with a general anesthetic in a
variety of surgical procedures.
4.
Actively teach medical students and junior residents the pertinent anatomy and
techniques of the various regional anesthetics.
5.
Perform upper extremity brachial plexus blocks (interscalene, supraclavicular,
infraclavicular, axillary).
6.
Perform lower extremity plexus blocks (lumbar plexus, femoral, sciatic).
7.
Properly plan and select equipment and local anesthetic agents for all regional anesthetic
procedures.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
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8.
Provide sedation to create optimal conditions for performing a given block, as well as
patient comfort and blunting of adverse hemodynamic responses.
9.
Demonstrate use of the peripheral nerve stimulator and ultrasound to assist in the
performance of peripheral nerve blocks.
10.
Recognize the need for general anesthesia following an inadequate regional anesthetic
and convert to general anesthesia safely and efficiently with minimal disruption of the planned
surgery.
11.
Recognize, evaluate and treat complications of regional blocks.
12.
Recognize and evaluate the patient with a potential central neuraxial hematoma in a
timely and efficient manner.
13.
Recognize and treat systemic local anesthetic toxicity.
14.
Demonstrate proficiency in developing analgesic regimens (multimodal in nature) during the
acute rehabilitative phase post surgery.
15.
Demonstrate the ability to effectively manage and acute pain team of junior residents and
acute pain nurses to provide appropriate follow up and evaluation of acute pain patients.
16.
Demonstrate mastery of low dose ketamine infusions and other complex medical pain
management strategies
17.
Demonstrate and understanding of high dose ketamine infusions (ketamine coma).
18.
Demonstrate the ability to care for patients with pain who have coexisting addiction and/or
are using suboxone (not uncommon among wounded veterans).
19.
Demonstrate the ability to lead multi-disciplinary care for patients with complex pain
syndromes using literature and guidelines (complex spine protocol, etc.)
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
1.
List important requirements for ambulatory/inpatient surgical procedures and how
regional anesthetics can be designed to meet these requirements.
2.
Describe the use of multimodal analgesia, in particular the use of peripheral blocks, and its
relationship to the goals of ambulatory/inpatient anesthesia.
3.
Discuss complications of peripheral blocks and their management.
4.
List indications and contraindications of specific peripheral nerve blocks and their impact
upon the degree of post-operative pain expected from the planned surgery.
5.
Describe the requirements regarding personnel, equipment, and resources involved in an
effective acute pain medicine service.
6.
Understand relevant pharmacokinetics and pharmacodynamics of common pain medications.
Objectives:
1.
Identify indications and contraindications for regional anesthesia.
2.
Understand and discuss the pharmacokinetics and pharmacodynamics of various multimodal
analgesics (ie anticonvulsants, NSAIDS, opioids, non-opioid adjuncts, local anesthetics) and the
differences among them.
3.
Understand and discuss the benefits and risks related to the various additives used with
local anesthetic solutions.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 123
4.
Select and defend the choice of block and local anesthetic for surgical procedures,
depending on duration, location and severity of patient illness.
5.
Display expert knowledge of anatomy pertinent to performing head and neck, upper and
lower extremity, plexus, sciatic, pleural, rib, spinal, epidural, and caudal anesthetic
procedures.
6.
Demonstrate expert knowledge of the anatomic and physiologic differences of the
obstetric and pediatric patient population that may affect the implementation use of a given
regional technique.
7.
Understand the benefits of a regional technique as it pertains to patient safety and
influence upon surgical outcome.
8.
Discuss the peripheral nerve blocks of the upper and lower extremity, including indications,
contraindications, side effects, local anesthetic choice, needle type, the use of indwelling catheters,
patient positioning, monitoring and the advantages/disadvantages of the various techniques and
equipment used.
9.
Discuss intravenous regional block (Bier block), including indications, side effects,
choice of local anesthetic, patient monitoring and its advantages/disadvantages.
10.
Discuss peripheral nerve blocks of the head, neck and chest, including indications,
contraindications, side effects, local anesthetics, needle type, the use of indwelling catheters,
patient positioning, monitoring and the advantages/disadvantages of the different techniques
and equipment.
11.
Discuss techniques for nerve localization; including peripheral nerve stimulation,
eliciting paresthesias, anatomic (e.g. bounce, pop, etc), and ultrasonic.
12.
Discuss various techniques for pain evaluation to include pain scales and
physiologic indicators.
13.
Discuss the pharmacokinetics and pharmacodynamics of opioids and non-steroidal antiinflamatories
14.
Discuss the indications, pharmacology, and side effects of ketamine.
15.
Describe the use of ketamine comas in pain management.
16.
Develop a plan for tapering of medication to include the use of suboxone and other
medications to treat possible addiction.
Interpersonal Skills and Communication
Goals:
Residents must be able to demonstrate interpersonal and communication skills that result in
effective information exchange and team-building with patients, their patient’s families, and
professional associates.
Objectives:
1.
Discuss with patients the advantages and potential disadvantages of regional anesthesia
and analgesia.
2.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
3.
Articulate the anesthetic plan to the attending anesthesiologist and explain its rationale.
4.
Conduct post-operative visits for in-patients, and call-backs for ambulatory patients to
evaluate patient satisfaction and determine the incidence of undesirable effects of the anesthetic.
5.
The resident must be sensitive to patient concerns about awareness and pain.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
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6.
The senior resident must be able to participate in multidisciplinary discussions
with the patients’ primary team and other ancillary/consultant services to optimize
analgesic regimens and avoid detracting from other essential aspects of patients’ care.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Interact with staff anesthesiologists, CRNAs, PACU nurses, and operating room staff in a
manner which reflects interpersonal respect, integrity and commitment to excellence in patient care.
2.
Manage interpersonal conflict with dignity and in a manner which avoids offensive
behavior and reflects emotional maturity.
3.
Protect patient confidentiality.
4.
Maintain a respectable appearance.
5.
Consult the surgical team and attending anesthesiologist when questions arise as to the
appropriateness of regional anesthesia or about the nature of the planned procedure, fostering an
atmosphere of collegiality and allowing the development of a plan which best serves the interest
of the patient.
6.
The resident must possess sufficient judgment and maturity to abort attempting regional
anesthetics when necessary.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Collect and analyze post-procedure data from anesthetic cases performed.
2.
Keep an accurate case log to document regional blocks performed, including the following
information: type of block, success of block, any complications encountered, overall anesthetic
plan, duration of block (from call-backs) and patient satisfaction.
3.
On a daily basis, report the information regarding block success and duration,
complications and patient satisfaction with the rotation directors, and provide an assessment
and plan for improving the quality of anesthetic care provided.
4.
Closely monitor the effects of pharmacologic analgesic choices during the acute
rehabilitate phase post-surgery for patients followed by the acute pain service.
Systems-Based Practice
Goal:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 125
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
For each ambulatory anesthetic case performed, analyze those factors which may
optimize the likelihood of PACU bypass, communicate these to the attending in the anesthetic
plan, and conduct the anesthetic accordingly.
2.
Assess causes of failure to achieve planned PACU bypass in ambulatory cases, and
suggest changes to improve success.
3.
Evaluate patient feedback data, identifying problems in anesthesia care and creating
potential solutions to enhance patient satisfaction and facilitate more effective care.
4.
Evaluate the cost-effectiveness of acute pain medicine care, including block techniques,
medications, and perioperative analgesia options.
III. REQUIRED READING
1.
Local Anesthetics, Chapter 30, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Spinal, Epidural, and Caudal Anesthesia, Chapter 51, Anesthesia, 7th edition, Ronald
Miller Ed. Churchill Livingston, 2010.
3.
Nerve Blocks, Chapter 52, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
IV. REFERENCE MATERIALS
1.
Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia
(New York School of Regional... by Admir Hadzic (Dec 7, 2011)
2.
Atlas of Regional Anesthesia: Expert Consult - Online and Print, 4e (Expert Consult Title:
Online + Print) by David L. Brown MD (Aug 4, 2010)
3.
Atlas of Ultrasound-Guided Regional Anesthesia: Expert Consult - Online and Print, 2e by
Andrew T. Gray MD (Oct 8, 2012)
4.
Ultrasound Guided Regional Anesthesia and Pain Medicine by Paul E. Bigeleisen (Nov 20,
2009)
5.
Acute Pain Management (Cambridge Medicine) by Raymond S. Sinatra, Oscar A. de LeonCassasola, Eugene R. Viscusi and Brian Ginsberg (Apr 27, 2009)
6.
Anesthesia and Analgesia – monthly sections on regional and ambulatory anesthesia.
7.
Web Sites:
www.nysora.com
www.dvcipm.org
www.usra.ca
www.neuraxiom.com
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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V. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee and
will be based on the written evaluations provided at the completion of this rotation. PGY 4/CA 3
residents must be determined to function consistently at the level of manager and must show the
ability to operate at the educator level to receive credit for an elective rotation in acute pain
medicine. The summative monthly evaluation will be based upon the following tools and
information
1.
Resident case logs.
2.
Tabulated QI data for the blocks and anesthetics performed by the resident.
3.
Resident written self-assessment of their educational needs in regional anesthesia,
recommendations for changes in systems and bedside care based upon the QI data and
educational needs assessment.
4.
Monthly evaluations by staff anesthesiologists with emphasis on punctuality, maturity,
clinical competence, rapport with patients, and fundamentals of knowledge. “On the fly” evaluations
will be used to address daily concerns.
5.
Resident evaluations of the staff and rotation.
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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GOALS AND OBJECTIVES FOR
SENIOR RESIDENTS IN ACUTE PAIN MEDICINE
AT LANDSTUHL REGIONAL MEDICAL CENTER
I. ROTATION DEFINITION
This rotation provides additional training in acute pain medicine. Senior residents will master the
use of regional anesthetic techniques for both in- patient and ambulatory surgery as well as medical
management of acute pain. Landstuhl Regional Medical Center (LRMC) provides an excellent site
for a regional anesthesia rotation for a senior resident due to the very large number of blocks
performed there. LRMC developed a very active regional anesthesia/acute pain medicine service in
response to the wars in Iraq and Afghanistan but it has remained robust as the war casualty volume
has decreased due to an active sports medicine program. LRMC is a distinct rotation because the
acute pain service has a far higher volume than WRNMMC and performs far more regional
anesthesia procedures than WRNMMC.
In this rotation, residents will further develop the necessary motor skills to place peripheral nerve
blocks and learning the principles of safe regional anesthesia. Senior residents are expected to
demonstrate proficiency in less complicated regional anesthetic techniques such as femoral block,
sciatic block, popliteal fossa block, brachial plexus blocks (interscalene block, supraclavicular,
infraclavicular, and axillary), intravenous regional anesthesia or caudal block. Senior residents are
expected to display mastery of paravertebral blocks, lumbar plexus blocks, and other invasive nerve
blocks. Senior residents are expected to also demonstrate mastery of basic medical management of
acute pain strategies (e.g. opioids and patient controlled analgesia) and mastery of advanced medical
management of pain (e.g. ketamine infusions, complex spine pain protocols, etc.).
II. RESIDENT RESPONSIBILITIES
Residents will be responsible for evaluating patients who are candidates for regional anesthesia or
who require consultative medical pain care. Residents will be expected to take a history and perform
a pertinent physical exam. Residents are expected, with supervision from Staff Anesthesiologist, to
plan and execute the appropriate medical, interventional or combination therapy for each patient on
the acute pain service. Residents are required to document medical care appropriately and to follow
patients while on the acute pain service looking for benefit and complication of therapy.
Daily assignment
1.
The resident will be assigned to the regional service for the day. The resident should
review the schedule for possible regional anesthesia candidates the day prior and the morning of
duty.
2.
The resident will work closely with the regional staff anesthesiologist to coordinate blocks.
The resident may perform all scheduled OR peripheral blocks preoperatively in the designated
“regional block area.” Spinal, epidural, and combined spinal-epidural blocks may be placed in the
operating room, either by the regional resident or by the OR room staff. Ultimately, the
anesthesiologist supervising the anesthetic case has final say regarding who does the block for that
National Capital Consortium Anesthesiology Residency
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room.
3.
The resident is responsible for reviewing the chart, interviewing and examining the patient
and discussing the anesthetic options with the staff anesthesiologist for each case.
4.
The resident will perform the block, document the procedure on the chart, follow the patient
in the operating room (noting any complications and checking for effectiveness), follow-up with the
patient in the recovery room, complete the appropriate post-operative orders, and visit the patients
post-operatively on the floor.
5.
At the end of each day, the schedule for the following day should be reviewed by the
resident and the regional anesthesiologist.
6.
The resident will participate in daily Acute Pain Service rounds and participate in the
management of perioperative pain and other aspects of perioperative care. Residents will write daily
notes, prescribe medications, and engage the primary admitting surgical services in the care of
operative patients.
7.
The resident will be responsible for evaluating all advanced acute pain catheters that arrive
to LRMC from down range medical facilities within 6 hours of arrival. In doing so, a consultation
will be conducted and documented indicating the history, past medical history, past surgical history,
social history, review of systems, physical exam, evaluation of the catheter site and function,
laboratory assessments, medications, and imaging as pertinent. This will be logged in the LRMC
acute pain registry as well.
While on the service, residents will keep a log of blocks, including the type of block, date,
indication, success or failure, and any complications. The resident should round on in-house
cases the next day after the regional procedure is performed, and follow up on any problems
identified when the APU staff calls outpatients the next day.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health. Residents are expected to:
1.
Provide a preoperative patient assessment, and suggest appropriate perioperative
interventions to ensure patient safety and reduce risk, based on findings and preexisting patient
conditions.
2.
Formulate an anesthetic plan, emphasizing the needs of the ambulatory patient and
integrating general, neuraxial, and peripheral regional anesthesia techniques to provide optimum
patient outcome and satisfaction.
3.
Provide peripheral and/or neuraxial blocks, sedation or general anesthesia in a competent
and safe manner, and provide continuity of care in the operating room, and, when possible, in the
PACU or same-day surgery unit.
4.
Provide a thorough medical plan in regards to acute pain including but not limited to opioids
and non-opioid medications (NSAIDs, anticonvulsants, antidepressants, PCAs, and etc.).
Objectives:
1.
Preoperatively evaluate and identify patients that are candidates for regional anesthetic
procedures.
2.
Perform brachial plexus, interscalene, intravenous regional, caudal, paravertebral, lumbar
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 129
plexus, sciatic and peripheral nerve blocks on appropriate patients under supervision with minimal
assistance and a high rate of success (>95%).
3.
Provide regional techniques with sedation or combined with a general anesthetic in a
variety of surgical procedures.
4.
Actively teach medical students and junior residents the pertinent anatomy and
techniques of the various regional anesthetics.
5.
Perform upper extremity brachial plexus blocks (interscalene, supraclavicular,
infraclavicular, axillary).
6.
Perform lower extremity plexus blocks (lumbar plexus, femoral, sciatic).
7.
Properly plan and select equipment and local anesthetic agents for all regional anesthetic
procedures.
8.
Provide sedation to create optimal conditions for performing a given block, as well as
patient comfort and blunting of adverse hemodynamic responses.
9.
Demonstrate use of the peripheral nerve stimulator and ultrasound to assist in the
performance of peripheral nerve blocks.
10.
Recognize the need for general anesthesia following an inadequate regional anesthetic
and convert to general anesthesia safely and efficiently with minimal disruption of the planned
surgery.
11.
Recognize, evaluate and treat complications of regional blocks.
12.
Recognize and evaluate the patient with a potential central neuraxial hematoma in a
timely and efficient manner.
13.
Recognize and treat systemic local anesthetic toxicity.
14.
Perform procedures with the dexterity required while using ultrasound, fluoroscopic and or
neurostimulator guidance techniques.
15.
Master advanced clinical automation hard and software devices utilized at LRMC including
but not limited to Dragon Medical Dictation, As-U-Type, and Power MIC II.
16.
Master acute pain/regional anesthesia medical billing/coding within AHALTA and Essentris
and other EMRs, electronic medical records.
Medical Knowledge
Goals:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
List important requirements for ambulatory surgical procedures and how regional
anesthetics can be designed to meet these requirements.
2.
Describe the use of multimodal analgesia, in particular the use of peripheral blocks, and its
relationship to the goals of ambulatory anesthesia.
3.
Discuss complications of peripheral blocks and their management.
4.
List indications and contraindications of specific peripheral nerve blocks and their impact
upon the degree of post-operative pain expected from the planned surgery.
Objectives:
1.
2.
Identify indications and contraindications for regional anesthesia.
Understand and discuss the pharmacokinetics and pharmacodynamics of local anesthetics
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 130
and the differences among them.
3.
Understand and discuss the benefits and risks related to the various additives used with
local anesthetic solutions.
4.
Select and defend the choice of block and local anesthetic for surgical procedures,
depending on duration, location and severity of patient illness.
5.
Display expert knowledge of anatomy pertinent to performing head and neck, upper and
lower extremity, plexus, sciatic, pleural, rib, spinal, epidural, and caudal anesthetic
procedures.
6.
Demonstrate expert knowledge of the anatomic and physiologic differences of the
obstetric and pediatric patient population that may affect the implementation use of a given
regional technique.
7.
Understand the benefits of a regional technique as it pertains to patient safety and
influence upon surgical outcome.
8.
Discuss the peripheral nerve blocks of the upper and lower extremity, including indications,
contraindications, side effects, local anesthetic choice, needle type, the use of indwelling catheters,
patient positioning, monitoring and the advantages/disadvantages of the various techniques and
equipment used.
9.
Discuss intravenous regional block (Bier block), including indications, side effects,
choice of local anesthetic, patient monitoring and its advantages/disadvantages.
10.
Discuss peripheral nerve blocks of the head, neck and chest, including indications,
contraindications, side effects, local anesthetics, needle type, the use of indwelling catheters,
patient positioning, monitoring and the advantages/disadvantages of the different techniques
and equipment.
11.
Discuss techniques for nerve localization; including peripheral nerve stimulation,
eliciting paresthesias, anatomic (e.g. bounce, pop, etc), and ultrasonic.
Interpersonal Skills and Communication
Goals:
Residents must be able to demonstrate interpersonal and communication skills that result in
effective information exchange and team-building with patients, their patient‟s families, and
professional associates.
Objectives:
1.
Discuss with patients the advantages and potential disadvantages of regional anesthesia
and analgesia.
2.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
3.
Articulate the anesthetic plan to the attending anesthesiologist and explain its rationale.
4.
Conduct post-operative visits for in-patients, and call-backs for ambulatory patients to
evaluate patient satisfaction and determine the incidence of undesirable effects of the anesthetic.
5.
The resident must be sensitive to patient concerns about awareness and pain.
Professionalism
Goal:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 131
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objective:
1.
Interact with staff anesthesiologists, CRNAs, PACU nurses, and operating room staff in a
manner which reflects interpersonal respect, integrity and commitment to excellence in patient care.
2.
Manage interpersonal conflict with dignity and in a manner which avoids offensive
behavior and reflects emotional maturity.
3.
Protect patient confidentiality.
4.
Maintain a respectable appearance.
5.
Consult the surgical team and attending anesthesiologist when questions arise as to the
appropriateness of regional anesthesia or about the nature of the planned procedure, fostering an
atmosphere of collegiality and allowing the development of a plan which best serves the interest
of the patient.
6.
The resident must possess sufficient judgment and maturity to abort attempting regional
anesthetics when necessary.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objective:
1.
Collect and analyze post-procedure data from anesthetic cases performed.
2.
Keep an accurate case log to document regional blocks performed, including the following
information: type of block, success of block, any complications encountered, overall anesthetic
plan, duration of block (from call-backs) and patient satisfaction.
3.
On a daily basis, report the information regarding block success and duration,
complications and patient satisfaction with the rotation directors, and provide an assessment
and plan for improving the quality of anesthetic care provided.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objective:
1.
For each ambulatory anesthetic case performed, analyze those factors which may
optimize the likelihood of PACU bypass, communicate these to the attending in the anesthetic
plan, and conduct the anesthetic accordingly.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 132
2.
Assess causes of failure to achieve planned PACU bypass in ambulatory cases, and
suggest changes to improve success.
3.
Evaluate patient feedback data, identifying problems in anesthesia care and creating
potential solutions to enhance patient satisfaction and facilitate more effective care.
4.
Evaluate the cost-effectiveness of regional anesthetic care, including block techniques,
medications, and perioperative analgesia options.
III. REQUIRED READING
1.
Local Anesthetics, Chapter 30, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Spinal, Epidural, and Caudal Anesthesia, Chapter 51, Anesthesia, 7th edition, Ronald
Miller Ed. Churchill Livingston, 2010.
3.
Nerve Blocks, Chapter 52, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
IV. REFERENCE MATERIALS
1.
Atlas of Regional Anesthesia. 2nd edition, David L. Brown, Ed. WB Saunders, 1999.
2.
Complications of Regional Anesthesia. BT Finucane, Ed. Churchill Livingstone, 1999.
3.
Peripheral Nerve Blocks: A Color Atlas. Jacques E Chelly, Ed. Lippincott, Williams &
Wilkins, 2004.
4.
Neural Blockade in Clinical Anesthesia and Management of Pain. 3rd edition, Michael J
Cousins M Ed. Lippincott-Raven, 1998.
5.
Regional Anesthesia: An Atlas of Anatomy and Techniques. Marc B Hahn Ed. Mosby,
1995.
6.
Anesthesia and Analgesia – monthly sections on regional and ambulatory anesthesia.
7.
Web Sites:
www.nysora.com
www.regionalblock.com
www.arapmi.com
V. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee and
will be based on the written evaluations provided at the completion of this rotation. Senior (PGY
3/CA 2 or PGY 4/CA 3) residents must be determined to function at the level of manager or higher
to receive credit for a rotation in acute pain medicine at LRMC. The summative monthly
evaluation will be based upon the following tools and information
1.
Resident case logs.
2.
Tabulated QI data for the blocks and anesthetics performed by the resident.
3.
Resident written self-assessment of their educational needs in regional anesthesia,
recommendations for changes in systems and bedside care based upon the QI data and
educational needs assessment.
4.
Monthly evaluations by staff anesthesiologists with emphasis on punctuality, maturity,
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 133
clinical competence, rapport with patients, and fundamentals of knowledge. “On the fly” evaluations
will be used to address daily concerns.
5.
Resident evaluations of the staff and rotation.
VI. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 134
GOALS AND OBJECTIVES FOR
CA-2 RESIDENTS IN CARDIOTHORACIC ANESTHESIA
AND TRANSESOPHAGEAL ECHOCARDIOGRAPHY
AT WRNMMC
I.
ROTATION DEFINITION
The cardiothoracic and echocardiography anesthesia rotation is a four week experience for CA-2
residents at WRNMMC. During this block the resident is first priority for all cardiac and thoracic
cases at WRNMMC. The resident will also be introduced to the basic principles of
echocardiography.
II.
GOALS AND OBJECTIVES
This rotation teaches the knowledge and skills required to successfully manage patients with cardiac
or pulmonary disease undergoing any thoracic or cardiac surgery. Successful management requires
a solid understanding of the general principles of anesthesia as well as a detailed knowledge of
cardiac disease. The necessity for this rotation is based on the following: (1) all general
anesthesiologists are expected to competently manage thoracic cases in clinical practice, (2)
cardiothoracic surgery exposes the anesthesiologist to unique principles and practices, (3) a rotation
in thoracic and cardiac anesthesia provides an in-depth, hands-on experience with a variety of potent
cardiotonic medications, and (5) the ability to use basic transesophageal echocardiography (TEE) is
becoming an expectation even for the general anesthesiologist.
Thoracic surgery is associated with increased perioperative morbidity and mortality. The
preoperative evaluation of these patients requires close attention to the cardiopulmonary system as a
unit. Preoperative evaluation of pulmonary function tests and arterial blood gases are extremely
important in the evaluation of a patient’s ability to survive a major pulmonary operation. Mastering
the technical aspects of the care of these patients such as lung isolation, placement of epidural
catheters, and understanding the physiological derangements induced by anesthesia, the lateral
position, and unilateral lung ventilation are of vital importance. An understanding of the normal
physiology of the lung, the changes induced by positioning, instrumentation, and pharmacologic
manipulation is the educational aim of training in thoracic anesthesia.
The residents will gain an understanding of cardiovascular and thoracic physiology and
pathophysiology. Residents will integrate their knowledge into the perioperative management of
patients undergoing cardiothoracic surgery. Residents will attain an understanding of the following:
1.
Anesthetic implications of cardiothoracic disease.
2.
Preoperative assessment of the cardiothoracic surgery patient.
3.
Methods of lung isolation.
4.
The determinants of cardiac output and the perioperative evaluation of cardiac function,
with a focus on basic skills in TEE.
5.
Anatomy and function of the cardiopulmonary bypass machine.
6.
The determinants of myocardial oxygen supply/demand.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 135
7.
Valvular heart disease.
8.
Cardiac conduction system, arrhythmias, and anti-arrhythmic agents.
9.
The recognition, assessment, and treatment of anesthetic complications in the
cardiothoracic surgery patient.
Patient Care
Goal:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of patients with cardiac disease, thoracic disease or those undergoing cardiac or
thoracic surgery.
1.
Perform an appropriate pre-anesthetic evaluation; including history, physical exam and
laboratory studies for patients with cardiac disease, thoracic disease or those undergoing cardiac or
thoracic surgery.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the patient’s medical history, expectations and anticipated
course of their condition.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care and enhance quality of life.
Objectives:
1.
Perform preoperative evaluations of the patient for thoracic or cardiac surgery, including:
a.
Detailed historical evaluation of cardiopulmonary status.
b.
Physical examination, including a detailed exam of the cardiovascular/pulmonary
systems.
c.
Evaluation of vascular access.
d.
Evaluation of diagnostic studies.
e.
Prescribing preoperative medication including a rationale plan for continuing or
discontinuing chronic medications.
2.
Formulate and discuss with the attending anesthesiologist an anesthetic plan that
considers the patient's disease, co-morbidities, proposed surgery and post-operative
requirements.
3.
Counsel the patient and their family and obtaining informed consent.
4.
Prepare routine and resuscitative drugs, the operating room, and monitoring equipment.
5.
Demonstrate facility with the induction of anesthesia for the thoracic or cardiac surgical
patient.
6.
Demonstrate proficiency with double lumen endotracheal tube placement and the use of
the flexible fiberoptic bronchoscope.
7.
Safely provide post-operative analgesia using epidural catheter techniques and
demonstrate awareness of potential complications and their management.
8.
Monitor and anticipate surgical manipulations and the subsequent cardiopulmonary
changes, taking action to minimize these effects. This includes the recognition of myocardial
ischemia via EKG, TEE and Swan-Ganz catheter monitoring.
9.
Ensure adequate anticoagulation with the ability to diagnose and treat heparin resistance.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 136
10.
Explain the special problems encountered when initiating cardiopulmonary bypass (CPB),
including: aortic intimal dissection, superior vena caval obstructions, reversal of flow, arterial
embolization, and venous airlock.
11.
While on CPB, the resident will understand, diagnose and treat when necessary:
a.
High and low perfusion pressures.
b.
Low urine output.
c.
Low blood flow.
d.
Pulsatile vs. nonpulsatile flow.
e.
Assessment of perfusion pressure and blood flow by MVO2 saturation.
f.
Abnormalities of ABGs.
g.
State of anticoagulation.
h.
Electrolyte disturbances.
i.
Neurological changes.
j.
Effects of CPB on coagulation factors.
k.
Hemodilution.
l.
Drug pharmacokinetics and pharmacodynamics.
m.
Diaphragmatic contraction.
12.
Explain the mechanics of the CPB pump equipment:
a.
Oxygenator: membrane vs. bubble.
b.
Heat exchanger.
c.
Function and position of monitors (oxygen saturation, air detector).
13.
Explain the maneuvers designed to remove air from cardiac chambers which have been
opened during the operation.
14.
Interpret the data from observation of the heart and optimize cardiac function with
pharmacological and intravascular volume manipulation, and diagnose and treat coronary artery
spasm and/or embolization during separation from CPB.
15.
Reverse anticoagulation with protamine, understanding dosage calculation, mechanism of
action, and adverse reactions.
16.
Diagnose and treat coagulopathies, understanding the indications for various blood
components.
17.
Stabilize patients post-CPB while optimizing pulmonary, coagulation, renal and
electrolyte status.
18.
Efficiently and safely transport the patient to the ICU, providing continuation of
monitoring and medications.
19.
In the ICU, establish all monitors, supervise institution of mechanical ventilation, assure
hemodynamic support with drugs as necessary, transfuse as necessary, and notify surgical and
nursing staff of past and ongoing management issues.
Medical Knowledge
Goal:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patients with cardiac disease, thoracic disease or
those undergoing cardiac or thoracic surgery.
1.
Apply relevant scientific knowledge and reasoning to the practice of cardiothoracic
anesthesia.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 137
2.
Demonstrate a sound knowledge base regarding cardiothoracic anatomy, extracorporeal
membrane oxygenation, physiology, and pharmacology.
3.
Understand recent developments in cardiac and thoracic anesthesia.
4.
Learn the fundamentals of basic TEE as a monitoring modality.
Objectives:
Cardiothoracic Anatomy and Physiology
1.
Explain pulmonary function testing and its prognostic utility.
2.
Explain and apply the principles of arterial blood gas analysis.
3.
Describe the physiological changes induced by anesthesia, assumption of the lateral
position, positive pressure ventilation and unilateral lung ventilation.
4.
Explain hypoxic pulmonary vasoconstriction and the effect of anesthetics and other drugs
on hypoxic pulmonary vasoconstriction.
5.
Understand the indications, contraindications, and possible complications associated with
unilateral lung ventilation.
6.
Explain the anesthetic implications of video assisted thoracoscopic surgery.
7.
Explain the Starling curve and the changes that occur with heart failure, inotropic agents,
and changes in volume status.
8.
Demonstrate knowledge of cardiac anatomy, including chamber and great vessel position,
size and function, coronary artery anatomy, and the conduction system.
9.
Demonstrate knowledge (both anatomic and pathophysiologic) of the common congenital
defects and the operations used to palliate and/or correct these defects.
10.
Gain an in-depth understanding of the physiology of cardiac function, including:
a.
Determinants of myocardial oxygen supply and demand.
b.
Definitions of preload, contractility, and afterload.
c.
Venous and arterial pressure waveforms and their analysis.
d.
The Fick and thermodilution methods of cardiac output determination.
e.
The calculation of systemic and pulmonary vascular resistance, and cardiac index.
Equipment
1.
The resident must obtain working knowledge of cardiac defibrillators, pacemakers, ECG,
pressure monitors, cardiac output computers, pulmonary artery catheters, TEE, cerebral oximeters,
Activated Clotting Time (ACT), and Hepcon monitors.
Arterial Catheters
1.
List the indications for arterial pressure monitoring.
2.
Explain the proper technique and list the complications associated with inserting arterial
catheters in radial, femoral, brachial, dorsalis pedis, and axillary arteries.
3.
Explain the various factors affecting accurate arterial pressure measurement and the
conditions that can result in false measurements.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 138
Central Venous and Pulmonary Artery Catheters
1.
List the indications for central venous and pulmonary artery pressure monitoring.
2.
Explain the proper technique and list the complications associated with insertion of
catheters in the internal and external jugular, and the subclavian veins.
3.
Describe the application of surface ultrasound for vascular access.
4.
Appropriately interpret and apply hemodynamic data obtained from central venous and
pulmonary artery catheters.
5.
Explain the circumstances in which pulmonary artery wedge pressure measurements are
inaccurate.
6.
Interpret and apply all hemodynamic data derived from invasive hemodynamic
monitoring.
Transesophageal Echocardiography
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Describe basic physics principles of ultrasound and Doppler.
Discuss acquisition and optimization of TEE images.
Describe normal cardiac anatomy and imaging plane correlation.
Identify the seven standard views of basic TEE.
Identify patient safety considerations in placement of the TEE probe.
Describe basic applications of quantitative Doppler.
Discuss techniques for estimating global ventricular function.
Evaluate regional ventricular systolic function and recognize pathology.
Explain how to recognize basic cardiac valve abnormalities.
Discuss identification of intracardiac masses in non-cardiac surgery.
Explain the use of TEE to perform a basic perioperative hemodynamic assessment.
Describe the basics of recognizing of congenital heart disease in the adult.
Case Management
1.
Explain the rationale for ordering lab tests.
2.
Explain the rationale behind different induction and maintenance techniques of anesthesia for
thoracic and cardiac surgery.
3.
Discuss different options for lung isolation.
4.
Discuss the role of and options for minimizing crystalloid use during thoracic surgery.
5.
Explain the potential problems encountered during off-pump cardiac revascularization.
6.
Explain the determination of the proper dose of heparin for regular and emergency
situations.
7.
Describe the assessment of anticoagulation in the perioperative period.
8.
Discuss factors that may influence heparin resistance and the appropriate therapy.
9.
Understand the special problems that may be encountered during CPB with:
a.
L to R and R to L shunts.
b.
Atherosclerotic coronary artery disease.
c.
Valvular disease: aortic insufficiency, aortic stenosis, mitral regurgitation, mitral
stenosis, and tricuspid insufficiency.
d.
Pericardial diseases.
e.
Pulmonary hypertension.
f.
Common congenital abnormalities.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 139
Atrial septal defect.
Ventricular septal defect.
Thoracic and/or arch aortic aneurysm.
Emergent cardiac surgery.
Cardiomyopathy.
10.
Discuss the use and complications of protamine for heparin reversal.
11.
Describe the expected post-operative recovery for the uncomplicated thoracic or cardiac
surgery patient.
12.
Explain the characteristics and management of conduction system abnormalities.
13.
Describe the changes in physiology and pharmacokinetics with hypothermia as they
pertain to management of arterial CO2 tension while on CPB and circulatory arrest.
14.
Describe the indications, mechanics and complications of circulatory assist devices.
15.
Explain the principles of myocardial preservation.
16.
Describe the mechanism of action, indications, contraindications, adverse reactions,
interactions and appropriate doses of the following drugs:
a.
Cardiotonic and/or vasoactive - epinephrine, norepinephrine, isoproterenol,
dopamine, dobutamine, milrinone, ephedrine, phenylephrine, vasopressin, nitroglycerin,
nitroprusside, verapamil, diltiazem, nicardipine, propranolol, esmolol, labetalol, and
metoprolol.
b.
Anesthetic agents - isoflurane, desflurane, halothane, sevoflurane, nitrous oxide,
fentanyl, sufentanil, morphine, benzodiazepines, ketamine, and scopolamine.
c.
Anti-arrhythmic - lidocaine, procainamide, amiodarone, and magnesium sulfate.
d.
Miscellaneous - digoxin, calcium chloride, adenosine, aminophylline,
theophylline, atropine, glycopyrrolate and angiotensin converting enzyme inhibitors and
receptor antagonists.
g.
h.
i.
j.
k.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
Discuss with patients with cardiac disease, thoracic disease or those undergoing cardiac
or thoracic surgery and family members the utility and advantages, as well as potential
disadvantages, of the different anesthetic options for the planned surgical or diagnostic procedure.
2.
Create and sustain a therapeutic and ethically sound relationship with patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 140
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession; and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices
3.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
4.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Goal:
Residents must investigate and evaluate their patient care practices and appraise and assimilate
scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to cardiac and
thoracic anesthesia. This includes, but is not limited to, the directed readings in the Core
Curriculum. In selected cases, it is appropriate to pursue additional scientific evidence in a reference
text or in an electronic online search.
2.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
3.
Apply information technology to manage information, access on-line medical
information, and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and learn how these activities may affect system performance.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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PAGE 141
III. REQUIRED READING
1.
Cardiothoracic Anesthesia and Transesophageal Echocardiography rotation handout
2.
Slinger, PD: Progress in Thoracic Anesthesia. A Society of Cardiovascular
Anesthesiologist Monograph, 2004
3.
Hensley FA, Martin DE, Gravlee GP: A Practical Approach to Cardiac Anesthesia. 4th
ed, 2008
4.
Perrino, AC, Reeves, ST: Transesophageal Echocardiography, 2nd ed, 2008
IV. RECOMMENDED READING
1.
Shanewise JS, Cheung AT, Aronson S, et al: ASE/SCA Guidelines for Performing a
Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination:
Recommendations of the American Society of Echocardiography Council for Intraoperative
Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for
Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr
12:884-900, 1999
V. EVALUATION
Final evaluation will be based upon clinical performance and preparation for the required chapter
reviews with the faculty. Successful completion of the one month block will be determined by the
clinical competence committee. A requisite to gain credit is that residents must perform at the
interpreter level by the completion of the rotation.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 142
GOALS AND OBJECTIVES FOR
CA-2 RESIDENTS IN CARDIOTHORACIC ANESTHESIA
AT WASHINGTON HOSPITAL CENTER
I.
ROTATION DEFINITION
The cardiothoracic anesthesia rotation at Washington Hospital Center (WHC) is a two month
experience for CA-2 residents. WHC is a high volume referral center for cardiothoracic surgery and
cares for patients with advanced disease states rarely seen at WRNMMC undergoing advanced
procedures rarely seen at WRNMMC (e.g. severe heart failure and having a ventricular assist device
placed). The overall goal of the rotation at WHC in cardiothoracic anesthesia as a PGY 3/CA 2 is to
gain a basic understanding. This rotation serves as a reinforcement of the rotation in cardiothoracic
anesthesia at WRNMMC. With the higher volume of cardiac surgery and higher volume of complex
cases than WRNMMC it provides an excellent learning environment for anesthesiology residents.
II.
GOALS AND OBJECTIVES
The cardiac anesthesia rotation teaches the knowledge and skills required to successfully manage
patients with cardiac disease undergoing either non-cardiac or cardiac surgery. Successful
management requires a solid understanding of the general principles of anesthesia as well as a
detailed knowledge of cardiac disease. That such a rotation is beneficial is illustrated by the
following points: (1) there is an increasing prevalence of patients with ischemic and valvular heart
disease presenting for non-cardiac surgery, (2) as patients with palliated or corrected congenital heart
disease grow older, they too will be presenting for anesthesia, (3) cardiac surgery exposes the
anesthesiologist to unique principles and practices, and (4) a rotation in cardiac anesthesia provides
an in-depth, hands-on experience with a variety of potent cardiotonic medications. Finally, the
rotation will provide familiarity with mechanical support of the circulation.
The residents will gain an understanding of cardiovascular physiology and the pathophysiology
associated with ischemic and valvular heart disease. Residents will integrate their knowledge into
the perioperative management of patients undergoing cardiac surgery. Residents will attain an
understanding of the following:
2.
3.
4.
5.
6.
7.
8.
1. Anesthetic implications of cardiac disease.
Preoperative assessment of the cardiac surgery patient.
The determinants of cardiac pump function and the perioperative evaluation of cardiac
function.
Anatomy and function of the cardiopulmonary bypass machine.
The determinants of myocardial oxygen supply/demand.
Valvular heart disease.
Cardiac conduction system, arrhythmias, and anti-arrhythmic agents.
The recognition, assessment, and treatment of anesthetic complications in the cardiac
surgery patient.
Thoracic surgery is associated with increased perioperative morbidity and mortality. The
preoperative evaluation of these patients requires close attention to the cardiopulmonary system as a
unit. Preoperative evaluation of pulmonary function tests and arterial blood gases are extremely
important in the evaluation of a patient’s ability to survive a major pulmonary operation. Mastering
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 143
the technical aspects of the care of these patients (i.e., placement of arterial catheters, epidural
catheters, and double lumen endotracheal tubes) and understanding the physiological derangements
induced by anesthesia, the lateral position, and unilateral lung ventilation are of vital importance.
Gaining understanding of the normal physiology of the lung, the changes induced by positioning,
instrumentation, and pharmacologic manipulation is the educational aim of training in thoracic
anesthesia.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems related to the care of patients with cardiac or thoracic disease
processes or patients undergoing cardiac or thoracic surgery. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation including history, physical exam and
laboratory studies.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the patient’s medical history, expectations and anticipated
course of their condition.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care and enhance quality of life.
Objectives:
Cardiac Anesthesia
1.
The resident will perform a complete pre-anesthetic evaluation of the patient , including:
a.
Detailed evaluation of cardiac status.
b.
Physical examination, including a detailed exam of the cardiovascular/pulmonary
systems.
c.
Evaluation of vascular access.
d.
Evaluation of diagnostic studies.
e.
Prescribing preoperative medication including a rationale plan for continuing or
discontinuing chronic medications.
2.
Counseling the patient and their family and obtaining informed consent.
3.
Formulation and discussion of the anesthetic plan with the attending anesthesiologist,
including consideration of the patient's disease, associated co-morbidities, proposed surgery, and
post-operative requirements.
4.
Preparation of routine and resuscitative drugs, the operating room, and monitoring
equipment.
5.
Demonstrate facility with the induction of anesthesia for the cardiac surgical patient.
6.
Monitor and anticipate surgical manipulations and the subsequent cardiopulmonary
changes, taking action to minimize these effects. This includes the recognition of myocardial
ischemia via EKG, TEE and Swan-Ganz catheter monitoring.
7.
Ensure adequate anticoagulation with the ability to diagnose and treat heparin resistance.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 144
8.
Explain the special problems encountered when initiating cardiopulmonary bypass (CPB),
including: aortic intimal dissection, superior vena caval obstructions, reversal of flow, arterial
embolization, and venous airlock.
9.
While on CPB, the resident will understand, diagnose and treat when necessary:
a.
High and low perfusion pressures. b.
Low urine output.
c.
Low blood flow.
d.
Pulsatile vs. nonpulsatile flow.
e.
Assessment of perfusion pressure and blood flow by MV02 saturation. f.
Abnormalities of ABGs.
g.
State of anticoagulation.
h.
Electrolyte disturbances. i.
Neurological changes.
j.
Effects of CPB on coagulation factors. k.
Hemodilution.
l.
Drug pharmacokinetics and pharmacodynamics. m.
Diaphragmatic contraction.
10.
Explain the mechanics of the CPB pump equipment:
a.
Calculation and formulation of the pump prime, pump heads and lines.
b.
Oxygenator: membrane vs. bubble.
c.
Heat exchanger.
d.
Function and position of monitors (oxygen saturation, air detector).
11.
Explain the maneuvers designed to remove air from cardiac chambers which have been
opened during the operation.
12.
Interpret the data from observation of the heart and optimize cardiac function with
pharmacological and intravascular volume manipulation, and diagnose and treat coronary artery
spasm and/or embolization during separation from CPB.
13.
Reverse anticoagulation with protamine, understanding dosage calculation, mechanism of
action, and adverse reactions.
14.
Diagnose and treat coagulopathies, understanding the indications for various blood
components.
15.
Stabilize patients post-CPB while optimizing pulmonary, coagulation, renal and
electrolyte status.
16.
Efficiently and safely transport the patient to the ICU, providing continuation of
monitoring and medications.
17.
In the ICU, establish all monitors, supervise institution of mechanical ventilation, assure
hemodynamic support with drugs as necessary, transfuse as necessary, and notify surgical and
nursing staff of past and ongoing management issues.
Thoracic Anesthesia
1.
Perform a preoperative evaluation of the patient for thoracic surgery with particular
attention to the cardiopulmonary system.
2.
Formulate and discuss with the attending anesthesiologist an anesthetic plan that
considers the patient's disease, co-morbidities, proposed surgery and post-operative
requirements.
3.
Demonstrate proficiency with arterial catheterization, double lumen endotracheal tube
placement, and the use of the flexible fiberoptic bronchoscope
4.
Safely provide post-operative analgesia using epidural catheter techniques and
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 145
demonstrate awareness of potential complications and their management.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of cardiac anesthesia.
2.
Demonstrate knowledge of anatomy, extracorporeal membrane oxygenation, physiology,
and pharmacology.
3.
Understand recent developments in cardiac and thoracic anesthesia.
Objectives:
Cardiac Anatomy and Physiology
1.
Explain the Starling curve and the changes that occur with heart failure, inotropic agents,
and changes in volume status.
2.
Demonstrate knowledge of cardiac anatomy, including chamber and great vessel position,
size and function, coronary arterial anatomy, and the conduction system.
3.
Regarding congenital heart-disease, demonstrate knowledge (anatomic and functional) of
the common defects and the operations used to palliate and/or correct these defects.
4.
Gain an in-depth understanding of the physiology of cardiac function, including:
a.
Determinants of myocardial oxygen supply and demand.
b.
Definitions of preload, contractility, and afterload.
c.
Venous and arterial pressure waveforms and their analysis.
d.
The Fick and thermodilution methods of cardiac output determination.
e.
The calculation of systemic and pulmonary vascular resistance, and cardiac index.
Equipment
1.
The resident must obtain working knowledge of cardiac defibrillators, pacemakers, EKG
and pressure monitors, cardiac output computers, pulmonary artery catheters (including fiberoptic
and pacing), transesophageal echocardiography, Activated Clotting Time (ACT), Hepcon monitors,
and thromboelastography.
Cardiovascular Monitoring
1.
List the indications for arterial, central venous and pulmonary artery catheterization.
Arterial Catheters
1.
Explain the proper technique and list the complications associated with inserting arterial
catheters in radial, femoral, brachial, dorsalis pedis, and axillary arteries.
2.
Explain the various factors affecting accurate arterial pressure measurement and the
problems that can result in false measurements.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 146
Central Venous and Pulmonary Artery Catheters
1.
Demonstrate the proper technique and list the complications associated with insertion of
catheters in the internal and external jugular, and the subclavian veins.
2.
Appropriately interpret and apply hemodynamic data obtained from central venous and
pulmonary artery catheters.
3.
Explain the circumstances in which pulmonary artery wedge pressure measurements are
inaccurate.
4.
Interpret and apply all hemodynamic data derived from invasive hemodynamic
monitoring.
Case Management
1.
Explain the rationale for ordering lab tests.
2.
Explain the interactions between premeditations and the various anesthetics.
3.
Explain the rationale behind different induction and maintenance techniques of anesthesia for
cardiac surgery.
4.
Explain the potential problems encountered during off-pump cardiac revascularization.
5.
Explain the determination of the proper dose of heparin and assessment of heparinization in
the perioperative period.
6.
Discuss factors that may influence heparin resistance and the appropriate therapy.
7.
Understand the special problems that may be encountered during CPB with:
a.
L to R and R to L shunts.
b.
Atherosclerotic coronary artery disease.
c.
Valvular disease: aortic insufficiency, aortic stenosis, mitral regurgitation, mitral
stenosis, and tricuspid insufficiency.
d.
Pericardial diseases.
e.
Pulmonary hypertension.
f.
Common congenital abnormalities. g.
Coarctation of the aorta.
h.
Tetralogy of Fallot.
i.
Patent ductus arteriosus. j.
Atrial septal defect.
k.
Ventricular septal defect.
l.
Thoracic and/or arch aortic aneurysm. m.
Emergent cardiac surgery.
n.
Cardiomyopathy.
8.
Discuss the use and complications of protamine for heparin reversal.
9.
Describe the expected post-operative recovery for the uncomplicated cardiac surgery
patient.
10.
Explain the characteristics and management of conduction system abnormalities.
11.
Describe the changes in physiology and pharmacokinetics with hypothermia as they
pertain to management of arterial C02 tension while on CPB and circulatory arrest.
12.
Describe the indications, mechanics and complications of circulatory assist devices.
13.
Explain the principles of myocardial preservation.
14.
Describe the mechanism of action, indications, contraindications, adverse reactions,
interactions and appropriate doses of the following drugs:
a.
Inotropes - epinephrine, norepinephrine, isoproterenol, dopamine, dobutamine,
amrinone, milrinone, ephedrine, phenylephrine, and glucagon.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 147
b.
Vasodilators - nitroglycerin, nitroprusside, and phentolamine.
c.
Calcium channel blockers - verapamil, nifedipine, and diltiazem.
d.
Beta adrenergic blockers - propranolol, esmolol, labetalol, metoprolol, and
atenolol.
e.
Anesthetic agents - isoflurane, desflurane, halothane, sevoflurane, nitrous oxide,
fentanyl, sufentanil, morphine, benzodiazepines, ketamine, and scopolamine.
f.
Anti-arrhythmic - lidocaine, procainamide, amiodarone, and magnesium sulfate.
g.
Miscellaneous - digoxin, calcium chloride, adenosine, aminophylline,
theophylline, atropine, glycopyrrolate and angiotensin converting enzyme inhibitors and
receptor antagonists.
Thoracic Anesthesia
The objectives will be accomplished through perioperative management of thoracic surgical
patients. Residents will be expected to:
1.
Explain pulmonary function testing and its prognostic utility.
2.
Explain and apply the principles of arterial blood gas analysis.
3.
Describe the physiological changes induced by anesthesia, assumption of the lateral
position, positive pressure ventilation and unilateral lung ventilation.
4.
Explain hypoxic pulmonary vasoconstriction and the effect of anesthetics and other drugs
on hypoxic pulmonary vasoconstriction.
5.
Understand the indications, contraindications, and possible complications associated with
unilateral lung ventilation.
6.
Explain the anesthetic implications of video assisted thoracoscopic surgery.
Interpersonal Skills and Communication
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the utility and advantages, as well as potential
disadvantages, of the different anesthetic options.
2.
Create and sustain a therapeutic and ethically sound relationship with patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goals:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 148
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession; and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices
3.
Demonstrate respect, compassion, integrity and responsiveness to the needs to patients
and society that supersedes self-interest.
4.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
5.
Demonstrate accountability to patients, colleagues and institution.
6.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Residents must investigate and evaluate their patient care practices and appraise and assimilate
scientific evidence to improve patient care. Residents are expected to:
1.
Locate, appraise, and assimilate evidence from scientific studies related to cardiac and
thoracic anesthesia. This includes, but is not limited to, the directed readings in the Core
Curriculum. In selected cases, it is appropriate to pursue additional scientific evidence in a reference
text or in an electronic online search.
2.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
3.
Apply information technology to manage information, access on-line medical
information; and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and learn how these activities may affect system performance.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 149
III. REQUIRED READING
1.
Cardiothoracic Rotation handout.
2.
Respiratory Physiology, Chapter 15, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
4.
Cardiovascular Monitoring, Chapter 40, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
5.
Transesophageal Echocardiography, Chapter 41, Anesthesia, 7th edition, Ronald Miller
Ed. Churchill Livingston, 2010.
6.
Anesthesia for Thoracic Surgery, Chapter 59, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
7.
Anesthesia for Adult Cardiac Surgery, Chapter 60, Anesthesia, 7th edition, Ronald Miller
Ed. Churchill Livingston, 2010.
8.
Cardiac Anesthesia, 6th edition, Joel A. Kaplan, David L. Reich, Joseph S. Savino. W.B.
Saunders, 2011.
IV. EVALUATION
Final evaluation will be based upon clinical performance. A requisite for gaining credit is performing
at least at the interpreter level by the completion of the rotation. Receiving credit for the rotation will
be determined by the clinical competence committee.
VI. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 150
GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN CARDIOTHORACIC ANESTHESIA
AT WASHINGTON HOSPITAL CENTER
I.
ROTATION DEFINITION
The cardiothoracic anesthesia rotation at Washington Hospital Center (WHC) for a PGY 4/CA 3 is
a one to four month experience. WHC is a high volume referral center for cardiothoracic surgery
and cares for patients with advanced disease states rarely seen at WRNMMC undergoing advanced
procedures rarely seen at WRNMMC (e.g. severe heart failure and having a ventricular assist
device placed). The major goal for a rotation at WHC in cardiothoracic anesthesia as a PGY 4/CA 3
is to allow the resident to attain mastery of cardiothoracic anesthesia.
II.
GOALS AND OBJECTIVES
The cardiac anesthesia rotation teaches the knowledge and skills required to successfully manage
patients with cardiac disease undergoing either non-cardiac or cardiac surgery. Successful
management requires a solid understanding of the general principles of anesthesia as well as a
detailed knowledge of cardiac disease. That such a rotation is beneficial is illustrated by the
following points: (1) there is an increasing prevalence of patients with ischemic and valvular heart
disease presenting for non-cardiac surgery, (2) as patients with palliated or corrected congenital
heart disease grow older, they too will be presenting for anesthesia, (3) cardiac surgery exposes
the anesthesiologist to unique principles and practices, and (4) a rotation in cardiac anesthesia
provides an in-depth, hands-on experience with a variety of potent cardiotonic medications.
Finally, the rotation will provide familiarity with mechanical support of the circulation.
The residents will gain an understanding of cardiovascular physiology and the pathophysiology
associated with ischemic and valvular heart disease. Residents will integrate their knowledge
into the perioperative management of patients undergoing cardiac surgery. Residents will attain
an understanding of the following:
2.
3.
4.
5.
6.
7.
8.
1. Anesthetic implications of cardiac disease.
Preoperative assessment of the cardiac surgery patient.
The determinants of cardiac pump function and the perioperative evaluation of cardiac
function.
Anatomy and function of the cardiopulmonary bypass machine.
The determinants of myocardial oxygen supply/demand.
Valvular heart disease.
Cardiac conduction system, arrhythmias, and anti-arrhythmic agents.
The recognition, assessment, and treatment of anesthetic complications in the cardiac
surgery patient.
Thoracic surgery is associated with increased perioperative morbidity and mortality. The
preoperative evaluation of these patients requires close attention to the cardiopulmonary system as
a unit. Preoperative evaluation of pulmonary function tests and arterial blood gases are extremely
important in the evaluation of a patient’s ability to survive a major pulmonary operation.
Mastering the technical aspects of the care of these patients (i.e., placement of arterial catheters,
epidural catheters, and double lumen endotracheal tubes) and understanding the physiological
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 151
derangements induced by anesthesia, the lateral position, and unilateral lung ventilation are of
vital importance. Gaining understanding of the normal physiology of the lung, the changes
induced by positioning, instrumentation, and pharmacologic manipulation is the educational aim
of training in thoracic anesthesia.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems related to the care of patients with cardiac or thoracic
disease processes or patients undergoing cardiac or thoracic surgery. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation including history, physical exam
and laboratory studies.
2.
Interact effectively with patients and their families, demonstrating respect and care
for individuals.
3.
Formulate a plan based on the patient’s medical history, expectations and
anticipated course of their condition.
4.
Work together with other members of the interdisciplinary health care team to
optimize patient care and enhance quality of life.
Objectives:
Cardiac Anesthesia
1.
The resident will perform a complete pre-anesthetic evaluation of the patient, including:
a.
Detailed evaluation of cardiac status.
b.
Physical examination, including a detailed exam of the
cardiovascular/pulmonary systems.
c.
Evaluation of vascular access.
d.
Evaluation of diagnostic studies.
e.
Prescribing preoperative medication including a rationale plan for continuing
or discontinuing chronic medications.
2.
Counseling the patient and their family and obtaining informed consent.
3.
Formulation and discussion of the anesthetic plan with the attending
anesthesiologist, including consideration of the patient's disease, associated co-morbidities,
proposed surgery, and post-operative requirements.
4.
Preparation of routine and resuscitative drugs, the operating room, and
monitoring equipment.
5.
Demonstrate facility with the induction of anesthesia for the cardiac surgical patient.
6.
Monitor and anticipate surgical manipulations and the subsequent cardiopulmonary
changes, taking action to minimize these effects. This includes the recognition of
myocardial ischemia via EKG, TEE and Swan-Ganz catheter monitoring.
7.
Ensure adequate anticoagulation with the ability to diagnose and treat heparin resistance.
8.
Explain the special problems encountered when initiating cardiopulmonary bypass
(CPB), including: aortic intimal dissection, superior vena caval obstructions, reversal of flow,
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 152
arterial embolization, and venous airlock.
9.
While on CPB, the resident will understand, diagnose and treat when necessary:
a.
High and low perfusion pressures.
b.
Low urine output.
c.
Low blood flow.
d.
Pulsatile vs. nonpulsatile flow.
e.
Assessment of perfusion pressure and blood flow by MV02 saturation.
f.
Abnormalities of ABGs.
g.
State of anticoagulation.
h.
Electrolyte disturbances.
i.
Neurological changes.
j.
Effects of CPB on coagulation factors.
k.
Hemodilution.
l.
Drug pharmacokinetics and pharmacodynamics.
m.
Diaphragmatic contraction.
10.
Explain the mechanics of the CPB pump equipment:
a.
Calculation and formulation of the pump prime, pump heads and lines.
b.
Oxygenator: membrane vs. bubble.
c.
Heat exchanger.
d.
Function and position of monitors (oxygen saturation, air detector).
11.
Explain the maneuvers designed to remove air from cardiac chambers which have been
opened during the operation.
12.
Interpret the data from observation of the heart and optimize cardiac function with
pharmacological and intravascular volume manipulation, and diagnose and treat coronary artery
spasm and/or embolization during separation from CPB.
13.
Reverse anticoagulation with protamine, understanding dosage calculation, mechanism of
action, and adverse reactions.
14.
Diagnose and treat coagulopathies, understanding the indications for various blood
components.
15.
Stabilize patients post-CPB while optimizing pulmonary, coagulation, renal and
electrolyte status.
16.
Efficiently and safely transport the patient to the ICU, providing continuation of
monitoring and medications.
17.
In the ICU, establish all monitors, supervise institution of mechanical ventilation, assure
hemodynamic support with drugs as necessary, transfuse as necessary, and notify surgical and
nursing staff of past and ongoing management issues.
18.
Manage severe heart failure pre or post surgery to include the use of left or right heart
ventricular assist devices or other extreme measures
Thoracic Anesthesia
1.
Perform a preoperative evaluation of the patient for thoracic surgery with particular
attention to the cardiopulmonary system.
2.
Formulate and discuss with the attending anesthesiologist an anesthetic plan that
considers the patient's disease, co-morbidities, proposed surgery and post-operative
requirements.
3.
Demonstrate proficiency with arterial catheterization, double lumen endotracheal
tube placement, and the use of the flexible fiberoptic bronchoscope
4.
Safely provide post-operative analgesia using epidural catheter techniques
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 153
and demonstrate awareness of potential complications and their management.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of cardiac anesthesia.
2.
Demonstrate knowledge of anatomy, extracorporeal membrane oxygenation,
physiology, and pharmacology.
3.
Understand recent developments in cardiac and thoracic anesthesia.
Objectives:
Cardiac Anatomy and Physiology
1.
Explain the Starling curve and the changes that occur with heart failure, inotropic
agents, and changes in volume status.
2.
Demonstrate knowledge of cardiac anatomy, including chamber and great vessel
position, size and function, coronary arterial anatomy, and the conduction system.
3.
Regarding congenital heart-disease, demonstrate knowledge (anatomic and functional)
of the common defects and the operations used to palliate and/or correct these defects.
4.
Gain an in-depth understanding of the physiology of cardiac function, including:
a.
Determinants of myocardial oxygen supply and
demand.
b.
Definitions of preload, contractility, and afterload.
c.
Venous and arterial pressure waveforms and their analysis.
d.
The Fick and thermodilution methods of cardiac output determination.
e.
The calculation of systemic and pulmonary vascular resistance, and cardiac
index.
Equipment
1.
The resident must obtain working knowledge of cardiac defibrillators, pacemakers,
EKG and pressure monitors, cardiac output computers, pulmonary artery catheters (including
fiberoptic and pacing), transesophageal echocardiography, Activated Clotting Time (ACT),
Hepcon monitors, and thromboelastography.
Cardiovascular Monitoring
1.
List the indications for arterial, central venous and pulmonary artery catheterization.
Arterial Catheters
1.
Explain the proper technique and list the complications associated with inserting
arterial catheters in radial, femoral, brachial, dorsalis pedis, and axillary arteries.
2.
Explain the various factors affecting accurate arterial pressure measurement and
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 154
the problems that can result in false measurements.
Central Venous and Pulmonary Artery Catheters
1.
Demonstrate the proper technique and list the complications associated with insertion
of catheters in the internal and external jugular, and the subclavian veins.
2.
Appropriately interpret and apply hemodynamic data obtained from central venous and
pulmonary artery catheters.
3.
Explain the circumstances in which pulmonary artery wedge pressure measurements are
inaccurate.
4.
Interpret and apply all hemodynamic data derived from invasive hemodynamic
monitoring.
Case Management
1.
Explain the rationale for ordering lab tests.
2.
Explain the interactions between premeditations and the various anesthetics.
3.
Explain the rationale behind different induction and maintenance techniques of anesthesia
for cardiac surgery.
4.
Explain the potential problems encountered during off-pump cardiac revascularization.
5.
Explain the determination of the proper dose of heparin and assessment of heparinization
in the perioperative period.
6.
Discuss factors that may influence heparin resistance and the appropriate therapy.
7.
Understand the special problems that may be encountered during CPB with:
a.
L to R and R to L shunts.
b.
Atherosclerotic coronary artery disease.
c.
Valvular disease: aortic insufficiency, aortic stenosis, mitral regurgitation, mitral
stenosis, and tricuspid insufficiency.
d.
Pericardial diseases.
e.
Pulmonary hypertension.
f.
Common congenital abnormalities.
g.
Coarctation of the aorta.
h.
Tetralogy of Fallot.
i.
Patent ductus arteriosus.
j.
Atrial septal defect.
k.
Ventricular septal defect.
l.
Thoracic and/or arch aortic aneurysm.
m.
Emergent cardiac surgery.
n.
Cardiomyopathy.
8.
Discuss the use and complications of protamine for heparin reversal.
9.
Describe the expected post-operative recovery for the uncomplicated cardiac surgery
patient.
10.
Explain the characteristics and management of conduction system abnormalities.
11.
Describe the changes in physiology and pharmacokinetics with hypothermia as they
pertain to management of arterial C02 tension while on CPB and circulatory arrest.
12.
Describe the indications, mechanics and complications of circulatory assist devices.
13.
Explain the principles of myocardial preservation.
14.
Describe the mechanism of action, indications, contraindications, adverse reactions,
interactions and appropriate doses of the following drugs:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 155
a.
Inotropes - epinephrine, norepinephrine, isoproterenol, dopamine, dobutamine,
amrinone, milrinone, ephedrine, phenylephrine, and glucagon.
b.
Vasodilators - nitroglycerin, nitroprusside, and phentolamine.
c.
Calcium channel blockers - verapamil, nifedipine, and diltiazem.
d.
Beta adrenergic blockers - propranolol, esmolol, labetalol, metoprolol, and
atenolol.
e.
Anesthetic agents - isoflurane, desflurane, halothane, sevoflurane, nitrous oxide,
fentanyl, sufentanil, morphine, benzodiazepines, ketamine, and scopolamine.
f.
Anti-arrhythmic - lidocaine, procainamide, amiodarone, and magnesium sulfate.
g.
Miscellaneous - digoxin, calcium chloride, adenosine, aminophylline,
theophylline, atropine, glycopyrrolate and angiotensin converting enzyme inhibitors and
receptor antagonists.
Thoracic Anesthesia
The objectives will be accomplished through perioperative management of thoracic surgical
patients. Residents will be expected to:
1.
Explain pulmonary function testing and its prognostic utility.
2.
Explain and apply the principles of arterial blood gas analysis.
3.
Describe the physiological changes induced by anesthesia, assumption of the
lateral position, positive pressure ventilation and unilateral lung ventilation.
4.
Explain hypoxic pulmonary vasoconstriction and the effect of anesthetics and other
drugs on hypoxic pulmonary vasoconstriction.
5.
Understand the indications, contraindications, and possible complications associated
with unilateral lung ventilation.
6.
Explain the anesthetic implications of video assisted thoracoscopic surgery.
Interpersonal Skills and Communication
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the utility and advantages, as well as
potential disadvantages, of the different anesthetic options.
2.
Create and sustain a therapeutic and ethically sound relationship with patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goals:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 156
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession;
and a commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices
3.
Demonstrate respect, compassion, integrity and responsiveness to the needs to patients
and society that supersedes self-interest.
4.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
5.
Demonstrate accountability to patients, colleagues and institution.
6.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Residents must investigate and evaluate their patient care practices and appraise and assimilate
scientific evidence to improve patient care. Residents are expected to:
1.
Locate, appraise, and assimilate evidence from scientific studies related to cardiac and
thoracic anesthesia. This includes, but is not limited to, the directed readings in the Core
Curriculum. In selected cases, it is appropriate to pursue additional scientific evidence in a
reference text or in an electronic online search.
2.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
3.
Apply information technology to manage information, access on-line medical
information; and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 157
improve health care and learn how these activities may affect system performance.
III. REQUIRED READING
1.
Cardiothoracic Rotation handout.
2.
Respiratory Physiology, Chapter 15, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill
Livingston, 2010.
4.
Cardiovascular Monitoring, Chapter 40, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
5.
Transesophageal Echocardiography, Chapter 41, Anesthesia, 7th edition, Ronald Miller
Ed. Churchill Livingston, 2010.
6.
Anesthesia for Thoracic Surgery, Chapter 59, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
7.
Anesthesia for Adult Cardiac Surgery, Chapter 60, Anesthesia, 7th edition, Ronald
Miller
Ed. Churchill Livingston, 2010.
8.
Cardiac Anesthesia, 6th edition, Joel A. Kaplan, David L. Reich, Joseph S. Savino.
W.B. Saunders, 2011.
IV. EVALUATION
Final evaluation will be based upon clinical performance. A requisite for gaining credit is
performing at least at the interpreter level by the completion of the rotation. Receiving credit for the
rotation will be determined by the clinical competence committee.
VI. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 158
GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN CARDIOTHORACIC ANESTHESIA
AT INOVA FAIRFAX
I.
ROTATION DEFINITION
The cardiothoracic anesthesia rotation at INOVA Fairfax for a PGY 4/CA 3 is a one to three month
experience. INOVA Fairfax is a high volume referral center for cardiothoracic surgery and cares
for patients with advanced disease states rarely seen at WRNMMC undergoing advanced
procedures rarely seen at WRNMMC (e.g. heart lung transplants). The major goal for a rotation at
INOVA Fairfax in cardiothoracic anesthesia as a PGY 4/CA 3 is to allow the resident to attain
mastery of cardiothoracic anesthesia.
II.
GOALS AND OBJECTIVES
The cardiac anesthesia rotation teaches the knowledge and skills required to successfully manage
patients with cardiac disease undergoing either non-cardiac or cardiac surgery. Successful
management requires a solid understanding of the general principles of anesthesia as well as a
detailed knowledge of cardiac disease. That such a rotation is beneficial is illustrated by the
following points: (1) there is an increasing prevalence of patients with ischemic and valvular heart
disease presenting for non-cardiac surgery, (2) as patients with palliated or corrected congenital
heart disease grow older, they too will be presenting for anesthesia, (3) cardiac surgery exposes
the anesthesiologist to unique principles and practices, and (4) a rotation in cardiac anesthesia
provides an in-depth, hands-on experience with a variety of potent cardiotonic medications.
Finally, the rotation will provide familiarity with mechanical support of the circulation.
The residents will gain an understanding of cardiovascular physiology and the pathophysiology
associated with ischemic and valvular heart disease. Residents will integrate their knowledge
into the perioperative management of patients undergoing cardiac surgery. Residents will attain
an understanding of the following:
2.
3.
4.
5.
6.
7.
8.
1. Anesthetic implications of cardiac disease.
Preoperative assessment of the cardiac surgery patient.
The determinants of cardiac pump function and the perioperative evaluation of cardiac
function.
Anatomy and function of the cardiopulmonary bypass machine.
The determinants of myocardial oxygen supply/demand.
Valvular heart disease.
Cardiac conduction system, arrhythmias, and anti-arrhythmic agents.
The recognition, assessment, and treatment of anesthetic complications in the cardiac
surgery patient.
Thoracic surgery is associated with increased perioperative morbidity and mortality. The
preoperative evaluation of these patients requires close attention to the cardiopulmonary system as
a unit. Preoperative evaluation of pulmonary function tests and arterial blood gases are extremely
important in the evaluation of a patient’s ability to survive a major pulmonary operation.
Mastering the technical aspects of the care of these patients (i.e., placement of arterial catheters,
epidural catheters, and double lumen endotracheal tubes) and understanding the physiological
derangements induced by anesthesia, the lateral position, and unilateral lung ventilation are of
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 159
vital importance. Gaining understanding of the normal physiology of the lung, the changes
induced by positioning, instrumentation, and pharmacologic manipulation is the educational aim
of training in thoracic anesthesia.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems related to the care of patients with cardiac or thoracic
disease processes or patients undergoing cardiac or thoracic surgery. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation including history, physical exam
and laboratory studies.
2.
Interact effectively with patients and their families, demonstrating respect and care
for individuals.
3.
Formulate a plan based on the patient’s medical history, expectations and
anticipated course of their condition.
4.
Work together with other members of the interdisciplinary health care team to
optimize patient care and enhance quality of life.
Objectives:
Cardiac Anesthesia
1.
The resident will perform a complete pre-anesthetic evaluation of the patient, including:
a.
Detailed evaluation of cardiac status.
b.
Physical examination, including a detailed exam of the
cardiovascular/pulmonary systems.
c.
Evaluation of vascular access.
d.
Evaluation of diagnostic studies.
e.
Prescribing preoperative medication including a rationale plan for continuing
or discontinuing chronic medications.
2.
Counseling the patient and their family and obtaining informed consent.
3.
Formulation and discussion of the anesthetic plan with the attending
anesthesiologist, including consideration of the patient's disease, associated co-morbidities,
proposed surgery, and post-operative requirements.
4.
Preparation of routine and resuscitative drugs, the operating room, and
monitoring equipment.
5.
Demonstrate facility with the induction of anesthesia for the cardiac surgical patient.
6.
Monitor and anticipate surgical manipulations and the subsequent cardiopulmonary
changes, taking action to minimize these effects. This includes the recognition of
myocardial ischemia via EKG, TEE and Swan-Ganz catheter monitoring.
7.
Ensure adequate anticoagulation with the ability to diagnose and treat heparin resistance.
8.
Explain the special problems encountered when initiating cardiopulmonary bypass
(CPB), including: aortic intimal dissection, superior vena caval obstructions, reversal of flow,
arterial embolization, and venous airlock.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 160
While on CPB, the resident will understand, diagnose and treat when necessary:
a.
High and low perfusion pressures.
b.
Low urine output.
c.
Low blood flow.
d.
Pulsatile vs. nonpulsatile flow.
e.
Assessment of perfusion pressure and blood flow by MV02 saturation.
f.
Abnormalities of ABGs.
g.
State of anticoagulation.
h.
Electrolyte disturbances.
i.
Neurological changes.
j.
Effects of CPB on coagulation factors.
k.
Hemodilution.
l.
Drug pharmacokinetics and pharmacodynamics.
m.
Diaphragmatic contraction.
10.
Explain the mechanics of the CPB pump equipment:
a.
Calculation and formulation of the pump prime, pump heads and lines.
b.
Oxygenator: membrane vs. bubble.
c.
Heat exchanger.
d.
Function and position of monitors (oxygen saturation, air detector).
11.
Explain the maneuvers designed to remove air from cardiac chambers which have been
opened during the operation.
12.
Interpret the data from observation of the heart and optimize cardiac function with
pharmacological and intravascular volume manipulation, and diagnose and treat coronary artery
spasm and/or embolization during separation from CPB.
13.
Reverse anticoagulation with protamine, understanding dosage calculation, mechanism of
action, and adverse reactions.
14.
Diagnose and treat coagulopathies, understanding the indications for various blood
components.
15.
Stabilize patients post-CPB while optimizing pulmonary, coagulation, renal and
electrolyte status.
16.
Efficiently and safely transport the patient to the ICU, providing continuation of
monitoring and medications.
17.
In the ICU, establish all monitors, supervise institution of mechanical ventilation, assure
hemodynamic support with drugs as necessary, transfuse as necessary, and notify surgical and
nursing staff of past and ongoing management issues.
18.
Manage severe heart failure pre or post surgery to include the use of left or right heart
ventricular assist devices or other extreme measures.
19.
Care for patients requiring heart and lung transplants with advanced disease processes.
9.
Thoracic Anesthesia
1.
Perform a preoperative evaluation of the patient for thoracic surgery with particular
attention to the cardiopulmonary system.
2.
Formulate and discuss with the attending anesthesiologist an anesthetic plan that
considers the patient's disease, co-morbidities, proposed surgery and post-operative
requirements.
3.
Demonstrate proficiency with arterial catheterization, double lumen endotracheal
tube placement, and the use of the flexible fiberoptic bronchoscope
4.
Safely provide post-operative analgesia using epidural catheter techniques
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 161
and demonstrate awareness of potential complications and their management.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of cardiac anesthesia.
2.
Demonstrate knowledge of anatomy, extracorporeal membrane oxygenation,
physiology, and pharmacology.
3.
Understand recent developments in cardiac and thoracic anesthesia.
Objectives:
Cardiac Anatomy and Physiology
1.
Explain the Starling curve and the changes that occur with heart failure, inotropic
agents, and changes in volume status.
2.
Demonstrate knowledge of cardiac anatomy, including chamber and great vessel
position, size and function, coronary arterial anatomy, and the conduction system.
3.
Regarding congenital heart-disease, demonstrate knowledge (anatomic and functional)
of the common defects and the operations used to palliate and/or correct these defects.
4.
Gain an in-depth understanding of the physiology of cardiac function, including:
a.
Determinants of myocardial oxygen supply and
demand.
b.
Definitions of preload, contractility, and afterload.
c.
Venous and arterial pressure waveforms and their analysis.
d.
The Fick and thermodilution methods of cardiac output determination.
e.
The calculation of systemic and pulmonary vascular resistance, and cardiac
index.
Equipment
1.
The resident must obtain working knowledge of cardiac defibrillators, pacemakers,
EKG and pressure monitors, cardiac output computers, pulmonary artery catheters (including
fiberoptic and pacing), transesophageal echocardiography, Activated Clotting Time (ACT),
Hepcon monitors, and thromboelastography.
Cardiovascular Monitoring
1.
List the indications for arterial, central venous and pulmonary artery catheterization.
Arterial Catheters
1.
Explain the proper technique and list the complications associated with inserting
arterial catheters in radial, femoral, brachial, dorsalis pedis, and axillary arteries.
2.
Explain the various factors affecting accurate arterial pressure measurement and
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the problems that can result in false measurements.
Central Venous and Pulmonary Artery Catheters
1.
Demonstrate the proper technique and list the complications associated with insertion
of catheters in the internal and external jugular, and the subclavian veins.
2.
Appropriately interpret and apply hemodynamic data obtained from central venous and
pulmonary artery catheters.
3.
Explain the circumstances in which pulmonary artery wedge pressure measurements are
inaccurate.
4.
Interpret and apply all hemodynamic data derived from invasive hemodynamic
monitoring.
Case Management
1.
Explain the rationale for ordering lab tests.
2.
Explain the interactions between premeditations and the various anesthetics.
3.
Explain the rationale behind different induction and maintenance techniques of anesthesia
for cardiac surgery.
4.
Explain the potential problems encountered during off-pump cardiac revascularization.
5.
Explain the determination of the proper dose of heparin and assessment of heparinization
in the perioperative period.
6.
Discuss factors that may influence heparin resistance and the appropriate therapy.
7.
Understand the special problems that may be encountered during CPB with:
a.
L to R and R to L shunts.
b.
Atherosclerotic coronary artery disease.
c.
Valvular disease: aortic insufficiency, aortic stenosis, mitral regurgitation, mitral
stenosis, and tricuspid insufficiency.
d.
Pericardial diseases.
e.
Pulmonary hypertension.
f.
Common congenital abnormalities.
g.
Coarctation of the aorta.
h.
Tetralogy of Fallot.
i.
Patent ductus arteriosus.
j.
Atrial septal defect.
k.
Ventricular septal defect.
l.
Thoracic and/or arch aortic aneurysm.
m.
Emergent cardiac surgery.
n.
Cardiomyopathy.
8.
Discuss the use and complications of protamine for heparin reversal.
9.
Describe the expected post-operative recovery for the uncomplicated cardiac surgery
patient.
10.
Explain the characteristics and management of conduction system abnormalities.
11.
Describe the changes in physiology and pharmacokinetics with hypothermia as they
pertain to management of arterial C02 tension while on CPB and circulatory arrest.
12.
Describe the indications, mechanics and complications of circulatory assist devices.
13.
Explain the principles of myocardial preservation.
14.
Describe the mechanism of action, indications, contraindications, adverse reactions,
interactions and appropriate doses of the following drugs:
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a.
Inotropes - epinephrine, norepinephrine, isoproterenol, dopamine, dobutamine,
amrinone, milrinone, ephedrine, phenylephrine, and glucagon.
b.
Vasodilators - nitroglycerin, nitroprusside, and phentolamine.
c.
Calcium channel blockers - verapamil, nifedipine, and diltiazem.
d.
Beta adrenergic blockers - propranolol, esmolol, labetalol, metoprolol, and
atenolol.
e.
Anesthetic agents - isoflurane, desflurane, halothane, sevoflurane, nitrous oxide,
fentanyl, sufentanil, morphine, benzodiazepines, ketamine, and scopolamine.
f.
Anti-arrhythmic - lidocaine, procainamide, amiodarone, and magnesium sulfate.
g.
Miscellaneous - digoxin, calcium chloride, adenosine, aminophylline,
theophylline, atropine, glycopyrrolate and angiotensin converting enzyme inhibitors and
receptor antagonists.
Thoracic Anesthesia
The objectives will be accomplished through perioperative management of thoracic surgical
patients. Residents will be expected to:
1.
Explain pulmonary function testing and its prognostic utility.
2.
Explain and apply the principles of arterial blood gas analysis.
3.
Describe the physiological changes induced by anesthesia, assumption of the
lateral position, positive pressure ventilation and unilateral lung ventilation.
4.
Explain hypoxic pulmonary vasoconstriction and the effect of anesthetics and other
drugs on hypoxic pulmonary vasoconstriction.
5.
Understand the indications, contraindications, and possible complications associated
with unilateral lung ventilation.
6.
Explain the anesthetic implications of video assisted thoracoscopic surgery.
Interpersonal Skills and Communication
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
Discuss with patients and family members the utility and advantages, as well as
potential disadvantages, of the different anesthetic options.
2.
Create and sustain a therapeutic and ethically sound relationship with patients.
3.
Use effective listening skills to elicit appropriate clinical information.
4.
Work effectively with others in the interdisciplinary health care team.
Professionalism
Goals:
National Capital Consortium Anesthesiology Residency
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Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the profession;
and a commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business practices
3.
Demonstrate respect, compassion, integrity and responsiveness to the needs to patients
and society that supersedes self-interest.
4.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
5.
Demonstrate accountability to patients, colleagues and institution.
6.
Demonstrate a commitment to excellence and ongoing professional development.
Practice Based Learning
Residents must investigate and evaluate their patient care practices and appraise and assimilate
scientific evidence to improve patient care. Residents are expected to:
1.
Locate, appraise, and assimilate evidence from scientific studies related to cardiac and
thoracic anesthesia. This includes, but is not limited to, the directed readings in the Core
Curriculum. In selected cases, it is appropriate to pursue additional scientific evidence in a
reference text or in an electronic online search.
2.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
3.
Apply information technology to manage information, access on-line medical
information; and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole and vice versa.
2.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
3.
Practice cost-effective health care.
4.
Advocate for quality patient care and assist patients in dealing with system complexities.
5.
Partner with health care managers and health care providers to assess, coordinate, and
National Capital Consortium Anesthesiology Residency
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PAGE 165
improve health care and learn how these activities may affect system performance.
III. REQUIRED READING
1.
Cardiothoracic Rotation handout.
2.
Respiratory Physiology, Chapter 15, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill
Livingston, 2010.
4.
Cardiovascular Monitoring, Chapter 40, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
5.
Transesophageal Echocardiography, Chapter 41, Anesthesia, 7th edition, Ronald Miller
Ed. Churchill Livingston, 2010.
6.
Anesthesia for Thoracic Surgery, Chapter 59, Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2010.
7.
Anesthesia for Adult Cardiac Surgery, Chapter 60, Anesthesia, 7th edition, Ronald
Miller
Ed. Churchill Livingston, 2010.
8.
Cardiac Anesthesia, 6th edition, Joel A. Kaplan, David L. Reich, Joseph S. Savino.
W.B. Saunders, 2011.
IV. EVALUATION
Final evaluation will be based upon clinical performance. A requisite for gaining credit is
performing at least at the interpreter level by the completion of the rotation. Receiving credit for the
rotation will be determined by the clinical competence committee.
VI. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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GOALS AND OBJECTIVES FOR
CA-2 RESIDENTS IN NEUROANESTHESIA
AT WRNMMC
I. ROTATION DEFINITION
The neuroanesthesia rotation at WRNMMC is a one month experience for CA-2 residents in
anesthesia for neurosurgical procedures.
II. GOALS AND OBJECTIVES
This rotation will introduce and concentrate on the basic practices of neuroanesthesia for patients
with normal or abnormal intracranial, neuraxial, cerebrovascular, and peripheral nerve
conditions. The basic sciences of anatomy, physiology, and physics as they relate to the preanesthetic assessment, intraoperative management, and post-operative care of the neurosurgical
patient will be emphasized. Patients with intracranial pathology represent a significant proportion
of the population requiring operative intervention. The physiology of intracranial dynamics and
the pharmacologic results of anesthetic intervention constitute a specialty field of knowledge
within that of general anesthesiology. Vascular malformations, trauma, and tumors all require an
understanding concerning their origin, natural clinical course and potential for therapeutic
intervention. Patients with complex pathology of the cervical, thoracic and lumbar spine make
up a significant portion of the patients residents will care for during their neuroanesthesia month
at WRNMMC. Significant considerations for these patients are the implication of spine and
spinal cord pathology for anesthetic plans, the interaction of anesthetics with mechanisms for
spinal cord monitoring, and the complexities of post-operative pain management for some of
these patients. Patients with chronic neurologic disorders make up a small portion of patients
cared for during a nueroanesthesia rotation at WRNMMC. This patient subgroup represents a
significant challenge in applied pharmacology. The goal of this rotation is proficiency in the
administration of anesthesia and perioperative care of the patient undergoing a neurosurgical
procedures or other procedures for patients with neurological disorders. The resident is expected to
demonstrate an understanding of:
1.
2.
Preoperative assessment of the neurosurgical patient, including coexisting diseases.
Intraoperative management, including:
a.
b.
c.
d.
e.
f.
Choice of anesthetic (general, regional, MAC).
Anesthetic agents as they apply to neurosurgical cases.
The risks and benefits of the agents chosen.
The effects of the anesthetics and adjuvant agents on abnormal neurophysiology.
Understanding abnormal central nervous system physiology.
Management of anesthesia for:
i.
Craniotomy for supratentorial masses.
ii.
Posterior fossa craniotomy (including the sitting position).
iii.
Epilepsy surgery.
iv.
Stereotactic surgery.
v.
CSF shunting procedures.
vi.
Head trauma.
vii.
Spinal column and spinal cord surgery (including injury).
viii.
Intracranial aneurysms and arteriovenous malformations.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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ix.
x.
xi.
Anesthesia for radiologic procedures.
Neuroendocrine Procedures.
Post-anesthesia recovery.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
anticipated course of their condition.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care.
Objectives:
1.
Demonstrate the basic skills of anesthesia, including airway management, intravenous
access, and placement of arterial, CVP, and long-arm CVP lines.
2.
Successfully manage complex neurosurgical cases.
3.
Utilize multiple anesthetic methods (topicalization, nerve blocks, nebulized local
anesthesia) in the preparation of a patient for awake intubations.
4.
Perform awake fiberoptic intubation and awake positioning with the ability to assess
neurologic function as needed.
5.
Insert, properly interpret, and respond to invasive hemodynamic monitors.
6.
Perform and properly maintain hypotensive anesthesia when indicated.
7.
Deliver case presentations for neurosurgical patients, including medical problems, preanesthesia concerns, airway management, lines, anesthetic medications, and extubation plans.
8.
Review the medical history and physical exam to define the type and severity of the
neurosurgical problem, as well as the other co-morbidities.
9.
Recognize patients with spinal cord pathology and determine which may require special
techniques (e.g., awake intubation) and positioning.
10.
Recognize which patients would be appropriate for early extubation (in OR or PACU)
considering their CNS, neuromuscular, and other medical conditions.
11.
Manage an elective craniotomy and understand the choice for the anesthetic agents.
12.
Evaluate CT/MRI images for obvious abnormalities such as epidural and subdural
hematomas, large strokes and masses.
13.
Manage spine surgery, including cases with potential for massive blood losses.
14.
Manage cases in the sitting position, including:
a.
Pre-cordial Doppler placement and recognition of air entrapment.
b.
Long-arm CVP placement and management.
15.
Manage craniotomy for neuroendocrine tumors.
16.
Plan an anesthetic that facilitates a safe and rapid emergent for early post-operative
neurological examination.
National Capital Consortium Anesthesiology Residency
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17.
Place a right atrial catheter for diagnosis and management of air embolism.
18.
Perform awake laryngoscopy, fiberoptic laryngoscopy, fast-track LMA or in-line
stabilization, demonstrating understanding of their use in patients with spinal cord injury.
19.
Perform preoperative patient assessment and choose an anesthetic plan specific for that
neurosurgical patient
20.
Demonstrate the knowledge and skills necessary to care for patients undergoing
anesthesia for intra-cranial mass surgery, intra-cranial vascular surgery, epilepsy surgery, stereotactic surgery, CSF shunting procedures, surgery for head trauma, radiographic procedures,
pituitary surgery, peripheral nerve surgery, for patients with muscle
disorders, and for patients with disorders of the neuromuscular junction.
21.
Provide appropriate treatment for increased intra-cranial pressure.
22.
Provide proper fluid management in neurosurgery patients.
23.
Manage patients with neurologic disease undergoing non-neurosurgery procedures.
24.
Provide initial post-operative care in the ICU/PACU.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of neuroanesthesia.
2.
Understand both normal and abnormal central nervous system physiology, neuroanatomy
relevant to neurosurgical procedures, cerebral and spinal cord blood volume and flow, the
anatomy of the blood brain barrier, the etiology of cerebral edema, the anatomy of peripheral
nerves and their innervation, and physiology of the NMJ and muscle.
3.
Understand neurophysiological monitoring, including EEG, SSEPS, MEPS, BAEPS,
EMG and ICP.
4.
Understand the anesthetic ramifications of increased ICP, intracranial masses, intracranial
vascular lesions, epilepsy, CSF shunting procedures, head and spine trauma, radiographic
procedures, pituitary surgery, peripheral nerve surgery, surgery on patients with muscle disorders,
and patients with disorders of muscle.
Objectives:
1.
Describe an appropriate anesthetic based on the clinical condition, goals of the procedure,
and anticipated intraoperative monitoring for neurosurgical procedures.
2.
Describe neuroanatomy relevant to a neurosurgical procedure.
3.
Understand and explain the physiology of cerebral metabolism, blood flow and blood
volume.
4.
Understand and explain the effects of anesthetic agents and adjuvant drugs on:
a.
Cerebral metabolism.
b.
Cerebral and spinal cord blood volume and blood flow.
c.
Blood brain barrier and cerebral edema.
d.
Cerebral protection, ischemia and resuscitation.
5.
Understand the application and the effects of anesthesia on neurophysiologic monitoring,
including:
National Capital Consortium Anesthesiology Residency
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a.
EEG
b.
SSEP
c.
MEP
d.
Peripheral and cranial nerve monitor
e.
BAERS
f.
EMG
g.
ICP
6.
Understand and describe the surgical and anesthetic considerations of perioperative fluid
management.
7.
Recognize, explain the etiology, and treat intracranial hypertension.
8.
Interpret and respond to data from monitoring devices (etCO2, CBF, EEG, EMG, SSEP,
BAER, and ICP).
9.
List, and describe ways to avoid, the problems associated with emergence from
anesthesia.
10.
Describe CBF and factors affecting it, including CO2 and O2 response and
pharmacological changes in CBF.
11.
Explain the advantages and disadvantages of the intravenous fluids available for
neurosurgical patients, including crystalloid, colloid, hypertonic saline solutions, blood
products, mannitol and dextrose-containing solutions.
12.
Explain the implications of patient positioning.
13.
Explain the pathophysiology of acute and chronic spinal cord injury, including the
cardiovascular and pulmonary consequences (including autonomic hyperreflexia).
14.
Explain the consequences of using depolarizing muscle relaxants in neurosurgical
patients and those with neurological diseases.
15.
Demonstrate the management of increased ICP during craniotomy and the indications,
contraindications and side effects of hyperventilation, barbiturate infusion, diuretics and CSF
drainage.
16.
Demonstrate knowledge and application of the principles and practice of airway
management and sedation requirements for patients undergoing stereo-tactic procedures under
GA or local anesthesia.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
Discuss with patients with neurological disorders or patients undergoing neurological
surgery and family members the utility and advantages, as well as potential disadvantages, of the
different anesthetic options.
2.
Establish good rapport with patients and families, addressing patient and family concerns
and anxieties.
3.
Create and sustain a therapeutic and ethically sound relationship with patients.
4.
Use effective listening skills to elicit appropriate clinical information.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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PAGE 170
5.
Work effectively with others in the interdisciplinary health care team.
6.
Establish working relationships with operating room staff, surgeons, residents and
attending anesthesiologists.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, integrity, responsiveness to the needs of patients and
society that supersedes self-interest, accountability to patients, society, and the profession, and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to performing duties as a physician and medical professional.
3.
Demonstrate a consistent work ethic.
4.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
5.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
6.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and
disabilities.
7.
Demonstrate accountability to patients, colleagues and institution.
8.
Demonstrate the integrity of a medical professional and a commitment to excellence and
ongoing professional development.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to
neuroanesthesia.
2.
Synthesize medical information from texts, lectures, and journal articles and apply this
information to the care of neurosurgical patients.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Use information technology to manage information, access on-line medical information,
and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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PAGE 171
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Explain how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole.
2.
Demonstrate understanding of the healthcare system as it relates to neurosurgery and
neuroanesthesiology.
3.
Demonstrate understanding of the global neurosurgical perioperative process, including
consultative assessments by neurologists, neurosurgeons, and radiologists, intraoperative
management, and post-operative care including ICU, floor care, rehabilitation, and home care.
4.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
5.
Practice cost-effective health care.
6.
Advocate for quality patient care and assist patients in dealing with system complexities.
7.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Neurosurgical Anesthesia, Ch 63 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Neurologic Monitoring, Ch 46 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
IV. EVALUATION
The faculty will evaluate all residents rotating through neuroanesthesia. Successful
completion of this rotation will be assessed by the Clinical Competence Committee and will
be based on the review of written evaluations from the faculty.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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PAGE 172
GOALS AND OBJECTIVES FOR
PGY 3/CA 2 RESIDENTS IN
NEUROANESTHESIA
AT JOHNS HOPKINS UNIVERSITY
I. ROTATION DEFINITION
The neuroanesthesia rotation at Johns Hopkins University (JHU) is a one month experience
for CA-2 residents in anesthesia for neurosurgical procedures. This rotation is intended as a
follow on to the neuroanesthesia rotation at WRNMMC. JHU has a very high volume of
neurosurgical cases with a very high degree of complexity. Residents will almost never see
some of the cases at WRNMMC that are fairly common place for the neuroanesthesia section
at JHU (e.g. intracranial arterio-venous malformations).
II. GOALS AND OBJECTIVES
This rotation will introduce and concentrate on the basic practices of neuroanesthesia for patients
with normal or abnormal intracranial, neuraxial, cerebrovascular, and peripheral nerve
conditions. The basic sciences of anatomy, physiology, and physics as they relate to the preanesthetic assessment, intraoperative management, and post-operative care of the neurosurgical
patient will be emphasized. Patients with intracranial pathology represent a significant proportion
of the population requiring operative intervention. The physiology of intracranial dynamics and
the pharmacologic results of anesthetic intervention constitute a specialty field of knowledge
within that of general anesthesiology. Vascular malformations, trauma, and tumors all require an
understanding concerning their origin, natural clinical course and potential for therapeutic
intervention. Patients with chronic neurologic disorders represent a patient subgroup who benefit
from the applied pharmacologic understanding of the neuroanesthesiologist. The goal of this
rotation is proficiency in the administration of anesthesia and perioperative care of the patient
undergoing a neurosurgical procedure. The resident is expected to demonstrate an understanding
of:
1.
2.
Preoperative assessment of the neurosurgical patient, including coexisting diseases.
Intraoperative management, including:
a.
b.
c.
d.
e.
f.
Choice of anesthetic (general, regional, MAC).
Anesthetic agents as they apply to neurosurgical cases.
The risks and benefits of the agents chosen.
The effects of the anesthetics and adjuvant agents on abnormal neurophysiology.
Understanding abnormal central nervous system physiology.
Management of anesthesia for:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
Craniotomy for supratentorial masses.
Posterior fossa craniotomy (including the sitting position).
Epilepsy surgery.
Stereotactic surgery.
CSF shunting procedures.
Head trauma.
Spinal column and spinal cord surgery (including injury).
Intracranial aneurysms and arteriovenous malformations.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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PAGE 173
ix.
x.
xi.
Anesthesia for radiologic procedures.
Neuroendocrine Procedures.
Post-anesthesia recovery.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
anticipated course of their condition.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care.
Objectives:
1.
Demonstrate the basic skills of anesthesia, including airway management, intravenous
access, and placement of arterial, CVP, and long-arm CVP lines.
2.
Successfully manage complex neurosurgical cases.
3.
Utilize multiple anesthetic methods (topicalization, nerve blocks, nebulized local
anesthesia) in the preparation of a patient for awake intubations.
4.
Perform awake fiberoptic intubation and awake positioning with the ability to assess
neurologic function as needed.
5.
Insert, properly interpret, and respond to invasive hemodynamic monitors.
6.
Perform and properly maintain hypotensive anesthesia when indicated.
7.
Deliver case presentations for neurosurgical patients, including medical problems, preanesthesia concerns, airway management, lines, anesthetic medications, and extubation plans.
8.
Review the medical history and physical exam to define the type and severity of the
neurosurgical problem, as well as the other co-morbidities.
9.
Recognize patients with spinal cord pathology and determine which may require special
techniques (e.g., awake intubation) and positioning.
10.
Recognize which patients would be appropriate for early extubation (in OR or PACU)
considering their CNS, neuromuscular, and other medical conditions.
11.
Manage an elective craniotomy and understand the choice for the anesthetic agents.
12.
Evaluate CT/MRI images for obvious abnormalities such as epidural and subdural
hematomas, large strokes and masses.
13.
Manage spine surgery, including cases with potential for massive blood losses.
14.
Manage cases in the sitting position, including:
a. Pre-cordial Doppler placement and recognition of air entrapment.
b. Long-arm CVP placement and management.
15.
Manage craniotomy for neuroendocrine tumors.
16.
Plan an anesthetic that facilitates a safe and rapid emergent for early post-operative
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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PAGE 174
neurological examination.
17.
Place a right atrial catheter for diagnosis and management of air embolism.
18.
Perform awake laryngoscopy, fiberoptic laryngoscopy, fast-track LMA or in-line
stabilization, demonstrating understanding of their use in patients with spinal cord injury.
19.
Perform preoperative patient assessment and choose an anesthetic plan specific for that
neurosurgical patient
20.
Demonstrate the knowledge and skills necessary to care for patients undergoing
anesthesia for intra-cranial mass surgery, intra-cranial vascular surgery, epilepsy surgery, stereotactic surgery, CSF shunting procedures, surgery for head trauma, radiographic procedures,
pituitary surgery, peripheral nerve surgery, for patients with muscle
disorders, and for patients with disorders of the neuromuscular junction.
21.
Provide appropriate treatment for increased intra-cranial pressure.
22.
Provide proper fluid management in neurosurgery patients.
23.
Manage patients with neurologic disease undergoing non-neurosurgery procedures.
24.
Provide initial post-operative care in the ICU/PACU.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of neuroanesthesia.
2.
Understand both normal and abnormal central nervous system physiology, neuroanatomy
relevant to neurosurgical procedures, cerebral and spinal cord blood volume and flow, the
anatomy of the blood brain barrier, the etiology of cerebral edema, the anatomy of peripheral
nerves and their innervation, and physiology of the NMJ and muscle.
3.
Understand neurophysiological monitoring, including EEG, SSEPS, MEPS, BAEPS,
EMG and ICP.
4.
Understand the anesthetic ramifications of increased ICP, intracranial masses, intracranial
vascular lesions, epilepsy, CSF shunting procedures, head and spine trauma, radiographic
procedures, pituitary surgery, peripheral nerve surgery, surgery on patients with muscle disorders,
and patients with disorders of muscle.
Objectives:
1.
Describe an appropriate anesthetic based on the clinical condition, goals of the procedure,
and anticipated intraoperative monitoring for neurosurgical procedures.
2.
Describe neuroanatomy relevant to a neurosurgical procedure.
3.
Understand and explain the physiology of cerebral metabolism, blood flow and blood
volume.
4.
Understand and explain the effects of anesthetic agents and adjuvant drugs on:
a.
Cerebral metabolism.
b.
Cerebral and spinal cord blood volume and blood flow.
c.
Blood brain barrier and cerebral edema.
d.
Cerebral protection, ischemia and resuscitation.
5.
Understand the application and the effects of anesthesia on neurophysiologic monitoring,
including:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 175
a. EEG
b. SSEP
c. MEP
d. Peripheral and cranial nerve monitor
e. BAERS
f. EMG
g. ICP
6.
Understand and describe the surgical and anesthetic considerations of perioperative fluid
management.
7.
Recognize, explain the etiology, and treat intracranial hypertension.
8.
Interpret and respond to data from monitoring devices (etCO2, CBF, EEG, EMG, SSEP,
BAER, and ICP).
9.
List, and describe ways to avoid, the problems associated with emergence from
anesthesia.
10.
Describe CBF and factors affecting it, including CO2 and O2 response and
pharmacological changes in CBF.
11.
Explain the advantages and disadvantages of the intravenous fluids available for
neurosurgical patients, including crystalloid, colloid, hypertonic saline solutions, blood
products, mannitol and dextrose-containing solutions.
12.
Explain the implications of patient positioning.
13.
Explain the pathophysiology of acute and chronic spinal cord injury, including the
cardiovascular and pulmonary consequences (including autonomic hyperreflexia).
14.
Explain the consequences of using depolarizing muscle relaxants in neurosurgical
patients and those with neurological diseases.
15.
Demonstrate the management of increased ICP during craniotomy and the indications,
contraindications and side effects of hyperventilation, barbiturate infusion, diuretics and CSF
drainage.
16.
Demonstrate knowledge and application of the principles and practice of airway
management and sedation requirements for patients undergoing stereo-tactic procedures under
GA or local anesthesia.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objective:
1.
Discuss with patients and family members the utility and advantages, as well as potential
disadvantages, of the different anesthetic options.
2.
Establish good rapport with patients and families, addressing patient and family concerns
and anxieties.
3.
Create and sustain a therapeutic and ethically sound relationship with patients.
4.
Use effective listening skills to elicit appropriate clinical information.
5.
Work effectively with others in the interdisciplinary health care team.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 176
6.
Establish working relationships with operating room staff, surgeons, residents and
attending anesthesiologists.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, integrity, responsiveness to the needs of patients and
society that supersedes self-interest, accountability to patients, society, and the profession, and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to performing duties as a physician and medical professional.
3.
Demonstrate a consistent work ethic.
4.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
5.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
6.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and
disabilities.
7.
Demonstrate accountability to patients, colleagues and institution.
8.
Demonstrate the integrity of a medical professional and a commitment to excellence and
ongoing professional development.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to
neuroanesthesia.
2.
Synthesize medical information from texts, lectures, and journal articles and apply this
information to the care of neurosurgical patients.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
4.
Use information technology to manage information, access on-line medical information,
and support their education.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 177
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Explain how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole.
2.
Demonstrate understanding of the healthcare system as it relates to neurosurgery and
neuroanesthesiology.
3.
Demonstrate understanding of the global neurosurgical perioperative process, including
consultative assessments by neurologists, neurosurgeons, and radiologists, intraoperative
management, and post-operative care including ICU, floor care, rehabilitation, and home care.
4.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
5.
Practice cost-effective health care.
6.
Advocate for quality patient care and assist patients in dealing with system complexities.
7.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Neurosurgical Anesthesia, Ch 63 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Neurologic Monitoring, Ch 46 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
IV. EVALUATION
The faculty will evaluate all residents rotating through neuroanesthesia. Successful
completion of this rotation will be assessed by the Clinical Competence Committee and will
be based on the review of written evaluations from the faculty.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 178
GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN
NEUROANESTHESIA
AT WRNMMC
I. ROTATION DEFINITION
The neuroanesthesia rotation at WRNMMC for a PGY 4 is an elective which may last one to
four months. This rotation is intended for residents seeking a mastery level understanding of
anesthesia for neurosurgery or neurological disorders. A PGY 4 is expected to become
proficient in advanced neuromonitoring and can lead a team including neurophysiologists or
other specialists.
II. GOALS AND OBJECTIVES
This rotation will introduce residents to care for patients with highly complex intracranial,
neuraxial, cerebrovascular, and peripheral nerve conditions who are undergoing advanced
interventional procedures. Anatomy, physiology, and physics as they relate to the pre- anesthetic
assessment, intraoperative management, and post-operative care of the neurosurgical patient will
be emphasized. Patients with intracranial pathology represent a significant proportion of the
population requiring operative intervention. The physiology of intracranial dynamics and the
pharmacologic results of anesthetic intervention constitute a specialty field of knowledge within
that of general anesthesiology. Vascular malformations, trauma, and tumors all require an
understanding concerning their origin, natural clinical course and potential for therapeutic
intervention. Patients with chronic neurologic disorders represent a patient subgroup who benefit
from the applied pharmacologic understanding of the neuroanesthesiologist. The goal of this
rotation is for a resident to achieve mastery of the administration of anesthesia and perioperative
care of the patient undergoing a neurosurgical procedures. The resident should also gain a
mastery of neuromonitoring techniques and be able to discuss the meaning of changes in
monitor readings beyond just the impact of anesthetics. The resident is expected to demonstrate
an in depth understanding of:
1.
2.
Preoperative assessment of the neurosurgical patient, including coexisting diseases.
Intraoperative management, including:
a.
b.
c.
d.
e.
f.
Choice of anesthetic (general, regional, MAC).
Anesthetic agents as they apply to neurosurgical cases.
The risks and benefits of the agents chosen.
The effects of the anesthetics and adjuvant agents on abnormal neurophysiology.
Understanding abnormal central nervous system physiology.
Management of anesthesia for:
i.
ii.
iii.
iv.
v.
vi.
vii.
Craniotomy for supratentorial masses.
Posterior fossa craniotomy (including the sitting position).
Epilepsy surgery.
Stereotactic surgery.
CSF shunting procedures.
Head trauma.
Spinal column and spinal cord surgery (including injury).
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 179
viii.
ix.
x.
xi.
Intracranial aneurysms and arteriovenous malformations.
Anesthesia for radiologic procedures.
Neuroendocrine Procedures.
Post-anesthesia recovery.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
anticipated course of their condition.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care.
5.
Understand current literature and controversies in neurosurgical anesthesia.
Objectives:
1.
Demonstrate the basic skills of anesthesia, including airway management, intravenous
access, and placement of arterial, CVP, and long-arm CVP lines.
2.
Successfully manage complex neurosurgical cases.
3.
Utilize multiple anesthetic methods (topicalization, nerve blocks, nebulized local
anesthesia) in the preparation of a patient for awake intubations.
4.
Perform awake fiberoptic intubation and awake positioning with the ability to assess
neurologic function as needed.
5.
Insert, properly interpret, and respond to invasive hemodynamic monitors.
6.
Perform and properly maintain hypotensive anesthesia when indicated.
7.
Deliver case presentations for neurosurgical patients, including medical problems, preanesthesia concerns, airway management, lines, anesthetic medications, and extubation plans.
8.
Review the medical history and physical exam to define the type and severity of the
neurosurgical problem, as well as the other co-morbidities.
9.
Recognize patients with spinal cord pathology and determine which may require special
techniques (e.g., awake intubation) and positioning.
10.
Recognize which patients would be appropriate for early extubation (in OR or PACU)
considering their CNS, neuromuscular, and other medical conditions.
11.
Manage an elective craniotomy and understand the choice for the anesthetic agents.
12.
Evaluate CT/MRI images for obvious abnormalities such as epidural and subdural
hematomas, large strokes and masses.
13.
Manage spine surgery, including cases with potential for massive blood losses.
14.
Manage cases in the sitting position, including:
a. Pre-cordial Doppler placement and recognition of air entrapment.
b. Long-arm CVP placement and management.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 180
15.
Manage craniotomy for neuroendocrine tumors.
16.
Plan an anesthetic that facilitates a safe and rapid emergent for early post-operative
neurological examination.
17.
Place a right atrial catheter for diagnosis and management of air embolism.
18.
Perform awake laryngoscopy, fiberoptic laryngoscopy, fast-track LMA or in-line
stabilization, demonstrating understanding of their use in patients with spinal cord injury.
19.
Perform preoperative patient assessment and choose an anesthetic plan specific for that
neurosurgical patient
20.
Demonstrate the knowledge and skills necessary to care for patients undergoing
anesthesia for intra-cranial mass surgery, intra-cranial vascular surgery, epilepsy surgery, stereotactic surgery, CSF shunting procedures, surgery for head trauma, radiographic procedures,
pituitary surgery, peripheral nerve surgery, for patients with muscle
disorders, and for patients with disorders of the neuromuscular junction.
21.
Provide appropriate treatment for increased intra-cranial pressure.
22.
Provide proper fluid management in neurosurgery patients.
23.
Manage patients with neurologic disease undergoing non-neurosurgery procedures.
24.
Provide initial post-operative care in the ICU/PACU.
25.
Demonstrate competency in interpretation of intraoperative monitoring techniques such as
electroencephalography, transcranial Doppler, jugular bulb oxymetry, motor evoked potentials and
sensory evoked potentials.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of neuroanesthesia.
2.
Understand both normal and abnormal central nervous system physiology, neuroanatomy
relevant to neurosurgical procedures, cerebral and spinal cord blood volume and flow, the anatomy
of the blood brain barrier, the etiology of cerebral edema, the anatomy of peripheral nerves and
their innervation, and physiology of the NMJ and muscle.
3.
Gain an in depth understanding of neurophysiological monitoring, including EEG,
SSEPS, MEPS, BAEPS, EMG and ICP.
4.
Understand the anesthetic ramifications of increased ICP, intracranial masses, intracranial
vascular lesions, epilepsy, CSF shunting procedures, head and spine trauma, radiographic
procedures, pituitary surgery, peripheral nerve surgery, surgery on patients with muscle disorders,
and patients with disorders of muscle.
Objectives:
1.
Describe an appropriate anesthetic based on the clinical condition, goals of the procedure,
and anticipated intraoperative monitoring for neurosurgical procedures.
2.
Describe neuroanatomy relevant to a neurosurgical procedure.
3.
Understand and explain the physiology of cerebral metabolism, blood flow and blood
volume.
4.
Understand and explain the effects of anesthetic agents and adjuvant drugs on:
a.
Cerebral metabolism.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 181
b.
Cerebral and spinal cord blood volume and blood flow.
c.
Blood brain barrier and cerebral edema.
d.
Cerebral protection, ischemia and resuscitation.
5.
Understand the application and the effects of anesthesia on neurophysiologic monitoring,
including:
a. EEG
b. SSEP
c. MEP
d. Peripheral and cranial nerve monitor
e. BAERS
f. EMG
g. ICP
6.
Understand and describe the surgical and anesthetic considerations of perioperative fluid
management.
7.
Recognize, explain the etiology, and treat intracranial hypertension.
8.
Interpret and respond to data from monitoring devices (etCO2, CBF, EEG, EMG, SSEP,
BAER, and ICP).
9.
List, and describe ways to avoid, the problems associated with emergence from
anesthesia.
10.
Describe CBF and factors affecting it, including CO2 and O2 response and
pharmacological changes in CBF.
11.
Explain the advantages and disadvantages of the intravenous fluids available for
neurosurgical patients, including crystalloid, colloid, hypertonic saline solutions, blood
products, mannitol and dextrose-containing solutions.
12.
Explain the implications of patient positioning.
13.
Explain the pathophysiology of acute and chronic spinal cord injury, including the
cardiovascular and pulmonary consequences (including autonomic hyperreflexia).
14.
Explain the consequences of using depolarizing muscle relaxants in neurosurgical
patients and those with neurological diseases.
15.
Demonstrate the management of increased ICP during craniotomy and the indications,
contraindications and side effects of hyperventilation, barbiturate infusion, diuretics and CSF
drainage.
16.
Demonstrate knowledge and application of the principles and practice of airway
management and sedation requirements for patients undergoing stereo-tactic procedures under
GA or local anesthesia.
17.
Demonstrate the ability to interpret raw and processed EEG readings.
18.
Discuss the significance of velocity changes in transcranial ultrasonography.
19.
Discuss the significance of changes in latency and amplitude in motor and sensory
evoked potentials and the meaning beyond just the effect of anesthetics (e.g. site of surgical
trespass based on changes in signals).
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 182
Objective:
1.
Discuss with patients and family members the utility and advantages, as well as potential
disadvantages, of the different anesthetic options.
2.
Establish good rapport with patients and families, addressing patient and family concerns
and anxieties.
3.
Create and sustain a therapeutic and ethically sound relationship with patients.
4.
Use effective listening skills to elicit appropriate clinical information.
5.
Work effectively with others in the interdisciplinary health care team.
6.
Establish working relationships with operating room staff, surgeons, residents and
attending anesthesiologists.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, integrity, responsiveness to the needs of patients and
society that supersedes self-interest, accountability to patients, society, and the profession, and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to performing duties as a physician and medical professional.
3.
Demonstrate a consistent work ethic.
4.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
5.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
6.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
7.
Demonstrate accountability to patients, colleagues and institution.
8.
Demonstrate the integrity of a medical professional and a commitment to excellence and
ongoing professional development.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to
neuroanesthesia.
2.
Synthesize medical information from texts, lectures, and journal articles and apply this
information to the care of neurosurgical patients.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 183
studies and other information on diagnostic and therapeutic effectiveness.
4.
Use information technology to manage information, access on-line medical information,
and support their education.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Explain how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole.
2.
Demonstrate understanding of the healthcare system as it relates to neurosurgery and
neuroanesthesiology.
3.
Demonstrate understanding of the global neurosurgical perioperative process, including
consultative assessments by neurologists, neurosurgeons, and radiologists, intraoperative
management, and post-operative care including ICU, floor care, rehabilitation, and home care.
4.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
5.
Practice cost-effective health care.
6.
Advocate for quality patient care and assist patients in dealing with system complexities.
7.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Neurosurgical Anesthesia, Ch 63 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Neurologic Monitoring, Ch 46 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
IV. EVALUATION
The faculty will evaluate all residents rotating through neuroanesthesia. Successful
completion of this rotation will be assessed by the Clinical Competence Committee and will
be based on the review of written evaluations from the faculty.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 184
GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN
NEUROANESTHESIA
AT JOHNS HOPKINS UNIVERSITY
I. ROTATION DEFINITION
The neuroanesthesia rotation at JHU for a PGY 4 is an elective which may last one to four
months. This rotation is intended for residents seeking a mastery level understanding of
anesthesia for neurosurgery or neurological disorders. A PGY 4 is expected to become
proficient in advanced neuromonitoring and can lead a team including neurophysiologists or
other specialists.
II. GOALS AND OBJECTIVES
This rotation will introduce residents to care for patients with highly complex intracranial,
neuraxial, cerebrovascular, and peripheral nerve conditions who are undergoing advanced
interventional procedures. Anatomy, physiology, and physics as they relate to the pre- anesthetic
assessment, intraoperative management, and post-operative care of the neurosurgical patient will
be emphasized. Patients with intracranial pathology represent a significant proportion of the
population requiring operative intervention. The physiology of intracranial dynamics and the
pharmacologic results of anesthetic intervention constitute a specialty field of knowledge within
that of general anesthesiology. Vascular malformations, trauma, and tumors all require an
understanding concerning their origin, natural clinical course and potential for therapeutic
intervention. Patients with chronic neurologic disorders represent a patient subgroup who benefit
from the applied pharmacologic understanding of the neuroanesthesiologist. The goal of this
rotation is for a resident to achieve mastery of the administration of anesthesia and perioperative
care of the patient undergoing a neurosurgical procedures. The resident should also gain a
mastery of neuromonitoring techniques and be able to discuss the meaning of changes in
monitor readings beyond just the impact of anesthetics. The resident is expected to demonstrate
an in depth understanding of:
1.
2.
Preoperative assessment of the neurosurgical patient, including coexisting diseases.
Intraoperative management, including:
a.
b.
c.
d.
e.
f.
Choice of anesthetic (general, regional, MAC).
Anesthetic agents as they apply to neurosurgical cases.
The risks and benefits of the agents chosen.
The effects of the anesthetics and adjuvant agents on abnormal neurophysiology.
Understanding abnormal central nervous system physiology.
Management of anesthesia for:
i.
ii.
iii.
iv.
v.
vi.
vii.
Craniotomy for supratentorial masses.
Posterior fossa craniotomy (including the sitting position).
Epilepsy surgery.
Stereotactic surgery.
CSF shunting procedures.
Head trauma.
Spinal column and spinal cord surgery (including injury).
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 185
viii.
ix.
x.
xi.
Intracranial aneurysms and arteriovenous malformations.
Anesthesia for radiologic procedures.
Neuroendocrine Procedures.
Post-anesthesia recovery.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation, including history, physical exam and
laboratory studies.
2.
Interact effectively with patients and their families, demonstrating respect and care for
individuals.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
anticipated course of their condition.
4.
Work together with other members of the interdisciplinary health care team to optimize
patient care.
5.
Understand current literature and controversies in neurosurgical anesthesia.
Objectives:
1.
Demonstrate the basic skills of anesthesia, including airway management, intravenous
access, and placement of arterial, CVP, and long-arm CVP lines.
2.
Successfully manage complex neurosurgical cases.
3.
Utilize multiple anesthetic methods (topicalization, nerve blocks, nebulized local
anesthesia) in the preparation of a patient for awake intubations.
4.
Perform awake fiberoptic intubation and awake positioning with the ability to assess
neurologic function as needed.
5.
Insert, properly interpret, and respond to invasive hemodynamic monitors.
6.
Perform and properly maintain hypotensive anesthesia when indicated.
7.
Deliver case presentations for neurosurgical patients, including medical problems, preanesthesia concerns, airway management, lines, anesthetic medications, and extubation plans.
8.
Review the medical history and physical exam to define the type and severity of the
neurosurgical problem, as well as the other co-morbidities.
9.
Recognize patients with spinal cord pathology and determine which may require special
techniques (e.g., awake intubation) and positioning.
10.
Recognize which patients would be appropriate for early extubation (in OR or PACU)
considering their CNS, neuromuscular, and other medical conditions.
11.
Manage an elective craniotomy and understand the choice for the anesthetic agents.
12.
Evaluate CT/MRI images for obvious abnormalities such as epidural and subdural
hematomas, large strokes and masses.
13.
Manage spine surgery, including cases with potential for massive blood losses.
14.
Manage cases in the sitting position, including:
a. Pre-cordial Doppler placement and recognition of air entrapment.
b. Long-arm CVP placement and management.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 186
15.
Manage craniotomy for neuroendocrine tumors.
16.
Plan an anesthetic that facilitates a safe and rapid emergent for early post-operative
neurological examination.
17.
Place a right atrial catheter for diagnosis and management of air embolism.
18.
Perform awake laryngoscopy, fiberoptic laryngoscopy, fast-track LMA or in-line
stabilization, demonstrating understanding of their use in patients with spinal cord injury.
19.
Perform preoperative patient assessment and choose an anesthetic plan specific for that
neurosurgical patient
20.
Demonstrate the knowledge and skills necessary to care for patients undergoing
anesthesia for intra-cranial mass surgery, intra-cranial vascular surgery, epilepsy surgery, stereotactic surgery, CSF shunting procedures, surgery for head trauma, radiographic procedures,
pituitary surgery, peripheral nerve surgery, for patients with muscle
disorders, and for patients with disorders of the neuromuscular junction.
21.
Provide appropriate treatment for increased intra-cranial pressure.
22.
Provide proper fluid management in neurosurgery patients.
23.
Manage patients with neurologic disease undergoing non-neurosurgery procedures.
24.
Provide initial post-operative care in the ICU/PACU.
25.
Demonstrate competency in interpretation of intraoperative monitoring techniques such as
electroencephalography, transcranial Doppler, jugular bulb oxymetry, motor evoked potentials and
sensory evoked potentials.
Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
Apply relevant scientific knowledge and reasoning to the practice of neuroanesthesia.
2.
Understand both normal and abnormal central nervous system physiology, neuroanatomy
relevant to neurosurgical procedures, cerebral and spinal cord blood volume and flow, the anatomy
of the blood brain barrier, the etiology of cerebral edema, the anatomy of peripheral nerves and
their innervation, and physiology of the NMJ and muscle.
3.
Gain an in depth understanding of neurophysiological monitoring, including EEG,
SSEPS, MEPS, BAEPS, EMG and ICP.
4.
Understand the anesthetic ramifications of increased ICP, intracranial masses, intracranial
vascular lesions, epilepsy, CSF shunting procedures, head and spine trauma, radiographic
procedures, pituitary surgery, peripheral nerve surgery, surgery on patients with muscle disorders,
and patients with disorders of muscle.
Objectives:
1.
Describe an appropriate anesthetic based on the clinical condition, goals of the procedure,
and anticipated intraoperative monitoring for neurosurgical procedures.
2.
Describe neuroanatomy relevant to a neurosurgical procedure.
3.
Understand and explain the physiology of cerebral metabolism, blood flow and blood
volume.
4.
Understand and explain the effects of anesthetic agents and adjuvant drugs on:
a.
Cerebral metabolism.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 187
b.
Cerebral and spinal cord blood volume and blood flow.
c.
Blood brain barrier and cerebral edema.
d.
Cerebral protection, ischemia and resuscitation.
5.
Understand the application and the effects of anesthesia on neurophysiologic monitoring,
including:
a. EEG
b. SSEP
c. MEP
d. Peripheral and cranial nerve monitor
e. BAERS
f. EMG
g. ICP
6.
Understand and describe the surgical and anesthetic considerations of perioperative fluid
management.
7.
Recognize, explain the etiology, and treat intracranial hypertension.
8.
Interpret and respond to data from monitoring devices (etCO2, CBF, EEG, EMG, SSEP,
BAER, and ICP).
9.
List, and describe ways to avoid, the problems associated with emergence from
anesthesia.
10.
Describe CBF and factors affecting it, including CO2 and O2 response and
pharmacological changes in CBF.
11.
Explain the advantages and disadvantages of the intravenous fluids available for
neurosurgical patients, including crystalloid, colloid, hypertonic saline solutions, blood
products, mannitol and dextrose-containing solutions.
12.
Explain the implications of patient positioning.
13.
Explain the pathophysiology of acute and chronic spinal cord injury, including the
cardiovascular and pulmonary consequences (including autonomic hyperreflexia).
14.
Explain the consequences of using depolarizing muscle relaxants in neurosurgical
patients and those with neurological diseases.
15.
Demonstrate the management of increased ICP during craniotomy and the indications,
contraindications and side effects of hyperventilation, barbiturate infusion, diuretics and CSF
drainage.
16.
Demonstrate knowledge and application of the principles and practice of airway
management and sedation requirements for patients undergoing stereo-tactic procedures under
GA or local anesthesia.
17.
Demonstrate the ability to interpret raw and processed EEG readings.
18.
Discuss the significance of velocity changes in transcranial ultrasonography.
19.
Discuss the significance of changes in latency and amplitude in motor and sensory
evoked potentials and the meaning beyond just the effect of anesthetics (e.g. site of surgical
trespass based on changes in signals).
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 188
Objective:
1.
Discuss with patients and family members the utility and advantages, as well as potential
disadvantages, of the different anesthetic options.
2.
Establish good rapport with patients and families, addressing patient and family concerns
and anxieties.
3.
Create and sustain a therapeutic and ethically sound relationship with patients.
4.
Use effective listening skills to elicit appropriate clinical information.
5.
Work effectively with others in the interdisciplinary health care team.
6.
Establish working relationships with operating room staff, surgeons, residents and
attending anesthesiologists.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
Demonstrate respect, compassion, integrity, responsiveness to the needs of patients and
society that supersedes self-interest, accountability to patients, society, and the profession, and a
commitment to excellence and on-going professional development.
2.
Demonstrate a commitment to performing duties as a physician and medical professional.
3.
Demonstrate a consistent work ethic.
4.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
5.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
6.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
7.
Demonstrate accountability to patients, colleagues and institution.
8.
Demonstrate the integrity of a medical professional and a commitment to excellence and
ongoing professional development.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
Locate, appraise, and assimilate evidence from scientific studies related to
neuroanesthesia.
2.
Synthesize medical information from texts, lectures, and journal articles and apply this
information to the care of neurosurgical patients.
3.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 189
studies and other information on diagnostic and therapeutic effectiveness.
4.
Use information technology to manage information, access on-line medical information,
and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
Explain how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole.
2.
Demonstrate understanding of the healthcare system as it relates to neurosurgery and
neuroanesthesiology.
3.
Demonstrate understanding of the global neurosurgical perioperative process, including
consultative assessments by neurologists, neurosurgeons, and radiologists, intraoperative
management, and post-operative care including ICU, floor care, rehabilitation, and home care.
4.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
5.
Practice cost-effective health care.
6.
Advocate for quality patient care and assist patients in dealing with system complexities.
7.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Neurosurgical Anesthesia, Ch 63 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Neurologic Monitoring, Ch 46 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
IV. EVALUATION
The faculty will evaluate all residents rotating through neuroanesthesia. Successful
completion of this rotation will be assessed by the Clinical Competence Committee and will
be based on the review of written evaluations from the faculty.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 190
GOALS AND OBJECTIVES FOR
PGY 3/CA 2 RESIDENTS IN PEDIATRIC
ANESTHESIA AT CHILDRENS NATIONAL
MEDICAL CENTER
I. ROTATION DEFINITION
Anesthesia for neonates, infants, and children requires an understanding of the physiologic and
pharmacologic differences from adults and their impact upon the anesthesiologist’s ability to
provide acceptable operative conditions and homeostasis during surgery and the postanesthetic
recovery period.
The pediatric anesthesia experience at the NCC will be comprised of a two month rotation at the
Children's National Medical Center, Washington, DC, as well as numerous opportunities to care
for pediatric patients undergoing diagnostic and surgical procedures at WRNMMC. The PGY
3/CA 2 resident is expected to attain a basic understanding of the physiology of neonates, infants,
and children as well as the pathophysiology of their illnesses. Residents are expected to
demonstrate the ability to apply this knowledge to varying clinical settings.
II. GOALS AND OBJECTIVES
The goals of the rotation at CNMC and the opportunities at WRNMMC are to provide the
resident with knowledge and experience necessary to administer anesthesia to neonates, infants
and children that may be encountered in a general anesthesia practice. The anesthesia techniques
and problems unique to the pediatric practice will primarily concern:
1.
2.
3.
Pre-anesthetic assessments and evaluation of the pediatric surgical patient.
Development of an anesthetic plan and intraoperative management of anesthesia.
Post-anesthetic recovery of the pediatric patient including alternatives for pain
management.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
4.
Perform an appropriate pre-anesthetic evaluation; including history, physical exam and
laboratory studies when needed.
Interact effectively with patients and their families demonstrating respect and care for
pediatric patients.
Formulate a plan based on the individual patient’s medical history, expectations and
anticipated course of their condition.
Work together with other members of the interdisciplinary health care team, to optimize
patient care and enhance quality of life.
Objectives:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 191
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Perform a pre-anesthetic assessment and prepare an anesthetic plan for an ASA 1 or 2
pediatric patient.
Manage children with a normal pediatric airway utilizing appropriate face mask, bag and
oral airway.
Intubate children with a normal pediatric airway with skill and speed using appropriate
blade and endotracheal tube.
Obtain appropriate intravenous access.
Obtain appropriate arterial access.
Assemble blood warming equipment and filters for transfusion in pediatric patients.
Manage an appropriate anesthetic for routine pediatric cases, i.e. hernia repair,
tonsillectomy, myringotomy tube placement, etc.
Manage laryngospasm in the pediatric patient.
Recognize and treat post-operative croup.
Appropriately administer fluid and blood transfusion therapy based on knowledge of the
following: maturation of renal function, body fluid compartments, perioperative fluid
requirements, types of IV solutions, estimation of blood volume, measurement of blood
loss, and indications for transfusion.
Gain experience managing airway emergencies such as epiglottitis, croup, and foreign
body aspiration.
Gain experience in the general management principles of surgical conditions in the
newborn and apply to specific conditions such as pyloric stenosis, tracheoesophageal
fistula, diaphragmatic hernia, omphalocele, gastroschisis, and necrotizing enterocolitis.
Gain experience in neonatal and pediatric resuscitation and intensive care including
transport of the sick infant, cardiopulmonary resuscitation, and the treatment of
intracranial hypertension.
Gain expertise regarding anesthetic principles for orthopedic and spine surgery,
specifically the surgical correction of scoliosis and its attendant need for possible
hypotensive anesthesia, hemodilution, intraoperative "wake-up," and evoked potential
monitoring.
Gain expertise in the management of specific clinical problems associated with pediatric
ophthalmology and otolaryngology (i.e., the bleeding tonsil, foreign bodies of the airway,
laser surgery of the airway, the use of topical anesthesia, nitrous oxide and ear surgery,
open eye injuries, and the oculocardiac reflex).
Medical Knowledge
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
Objectives:
Physiology
1.
2.
Discuss pediatric physiology of the nervous system, including such topics as
sympathetic/parasympathetic development, reflexes and blood-brain barrier development.
Discuss pediatric physiology of the respiratory system, including the airway of the
neonate, infant, and child, pulmonary physiology as related to growth, reactive airway
disease, and normal respiratory values (i.e., lung structure, lung volumes, and respiratory
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 192
mechanics).
3.
Discuss pediatric physiology of the cardiovascular system, including cardiac output‟s
relation to pulse, hemodynamic changes at birth, normal hemodynamic values and
physiologic anemia.
4.
Demonstrate knowledge of the pathophysiology of congenital heart disease including
fetal circulation, circulatory changes at birth, and the classification and incidence of
congenital heart disease (CHD).
5.
Discuss pediatric physiology of the hepatic system, including drug metabolism, synthetic
functions, glycogen storage, neonatal jaundice, and kernicterus.
6.
Discuss pediatric physiology of the renal system, including water and solute handling,
developmental changes of GFR, maintenance fluids, and normal blood volumes.
7.
Discuss pediatric physiology of the hematologic system, including normal values, fetal
hemoglobin oxygen dissociation curve, sickle cell anemia, thalassemia, transfusion therapy, and
hemophilia.
8.
Discuss pediatric physiology of glucose homeostasis, NPO guidelines, and GFR.
9.
Discuss pediatric physiology of temperature regulation, including heat loss during
anesthesia, non-shivering thermogenesis, and heat conservation.
Preoperative Preparation
1.
2.
3.
4.
5.
Demonstrate knowledge and aptitude in pre-anesthetic evaluation and preparation for
surgery, i.e., preoperative fasting, routine laboratory tests, psychological preparation and
pharmacological premedication.
Discuss management of routine and complex preoperative problems, including the infant
with an upper respiratory infection, pre-anesthetic labs, heart murmur, difficult airways,
mediastinal mass, and outpatient surgery and the ex-premature infant.
Understand the psychological aspects of pediatric anesthesia, including separation
anxiety, body image, psychological preparation of the toddler and adolescent.
Discuss pediatric sedation techniques, via the oral, nasal, transmucosal, IM, IV and rectal
routes.
Demonstrate knowledge of common preexisting medical conditions (such as anemia, RDS
& BPD, hemophilia, diabetes mellitus, cystic fibrosis, asthma, upper respiratory tract
infection, etc.) and their anesthetic implications.
Case Management
1.
2.
3.
4.
Demonstrate understanding of pediatric outpatient anesthesia, specifically its advantages,
patient selection, pre-anesthetic evaluation and instructions, anesthetic techniques,
recovery, and discharge criteria.
Demonstrate the proper use of pediatric anesthesia circuits, based on an in-depth
understanding of their classification, and facility with pediatric mechanical ventilation.
Demonstrate understanding and application of the general principles of pediatric
pharmacology, including dosage formulas for children, administration of inhalational
anesthetic agents (uptake, elimination, induction, emergence, etc.), intravenous agents
(induction, maintenance, antagonists), muscle relaxants (neuro-muscular physiology,
depolarizing relaxants, nondepolarizing relaxants, reversal), anticholinergic drugs, and
medications for treating post-operative analgesia.
Discuss pediatric induction techniques, including inhalation, IM, IV, rectal and the use of
induction rooms.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
5.
6.
7.
8.
9.
10.
11.
12.
13.
PAGE 193
Define appropriate endotracheal tube size and insertion depth.
Describe different blade options for pediatric intubation.
Recognize and define alternatives in management of difficult/problematic airways, e.g.
Pierre-Robin, pyloric stenosis, foreign body aspiration, etc.
Discuss pediatric regional anesthesia, including caudal, ilioinguinal, iliohypogastric and
penile nerve blocks.
Discuss management of routine and complex operative problems, including masseter
spasm, epiglottitis, croup, foreign body aspiration, pyloric stenosis, post-tonsillectomy
hemorrhage, omphalocele, gastroschisis, tracheoesophageal fistula, diaphragmatic hernia,
meningomyelocele, and elevated intracranial pressure.
Demonstrate understanding of fluid replacement therapy and calculate estimated blood
volume and allowable blood loss.
Demonstrate understanding of the general principles of pediatric neurosurgery and apply
them to the control of ICP, posterior fossa surgery, hydrocephalus, meningomyelocele,
head trauma, craniosynostosis, and neurodiagnostic procedures.
Demonstrate understanding of the principles of correction for lesions such as PDA, aortic
coarctation, atrial septal defect, ventricular septal defect, tetralogy of Fallot, transposition
of the great vessels, and total anomalous pulmonary venous drainage.
Explain the proper use of antibiotic prophylaxis for the patient with cardiac disease.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objective:
1.
2.
3.
4.
5.
6.
Discuss with patients and family members the advantages and disadvantages of the
different anesthetic options.
Establish good rapport with patients and families, addressing patient and family concerns
and anxieties.
Create and sustain a therapeutic and ethically sound relationship with patients.
Use effective listening skills to elicit appropriate clinical information.
Work effectively with others in the interdisciplinary health care team.
Establish working relationships with operating room staff, surgeons, resident and
attending anesthesiologists.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 194
Objective:
1.
2.
3.
4.
5.
6.
7.
8.
Demonstrate respect, compassion, and integrity, responsiveness to the needs of patients
and society that supersedes self-interest, accountability to patients, society, and the
profession, and a commitment to excellence and on-going professional development
Demonstrate a commitment to performing duties as a physician and medical professional.
Demonstrate a consistent work ethic.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
Demonstrate accountability to patients, colleagues and institution.
Demonstrate the integrity of a medical professional and a commitment to excellence and
ongoing professional development.
Practice Based Learning
Goal:
Residents must investigate and evaluate their patient care practices and appraise and assimilate
scientific evidence to improve patient care.
Objectives:
1.
2.
3.
4.
Locate, appraise, and assimilate evidence from scientific studies related to pediatric
anesthesia.
Synthesize medical information from texts, lectures, and journal articles and apply this
information to the care of pediatric patients.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness
Use information technology to manage information, access on-line medical information,
and support their education.
Systems Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value. Residents are expected to:
1.
2.
3.
4.
5.
6.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole.
Understand the healthcare system as it relates to pediatrics and pediatric anesthesiology.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
Practice cost-effective health care.
Advocate for quality patient care and assist patients in dealing with system complexities.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 195
III. REQUIRED READING
1.
Pediatric Anesthesia, Chapter 82, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
A Practice of Anesthesia for Infants and Children, 4th edition, Charles J. Cote, Jerrold
Lerman, I. David Todres. WB Saunders, 2008.
IV. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and based upon review of the written evaluation from Children's National Medical Center.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 196
GOALS AND OBJECTIVES FOR
PGY 4/CA 3 RESIDENTS IN PEDIATRIC ANESTHESIA
AT CHILDRENS NATIONAL MEDICAL CENTER
I. ROTATION DEFINITION
Anesthesia for neonates, infants, and children requires an understanding of the physiologic and
pharmacologic differences from adults and their impact upon the anesthesiologist’s ability to
provide acceptable operative conditions and homeostasis during surgery and the postanesthetic
recovery period.
The pediatric anesthesia experience for a PGY 4/CA 3 may be comprised of a one to four month
rotation at the Children's National Medical Center, Washington, DC. The PGY 4/CA 3 resident is
expected to demonstrate an in depth understanding of the physiology of neonates, infants, and
children as well as the pathophysiology of their illnesses. PGY 4/CA 3 residents are expected to
take on cases of greater complexity than PGY 3/CA 2 residents. PGY 4/CA 3 residents are expected
to show a mastery of pediatric anesthesiology concerns. The major difference between rotations as
a PGY 3/Ca 2 and PGY 4/CA 3 is comfort level with abnormal pediatric airway anatomy and
physiology. PGY 4/CA 3 residents are expected to show mastery of “normal” physiology and
anatomy and to be able to handle “abnormal”physiology and anatomy. Residents are expected to
demonstrate the ability to apply this knowledge to varying clinical settings.
II. GOALS AND OBJECTIVES
The goals of the rotation at CNMC are to provide the resident with knowledge and experience
necessary to administer anesthesia to neonates, infants and children that may be encountered in a
general anesthesia practice. The anesthesia techniques and problems unique to the pediatric
practice will primarily concern:
1.
2.
3.
Pre-anesthetic assessments and evaluation of the pediatric surgical patient.
Development of an anesthetic plan and intraoperative management of anesthesia.
Post-anesthetic recovery of the pediatric patient including alternatives for pain
management.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health. Residents are expected to:
1.
Perform an appropriate pre-anesthetic evaluation; including history, physical exam and
laboratory studies when needed.
2.
Interact effectively with patients and their families demonstrating respect and care for
pediatric patients.
3.
Formulate a plan based on the individual patient’s medical history, expectations and
anticipated course of their condition.
4.
Work together with other members of the interdisciplinary health care team, to optimize
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 197
patient care and enhance quality of life.
Objectives:
1.
Perform a pre-anesthetic assessment and prepare an anesthetic plan for an ASA 3 or greater
pediatric patients.
2.
Manage children with an abnormal pediatric airway utilizing appropriate face mask, bag
and oral airway.
3.
Intubate children with an abnormal pediatric airway with skill and speed using appropriate
blade and endotracheal tube.
4.
Obtain appropriate intravenous access.
5.
Obtain appropriate arterial access.
6.
Assemble blood warming equipment and filters for transfusion in pediatric patients.
7.
Manage an appropriate anesthetic for routine pediatric cases, i.e. hernia repair,
tonsillectomy, myringotomy tube placement, etc.
8.
Manage laryngospasm in the pediatric patient.
9.
Recognize and treat post-operative croup.
10.
Appropriately administer fluid and blood transfusion therapy based on knowledge of the
following: maturation of renal function, body fluid compartments, perioperative fluid requirements,
types of IV solutions, estimation of blood volume, measurement of blood loss, and indications for
transfusion.
11.
Demonstrate mastery managing airway emergencies such as epiglottitis, croup, and foreign
body aspiration.
12.
Demonstrate mastery in the general management principles of surgical conditions in the
newborn and apply to specific conditions such as pyloric stenosis, tracheoesophageal fistula,
diaphragmatic hernia, omphalocele, gastroschisis, and necrotizing enterocolitis.
13.
Demonstrate mastery in neonatal and pediatric resuscitation and intensive care including
transport of the sick infant, cardiopulmonary resuscitation, and the treatment of intracranial
hypertension.
14.
Demonstrate mastery of anesthetic principles for orthopedic and spine surgery, specifically
the surgical correction of scoliosis and its attendant need for possible hypotensive anesthesia,
hemodilution, intraoperative "wake-up," and evoked potential monitoring.
15.
Demonstrate mastery in the management of specific clinical problems associated with
pediatric ophthalmology and otolaryngology (i.e., the bleeding tonsil, foreign bodies of the airway,
laser surgery of the airway, the use of topical anesthesia, nitrous oxide and ear surgery, open eye
injuries, and the oculocardiac reflex).
Medical Knowledge
Goal:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to pediatric anesthesia care.
Objectives:
Physiology
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 198
1.
Discuss pediatric physiology of the nervous system, including such topics as
sympathetic/parasympathetic development, reflexes and blood-brain barrier development.
2.
Discuss pediatric physiology of the respiratory system, including the airway of the neonate,
infant, and child, pulmonary physiology as related to growth, reactive airway disease, and normal
respiratory values (i.e., lung structure, lung volumes, and respiratory mechanics).
3.
Discuss pediatric physiology of the cardiovascular system, including cardiac output’s
relation to pulse, hemodynamic changes at birth, normal hemodynamic values and physiologic
anemia.
4.
Demonstrate knowledge of the pathophysiology of congenital heart disease including fetal
circulation, circulatory changes at birth, and the classification and incidence of congenital heart
disease (CHD).
5.
Discuss pediatric physiology of the hepatic system, including drug metabolism, synthetic
functions, glycogen storage, neonatal jaundice, and kernicterus.
6.
Discuss pediatric physiology of the renal system, including water and solute handling,
developmental changes of GFR, maintenance fluids, and normal blood volumes.
7.
Discuss pediatric physiology of the hematologic system, including normal values, fetal
hemoglobin oxygen dissociation curve, sickle cell anemia, thalassemia, transfusion therapy, and
hemophilia.
8.
Discuss pediatric physiology of glucose homeostasis, NPO guidelines, and GFR.
9.
Discuss pediatric physiology of temperature regulation, including heat loss during
anesthesia, non-shivering thermogenesis, and heat conservation.
Preoperative Preparation
1.
Demonstrate knowledge and aptitude in pre-anesthetic evaluation and preparation for
surgery, i.e., preoperative fasting, routine laboratory tests, psychological preparation and
pharmacological premedication.
2.
Discuss management of routine and complex preoperative problems, including the infant
with an upper respiratory infection, pre-anesthetic labs, heart murmur, difficult airways,
mediastinal mass, and outpatient surgery and the ex-premature infant.
3.
Understand the psychological aspects of pediatric anesthesia, including separation anxiety,
body image, psychological preparation of the toddler and adolescent.
4.
Discuss pediatric sedation techniques, via the oral, nasal, transmucosal, IM, IV and rectal
routes.
5.
Demonstrate knowledge of common preexisting medical conditions (such as anemia, RDS
& BPD, hemophilia, diabetes mellitus, cystic fibrosis, asthma, upper respiratory tract infection,
etc.) and their anesthetic implications.
Case Management
1.
Demonstrate understanding of pediatric outpatient anesthesia, specifically its advantages,
patient selection, pre-anesthetic evaluation and instructions, anesthetic techniques, recovery, and
discharge criteria.
2.
Demonstrate the proper use of pediatric anesthesia circuits, based on an in-depth
understanding of their classification, and facility with pediatric mechanical ventilation.
3.
Demonstrate understanding and application of the general principles of pediatric
pharmacology, including dosage formulas for children, administration of inhalational anesthetic
agents (uptake, elimination, induction, emergence, etc.), intravenous agents (induction,
maintenance, antagonists), muscle relaxants (neuro-muscular physiology, depolarizing relaxants,
nondepolarizing relaxants, reversal), anticholinergic drugs, and medications for treating postNational Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 199
operative analgesia.
4.
Discuss pediatric induction techniques, including inhalation, IM, IV, rectal and the use of
induction rooms.
5.
Define appropriate endotracheal tube size and insertion depth.
6.
Describe different blade options for pediatric intubation.
7.
Recognize and define alternatives in management of difficult/problematic airways, e.g.
Pierre-Robin, pyloric stenosis, foreign body aspiration, etc.
8.
Discuss pediatric regional anesthesia, including caudal, ilioinguinal, iliohypogastric and
penile nerve blocks.
9.
Discuss management of routine and complex operative problems, including masseter
spasm, epiglottitis, croup, foreign body aspiration, pyloric stenosis, post-tonsillectomy hemorrhage,
omphalocele, gastroschisis, tracheoesophageal fistula, diaphragmatic hernia, meningomyelocele,
and elevated intracranial pressure.
10.
Demonstrate understanding of fluid replacement therapy and calculate estimated blood
volume and allowable blood loss.
11.
Demonstrate understanding of the general principles of pediatric neurosurgery and apply
them to the control of ICP, posterior fossa surgery, hydrocephalus, meningomyelocele, head
trauma, craniosynostosis, and neurodiagnostic procedures.
12.
Demonstrate understanding of the principles of correction for lesions such as PDA, aortic
coarctation, atrial septal defect, ventricular septal defect, tetralogy of Fallot, transposition of the
great vessels, and total anomalous pulmonary venous drainage.
13.
Explain the proper use of antibiotic prophylaxis for the patient with cardiac disease.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
2.
3.
4.
5.
6.
Discuss with patients and family members the advantages and disadvantages of the different
anesthetic options.
Establish good rapport with patients and families, addressing patient and family concerns
and anxieties.
Create and sustain a therapeutic and ethically sound relationship with patients.
Use effective listening skills to elicit appropriate clinical information.
Work effectively with others in the interdisciplinary health care team.
Establish working relationships with operating room staff, surgeons, resident and attending
anesthesiologists.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 200
Objectives:
1.
Demonstrate respect, compassion, and integrity, responsiveness to the needs of patients
and society that supersedes self-interest, accountability to patients, society, and the
profession, and a commitment to excellence and on-going professional development
2.
Demonstrate a commitment to performing duties as a physician and medical professional.
3.
Demonstrate a consistent work ethic.
4.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
5.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
6.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and
disabilities.
7.
Demonstrate accountability to patients, colleagues and institution.
8.
Demonstrate the integrity of a medical professional and a commitment to excellence and
ongoing professional development.
Practice Based Learning
Goal:
Residents must investigate and evaluate their patient care practices and appraise and assimilate
scientific evidence to improve patient care.
Objectives:
1.
2.
3.
4.
Locate, appraise, and assimilate evidence from scientific studies related to pediatric
anesthesia.
Synthesize medical information from texts, lectures, and journal articles and apply this
information to the care of pediatric patients.
Apply knowledge of study designs and statistical methods to the appraisal of clinical studies
and other information on diagnostic and therapeutic effectiveness
Use information technology to manage information, access on-line medical information,
and support their education.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
2.
3.
4.
5.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and society as a whole.
Understand the healthcare system as it relates to pediatrics and pediatric anesthesiology.
Practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
Practice cost-effective health care.
Advocate for quality patient care and assist patients in dealing with system complexities.
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6.
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Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance
III. REQUIRED READING
1.
Pediatric Anesthesia, Chapter 82, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
A Practice of Anesthesia for Infants and Children, 4th edition, Charles J. Cote, Jerrold
Lerman, I. David Todres. WB Saunders, 2008.
3.
Gregory’s Pediatric Anesthesia. George A. Gregory and Dean Andropoulos. Wiley and
Blackwell. 2011.
IV. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and based upon review of the written evaluation from Children's National Medical Center.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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PROGRAM GOALS AND OBJECTIVES FOR
SENIOR RESIDENTS IN TRAUMA
ANESTHESIA
I. ROTATION DEFINITION
The purpose of this rotation is to provide residents with a focused exposure to the preoperative
and intraoperative care of the acutely injured patient. This rotation meets the RRC requirement
for trauma and is designed to train residents for their unique role as military anesthesiologists.
As a military anesthesiologist, residents may be deployed to remote locations at any time. The
importance of meaningful trauma anesthesia training cannot be overemphasized. Currently the
training is conducted either at the Washington Hospital Center in Washington, DC or the
University of Maryland’s Shock Trauma Unit in Baltimore, MD. Both locations are designated
as level I trauma centers by the American College of Surgeons. This is a one month rotation in
the Trauma Resuscitating Unit/Operating Theater. Residents will be an active member of the
trauma team. They will learn the basic principles of trauma care and how to develop a plan for
the trauma patient.
II. ACGME CORE COMPETENCIES
Residents will be expected to demonstrate competence in the six ACGME general competencies
as outlined below. Evaluations will be used to assess their progress in attaining these goals and
also to promote continuous learning.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
4.
5.
6.
Perform an appropriate evaluation, including history, physical exam and laboratory
studies when needed.
Demonstrate the basic skills necessary for triage and care of acute trauma patients.
Manage patients with acute traumatic injuries undergoing diagnostic workups and
surgery.
Perform preoperative patient assessment and formulate an anesthetic plan using sound
medical knowledge and judgment.
Provide safe, efficient, and compassionate care to trauma patients.
Manage induction, maintenance, and emergence of both simple and complex trauma
cases.
Objectives:
1.
2.
Demonstrate detail-oriented systems based management of trauma patients.
Demonstrate proficiency with the placement of intravenous lines (internal jugular,
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
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subclavian, femoral).
Demonstrate proficiency with the placement /interpretation of CVP and PA catheter data.
Demonstrate proficiency with placement of arterial lines (radial, axillary, femoral,
dorsalis pedis).
Perform initial assessment and stabilization of trauma patients.
Perform appropriate assessment and airway management in trauma patients with
emphasis on:
a.
Initial assessment and indication for airway control.
b.
Cervical spine evaluation.
c.
Alternate intubation techniques.
Demonstrate various methods of respiration/ventilation including advanced modes of
ventilation.
Manage respiratory failure including ARDS.
Demonstrate effective cardiopulmonary resuscitation.
Evaluate and manage increased ICP and other neurological emergencies.
Evaluate and manage oliguria and renal failure.
Evaluate and manage massive bleeding and transfusion.
Evaluate and manage the patient in hypovolemic, cardiogenic, neurogenic and septic
shock.
Demonstrate the use of the Rapid Infusion System.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
1.
2.
3.
4.
Apply relevant scientific knowledge and reasoning to the practice of trauma anesthesia.
Understand the pathophysiology of traumatic injuries and their impact upon anesthetic
management.
Understand the pharmacology of anesthetic agents and their impact upon trauma
pathophysiology.
Understand the principles and the endpoints of resuscitation in trauma patients.
Objectives:
1.
2.
3.
4.
5.
6.
7.
Describe trauma team organization and dynamics.
List and explain the priorities of ATLS management.
Discuss the benefits and limitation of trauma scoring systems and the Glasgow coma
scale.
Explain the principles of volume status assessment in trauma patients.
Describe the pathophysiology of trauma with an emphasis on:
a.
Cardiovascular physiology.
b.
Traumatic brain and spinal cord injury.
c.
Pelvic and long bone fractures.
d.
Thoracic aorta injuries.
Identify the priorities in acute resuscitation and define the end points of resuscitation.
Discuss the pros and cons of volume/pressure limited vs. full resuscitation.
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Goals and Objectives
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8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
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Compare and contrast the use of crystalloid (hyper and isotonic) and colloid fluids in
trauma resuscitation.
List transfusion criteria for blood and blood products with an emphasis on the application
in acute trauma.
Identify the role of Anesthesiologists in airway assessment in the Trauma Resuscitation
Unit.
Describe the algorithm for emergency airway management.
State the goals and methods of evaluation of an acute traumatic abdomen.
List and justify the considerations for urgent (non-emergent) surgery.
Define the role of regional anesthesia in trauma care.
List various techniques for general anesthesia for trauma.
Discuss the considerations regarding the decision to extubate a patient.
Summarize the principles of operative management of acute spinal cord injury.
Define the principles for operative management of major orthopedic cases.
Describe the operative management of patients with traumatic brain injury.
Discuss and defend the management principles for cardiovascular, pulmonary and renal
failure in the ICU and OR.
Define the management principles of sepsis and sepsis syndromes in the ICU and OR.
State the principles and methods of routine prophylaxis for
a.
DVT.
b.
Gastritis / stress ulceration.
c.
Delirium tremens.
Formulate and justify a management plan for septic shock.
Define the nutritional goals and techniques for ICU patients.
State the rational for advanced ventilatory management and define the use of APRV,
noninvasive positive pressure ventilation and prone positioning
Describe the techniques used in escalating management for severe traumatic brain injury
(TBI).
Summarize the basics of oxygen delivery and utilization, with particular emphasis on the
systemic inflammatory response syndrome and multi-organ system failure.
Interpersonal Skills and Communication
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, patients’ families, and professional
associates.
Objectives:
1.
2.
3.
4.
Discuss with patients and family members the advantages and disadvantages of the
different anesthetic options.
Establish and sustain a therapeutic and ethically sound relationship with patients and
families, addressing patient and family concerns and anxieties.
Establish collaborative working relationships and effectively communicate with operating
room staff, surgeons, residents and attending anesthesiologists.
Work as part of an anesthesia care team.
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Professionalism
Goal:
Residents must demonstrate a commitment to professional responsibilities, adherence to ethical
principles, and sensitivity to diverse patient populations.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate responsiveness to the needs of patients and society that supersedes selfinterest as well as accountability to patients, society, and the profession.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate respect to patients, families, and operating room staff.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and
disabilities.
Practice Based Learning
Goal:
Residents must investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices.
Objectives:
1.
2.
3.
4.
Use information technology to manage information, access on-line medical information
and support their education.
Locate, appraise, synthesize, and assimilate medical information from texts, lectures, and
journal articles, and apply this information to the care of trauma and critically injured
patients.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
National Capital Consortium Anesthesiology Residency
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optimal value.
Objectives:
1.
2.
3.
4.
5.
Understand the integration of the health care system as it relates to trauma, critical care
and anesthesiology.
Understand the resources and patient flow from the point of injury, to diagnosis and
triage in the trauma resuscitation unit, through the intraoperative period, and to the postoperative phase either in the ICU or on the hospital ward.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
Practice within the context of the health care institution and in cooperation with other
health care professionals.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
Anesthesia for Trauma, Ch 72. Anesthesia, 7th edition, Ronald Miller Ed. Churchill Livingston,
2010.
IV. EVALUATION
All residents will be evaluated by the faculty. At the completion of the resident’s rotation, a
summary evaluation will be prepared and submitted to the Clinical Competence. The summary
clinical evaluation will include input from all faculty staff with whom the resident worked during
the rotation.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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PROGRAM GOALS AND OBJECTIVES FOR
CA-3 RESIDENTS AS CLINICAL TEACHING CHIEFS
I. ROTATION DEFINITION
This rotation is a one month block for CA 3 residents at WRB. During this rotation, residents will
function as educators and be tasked with teaching medical students, residents and faculty. The
teaching chief resident will also take part in managing the clinical schedule and participating in
administrative staff meetings related to the operation of an Anesthesia Department.
Learning to function as an educator is necessary for anesthesiologists. Graduates must be able to
educate not only patients but also non-anesthesiologists about the risks of anesthesia and the risks
patients face when receiving anesthesia. In addition, being able one’s self is a key part of practice
based learning. This one month rotation is mostly focused on helping residents to assimilate new
material, convey an understanding of it, and help incorporate it into everyday practice. Residents
will be primarily responsible for preparing the material for the department’s weekly academic day.
The teaching chief resident will be responsible for creating a lecture and a quiz based on the
assigned reading for the week. They will also be responsible for picking 1-2 articles for a journal
club discussion. The teaching chief will assign them to another resident and will mentor them in
presenting the article. Each week there will be one core faculty member assigned to aid the
teaching chief in completing the task.
Advanced training in systems based practice is critical to our specialty, especially since it is not
uncommon for military anesthesia residency program graduates to be placed in a department head
position immediately upon graduation. A goal of this rotation is to prepare the newly graduated
anesthesiologist to manage the more common clinical and administrative problems encountered as
the leader of an anesthesiology department. The abrupt assumption of such a responsibility may be
overwhelming. Although many of the clinical issues are covered in residency, there are several
administrative, managerial and leadership topics that are equally as important but not covered as
thoroughly.
The suggested schedule is as follows:
 Monday – prepare quiz and lecture, pick out 1-2 articles related to the topic of the week
 Tuesday – quiz due to core faculty preceptor of the week by 1600
 Wednesday – lecture due to core faculty preceptor by 1600
 Thursday – Teaching chief will serve as assistant to the medical director (commonly
referred to as the floor runner) until academic day commences at 1300. Responsibilities will
include attending scheduling meetings, creating a work schedule, facilitating emergent case
completion or schedule changes.
 Friday – Serve as assistant to the medical director.
II. GOALS AND OBJECTIVES
Residents will be expected to demonstrate competence in the six ACGME general competencies as
outlined below. Evaluations will be used to assess their progress in attaining these goals and also
to promote continuous learning. At the end of this rotation residents will be expected to meet the
following objectives:
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Patient Care
Goal:
Residents must provide patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health.
1.
Understand the standards for pre-anesthesia care.
2.
Understand the current Practice Guidelines for Pre-anesthesia Evaluation and the Practice
Guidelines for Preoperative Fasting.
3.
Serve as a staff anesthesiologist for junior residents on various types of cases.
Objectives:
1.
2.
3.
4.
5.
6.
Participate in monthly Quality Assurance meetings.
Participate in OR management decision-making.
Make daily staffing assignments for residents and medical students.
Function as the staff anesthesiologist for junior residents on simple and complex cases.
Deliver lectures to medical students.
Participate in the development of simulator teaching material.
Medical Knowledge
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
2.
Understand current benchmark practices in anesthesia and clinical care.
Understand the Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists
and the Continuum of Depth of Sedation, Definition of General Anesthesia and Levels of
Sedation/Analgesia.
Objectives:
1.
Define leadership and distinguishing it from management.
2.
Compare and contrast different leadership styles (e.g., authoritarian, coercive, coaching,
passive, etc.).
3.
Understand the typical hospital organizational structure and function.
4.
Understand the role and function of an Anesthesia Department Head.
5.
Understand standard performance benchmarks for ORs and clinics.
6.
Understand the basics of core and supplemental privileging for anesthesiologists and nurse
anesthetists.
7.
Understand the implementation of sedation policies.
8.
Understand the JCAHO accreditation process.
9.
Understand the Pharmacy and Therapeutics Application Procedures.
10.
Understand the Quality Assurance process.
Interpersonal Skills and Communication
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Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates. During the teaching chief month residents will be presenting material at the weekly
academic day conference. Residents will also serve as assistant to the medical director and will
need to show strong communication skills to facilitate efficient operation of the OR at WRNMMC.
Objectives:
1.
2.
3.
Establish and sustain a therapeutic and ethically sound relationship with patients and
families, addressing patient and family concerns and anxieties.
Establish good collaborative working relationships and effectively communicate with
operating room staff, surgeons, junior residents and attending anesthesiologists.
Work as part of an anesthesia care team.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
2.
3.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate a responsiveness to the needs of subordinates, patients and society that
supersedes self-interest, and accountability to patients, society, and the profession.
Demonstrate a consistent work ethic and be a role model for junior residents and medical
students.
Practice Based Learning
Goal:
Residents investigate and evaluate their patient care practices and appraise and assimilate scientific
evidence to improve patient care. Residents are expected to:
Objectives:
1.
2.
3.
Use information technology to manage information, access on-line medical information,
and support their education.
Locate, appraise, synthesize, and assimilate, medical information from texts, lectures, and
journal articles, and apply this information to the leadership and management of an
Anesthesia Department.
Make informed decisions about diagnostic and therapeutic interventions based on patient
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Goals and Objectives
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PAGE 210
information and preferences, up-to-date scientific evidence, and clinical judgment
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
2.
3.
4.
5.
Understand the integration of the health care system as it relates to anesthesiology.
Understand the concept of the Anesthesia Care Team.
Understand the Guidelines for Delineation of Clinical Privileges in Anesthesiology.
Understand the Organization of an Anesthesia Department.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and describe these activities impact upon system performance
III. REQUIRED READING
Weekly assigned reading and other material assigned by core faculty preceptor of the week.
IV. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and will be based on the written evaluations provided at the completion of this rotation.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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PROGRAM GOALS AND OBJECTIVES FOR
CA-3 RESIDENTS IN OPERATIONAL ANESTHESIA
AND HUMANITARIAN MISSIONS
I. ROTATION DEFINITION
The Operational Anesthesia rotation for the National Capital Consortium is designed to introduce
residents to basic concepts in preparation and implementation of anesthesia care in austere
environments. The rotation is one month in length and consists of planning and deploying in
support of a 2 week Operational Anesthesia mission, and upon return writing a paper and
presenting that experience to the NCC Anesthesiology Program. During this rotation the resident
will function under the supervision of a staff anesthesiologist. These missions will be facilitated
through educational affiliations with private non-profit organizations that will manage many of
the logistical considerations. During the preparation and deployment phase the resident will
utilize contacts in these organizations to more fully understand the logistical considerations
involved in the overall planning of such operations.
II. GOALS AND OBJECTIVES
The goal of the Operational Anesthesia Rotation is to provide direct support to the 1998 Military
Unique Graduate Medical Education Program for Anesthesiology which states that:
The future of military medicine depends upon our ability to produce a unique product; a more
capable, flexible medical professional who will perform the mission under any and all
conditions during peacetime or war. Today‟s military is being asked to deploy in an
increasing range of operational scenarios. Rather than a reduced schedule to match the rapid
downsizing, the operational tempo has dramatically increased and military medical
departments are deploying alongside to provide healthcare support in a wide variety of
situations.
Military medicine is faced with three competing imperatives. We must learn to
balance the very different requirements of peacetime healthcare, humanitarian
missions and combat support operations, each of which has a unique mix of
personnel, equipment, and medications. These tasks, while competing, do not
stand in isolation. Indeed, none can exist without the others. Like legs of a threelegged stool, they support each other and combine to make a stable platform.
Training and care provided in one area is intricately linked with and ultimately
enhances the ability to provide care in all aspects of our healthcare system.
Military medical readiness is more than being fit or putting on a uniform.
Medical readiness implies the ability to perform any mission, anytime, anywhere.
First and foremost, our job is to keep the fighting forces healthy, fit and ready to
go to war. If that can be better achieved through the civilian healthcare system,
military medicine can pack its bags and go home. We know historically, however,
that as soon as our troops deploy, we will be alongside, providing both immediate
and ongoing medical care, working to prevent illnesses and standing by to
provide combat casualty care. To be ‘ready’, military medical professionals must
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be, first and foremost, competent in their chosen field. In addition, they must have
three elements of training above and beyond that of their civilian counterparts.
These include:
1) Specialized medical training in such areas as Weapons of Mass Destruction
(WMD), field sanitation, 3rd world endemic diseases and the like.
2) Operational experience/exposure so they understand the environment and
conditions under which they will work. What drugs and equipment do they have
and what don’t they have? How do they handle austere conditions in the field,
aboard ship or in a host nation hospital?
How does one overcome poor
communications, limited triage and transport capabilities and what unique
threats must be considered? Our providers must understand their capabilities
and their limitations.
3) Doctrinal training so they understand the system under which they work; why
they are there and how they operate in conjunction with their line counterparts.
Further, there must be some understanding of working within a joint environment,
not only with our sister services, but with host nations, governmental and nongovernmental organizations, allies, coalition partners, etc.
Currently, the academic training centers do an excellent job in training for peacetime care.
However, the functional capability of providing realistic equipment training for austere
environments is limited due to clinical and regulatory pressures. In addition, the current training
does not effectively train residents for the care of surgical patients in situation of professional
isolation and reduced logistical support. By collaborating with organizations with worldrenowned excellence in humanitarian assistance and austere medicine, residents will be able to
gain realistic training and insight into the difficulties of planning and executing deployment
missions and establish a list of core reference and modular training units that should be available
to the faculty and residents of the National Capital Consortium Anesthesiology Residency.
Residents will be expected to demonstrate competence in the six ACGME general competencies
as outlined below. Evaluations will be used to assess their progress in attaining these goals and
also to promote continuous learning.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
Perform an appropriate evaluation; including history, physical exam and laboratory
studies when needed.
Perform preoperative patient assessment and formulate an anesthetic plan, using sound
medical knowledge and judgment.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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PAGE 213
3.
4.
Provide safe, efficient, and compassionate care.
Manage induction, maintenance, and emergence of both simple and complex cases.
Objectives:
1.
Regional anesthesia for anesthesia and post-operative pain management in the austere
environment.
2.
Field anesthesia machines, ventilators, monitors, oxygen concentrators and other
equipment unique to the austere environment.
3.
Volatile anesthesia without nitrous oxide.
4.
Equipment modifications:
a. Ventilator modification to use compressed air as the drive gas.
b. Logistical management to maximum benefit.
c. Non-disposable sterilization techniques.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
2.
Apply relevant scientific knowledge and reasoning austere environments.
Understand the use of field anesthesia machines with limited resources (electricity and
oxygen).
Objectives:
1.
Preparation for deployment or individual travel to medically high threat areas, including:
a. Medical threat estimation.
b. Developing basic Preventive Medicine policies applicable to mission success. c.
Individual travel medicine consultation.
2.
Describing the clinical presentation, transmission mechanisms, and preventive measures for
endemic infectious.
3.
Describing food and water sanitation in an austere environment.
4.
Explain the appropriate use of regional nerve block techniques to extend capabilities in a
mass casualty situation or to minimize risk in austere environments.
5.
Describe to extend capabilities under austere conditions and the risks/benefits of
TIVA.
6.
Discuss the advantages and disadvantages of general anesthesia with spontaneous
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ventilation with respect to compressed gas requirements of field anesthesia machines and
patient safety.
7.
Discuss the impact of environmental factors on equipment performance and describe the
reduction of adverse effects.
8.
Discuss challenges to the implementation of universal precautions in the austere
environment.
9.
Discuss methods for sterilization and decontamination of reusable medical equipment in the
austere environment.
10.
Explain the pathophysiology, prevention, and management of heat stress and injury in the
austere environment.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients‟ families, and professional
associates.
Objectives:
1.
2.
3.
4.
Discuss with patients and family members the advantages and disadvantages of the
different anesthetic options.
Establish and maintain a therapeutic and ethically sound relationship with patients and
families, addressing patient and family concerns and anxieties.
Establish collaborative working relationships and effectively communicate with operating
room staff, surgeons, residents and attending anesthesiologists.
Work as part of an anesthesia care team.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
2.
3.
4.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
Demonstrate sensitivity and responsiveness to patients‟ culture, age, gender, and
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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5.
6.
7.
PAGE 215
disabilities and display the integrity expected of a medical professional.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
2.
Describe how environmental factors affecting equipment (e.g., heat, cold, pressure, dirt,
sand, etc.).
List the limitations of care in the austere environment.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value.
Objectives:
1.
2.
3.
4.
Explain the integration of humanitarian missions in the health care system of the host
nation.
Explain the resource limitations and the continued capacity to provide excellent care.
Practice resource-effective health care and resource allocation that does not compromise
quality of care.
Practice within the context of the host nation’s medical system and in cooperation with
other health care professionals.
III. REQUIRED READING
1. al-Harby S. The evolving pattern of war-related injuries from the Afghanistan conflict. Mil
Med 161: p163-164, 1996.
2. Bacic A, Gluncic I and Buklijas J. Titrated total intravenous anaesthesia (TIVA) in war. J R
Army Med Corps 142: p103-105, 1996.
3. Bell G and Ralph J. Drawbacks of pushovers. Anaesthesia 55: p1000-1002, 2000.
4. Blood C, Gauker E, Jolly R and Pugh W. Comparisons of casualty presentation and admission
rates during various combat operations. Mil Med 159: p457-461, 1994.
National Capital Consortium Anesthesiology Residency
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5. Casinelli P and Reynolds P. Adapting the Ohmeda UPAC draw-over vaporizer for use in the
modern operating room. Mil Med 159: p600-602, 1994.
6. Doe J. 1. Combat Trauma Overview. In: Anesthesia and Perioperative Care of the Combat
Casualty, edited by Zajtchuk R and Grande C. Falls Church: Office of the Surgeon General,
1995, p. 1-42.
7. Gofrit O, Leibovici D, Shapira S, Shemer J, Stein M and Michaelson M. The trimodal death
distribution of trauma victims: military experience from the Lebanon War. Mil Med 162: p24-26,
1997.
8. Habek D, Ferencak V and Kelava B. Activities of the 105th Croatian Army Brigade Medical
Corps during the 1991-1992 war. Mil Med 161: p537-541, 1996.
9. Hawkins J, Ciresi S and Phillips W. Clinical evaluation of pushover mechanical ventilation
with the Ohmeda Universal Portable Anesthesia Complete vaporizer. Mil Med 163: p164-168,
1998.
10. Jarvis D and Brock-Utne J. Use of an oxygen concentrator linked to a draw-over vaporizer
(anesthesia delivery system for underdeveloped nations). Anesth Analg 72: p805-810, 1991.
11. Koehler R, Smith R and Bacaner T. Triage of American combat casualties: the need for
change. Mil Med 159: p541-547, 1994.
12. Leedham C, Blood C and Newland C. A descriptive analysis of wounds among U.S. Marines
treated at second-echelon facilities in the Kuwaiti theater of operations. Mil Med 158: p508-512,
1993.
13. Lilly J. Considerations on propofol administration in the field anesthesia setting (Echelons II
and III). Mil Med 156: p129-131, 1991.
14. Lunn D and Residentsng P. The Ohmeda Universal PAC drawover apparatus. A technical
and clinical evaluation. Anaesthesia 50: p870-874, 1995.
15. Riley B and Mahoney P. Battlefield trauma life support: its use in the resuscitation
department of 32 Field Hospital during the Gulf War. Mil Med 161: p542-546, 1996.
16. Ropac D and Milas J. Military casualties in Baranja and east Slavonia during the first 9
months of the war in Croatia. Mil Med 164: p643-647, 1999.
17. Saissy J. Simplified use of mixed propofol and alfentanil for anesthesia in remote locations.
Mil Med 165: p195-199, 2000.
18. Tighe S and Rudland S. Anesthesia in northern Iraq: an audit from a field hospital. Mil Med
159: p86-90, 1994.
19. Zajtchuk R and Sullivan G. Battlefield trauma care: focus on advanced technology. Mil Med
160: p1-7, 1995.
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IV. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee and
will be based on the written evaluations provided at the completion of this rotation.
III. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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PROGRAM GOALS AND OBJECTIVES FOR
CA-3 RESIDENTS IN THE CLINICAL SCIENTIST TRACK
I. ROTATION DEFINITION
The rational for the development and implementation of a clinical scientist track is to offer
talented, motivated and dedicated residents the opportunity to pursue research interests and begin
to develop an academic career. This one to six-month block is designed to develop the senior
anesthesiology resident into a clinical/animal researcher with skills sufficient to function at an
entry level in an academic environment.
II. GOALS AND OBJECTIVES:
Patient Care
Goal:
Residents will investigate topics pertinent to patient care in order to grow as physician scientists.
Objectives:
Actively participate in the design, approval, and implementation of at least one clinical or
1.
animal research protocol, which includes the detailed development of the methodology,
participation in the power analysis and statistical plan and involvement in the budget development.
Medical Knowledge:
Goals:
1.
2.
3.
4.
5.
6.
7.
Research Administration - Understand the administrative, logistic, fiscal, and ethical
issues related to the development and implementation of clinical and animal research
protocols.
Research Design – Understand the design of research studies from the simple to the
complex, ranging from case-control studies to fully randomized double blind placebo
controlled studies.
Statistical Analysis – Explain the appropriate statistical approach to empirical data
analysis, including an a priori data configuration that is appropriate to planned statistical
approaches, the differences between inferential and descriptive statistical methods, and
the differences between parametric and nonparametric statistics.
Research Technology – Describe the principles of data acquisition, including
digital/analog data acquisition, sensor development and placement, and computer
acquisition of data.
Writing – Acquire skills in technical writing that facilitate completion of scientific
abstracts and manuscripts suitable for publication.
Human subjects – Describe the principles and design of a human subject participation
protocol and its submission to an Institutional Review Board.
Animal Subjects – Describe the principles and design of an animal research protocol and
its submission to an Institutional Animal Care and Use Committee.
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Goals and Objectives
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8.
9.
10.
11.
12.
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Learn and participate in the techniques used in the research project.
Participate in screening and consenting patients, data collection, and analysis.
Participate in animal management, data collection and laboratory analysis.
Prepare drafts of abstracts, manuscripts and protocols.
Conduct Medline searches for research literary support and the national patent database
for support of new technology transfers.
Objectives:
1.
2.
3.
4.
5.
6.
Describe differences, advantages, and disadvantages of different research designs.
Compare and contrast descriptive and inferential statistics and defend the choice of
applicable statistical tests.
Describe the content and outline of a scientific manuscript.
Appropriately chose and explain the benefits of analytical methods chosen for the
research project.
Explain the process of animal and human protocol approval.
Design and implement a data management plan for a research protocol.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building.
Objectives:
1.
Establish and maintain a therapeutic and ethically sound relationship with patients
and families, addressing patient and family concerns and anxieties.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
2.
3.
4.
5.
6.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
Demonstrate sensitivity and responsiveness to patients‟ culture, age, gender, and
disabilities and display the integrity expected of a medical professional.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
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7.
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confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient‟s culture, age, gender and
disabilities.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care. Residents may use a research rotation to
investigate a question relate to a problem or perceived problem in patient care.
Objectives:
1.
Residents may design a problem based educational/research project.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value. During a research rotation residents may elect to investigate a topic related to systems based
practice.
Objectives:
1.
Use scientific evidence to determine the most effective use of medical resources.
V. CONFERENCES AND LECTURES
RESEARCH DESIGN
1. The Research Question
2. Choosing a Study population
3. Planning Measurements
4. Designing Studies – Cohort Studies
5. Designing Studies – Cross-sectional and Case-control Studies
6. Designing Studies – Experimental Studies
7. Designing Studies – Diagnostic Tests
8. Estimating Sample Size: Hypothesis and Underlying Principles
9. Estimating Sample Size and Power
10. Data Management and Analysis Plan
11. Institutional Review Board and Human Subject Issues
STATISTICS
1. Types of Variables
2. Probability and Normal Distribution
3. Describing Data
4. Exploratory vs. Confirmatory Data Analysis
5. Parametric Statistical Methods
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6. Non Parametric Statistical Methods
7. Analysis of Frequency Data
8. Regression Analysis
WRITING DEVELOPMENT SKILLS
1.
Abstracts
2.
Introduction
3.
Methods
4.
Results
5.
Statistical Methods
6.
Conclusions
7.
References
8.
Tables and Graphs
REVIEW COMMITTEE MEETINGS
1.
2.
3.
4.
Attend monthly Clinical Investigation Committee Meetings.
Attend Institutional Review Board Meetings.
Attend Institutional Animal Care and Use Committee Meetings.
Review specific protocols to be discussed at the monthly meetings.
VI. REQUIRED READING
1..
Zeiger, M. Essentials of Writing Biomedical Research Papers, McGraw Hill, 1991.
2.
Glantz, S.A. Primer of Biostatistics, 4th Ed, New York, McGraw-Hill, 1997.
3.
Hulley, S.B, Cummings, S.R. Designing Clinical Research, Williams and Wilkins, 1988.
4.
Bailar, J.C., Mosteller F. Medical Uses of Statistics, NEJM Books, 1992.
5.
Sackett D.L., Haynes B.R. Clinical Epidemiology, Little, Brown and Co, 1991.
VII. AVAILABLE RESOURCES
LABORATORY INSTRUMENTATION
1.
HPLC
2.
GC
3.
Blood Gas Analysis
4.
Spectrophotometry
5.
Chemiluminescence
6.
ELISA
7.
PCR
8.
Southern Blot
9.
Western Blot
10.
Scintillation Counting
RESEARCH RESOURCES
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The National Capital Consortium has complete accredited research facilities and administration
available to support the conduct of human, animal and basic science research. Departmental
facilities available include 500 sq. ft of space for animal instrumentation and experimentation
and 1000 sq. ft of shared laboratory space with instrumentation listed above.
PARTICIPATING FACULTY
Saiid Bina, PhD
John Capacchione, MD
Richard R. Kyle, MS
Sheila Muldoon, MD
Pushpa Sharma, PhD
Ryan J Keneally, MD
VIII. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and will be based on the written evaluations provided at the completion of this rotation.
IX.
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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PROGRAM GOALS AND OBJECTIVES FOR
CBY/PGY 1 RESIDENTS IN THE GENERAL OPERATING
ROOM
I. ROTATION DEFINITION:
The General Operating Room (GOR) rotation is planned and intended to provide the new
CBY/PGY1 with a basic, broad introduction to the practice of anesthesiology. The knowledge to
be gained, both clinical and cognitive, is in the realms of the basics of anesthesia and general
medicine. Teaching will be divided broadly into three areas: pre-anesthetic assessment,
intraoperative anesthesia management, and post-anesthesia care with an emphasis on skills that
are critical for CBY/PHY1s to develop (e.g. history taking, physical examination, basic
differential diagnosis and test interpretation).
II. GOALS AND OBJECTIVES
The goals of this rotation for beginning CBY/PGY1 residents are to provide a broad perspective of
anesthesia and medicine, such that the trainee should acquire a basic understanding of preanesthetic, intraoperative and post-anesthetic issues, and to prepare residents to advance into
further basic anesthesia rotations where they will be expected to function with lesser supervision.
This will provide residents with experiences in a wide range of surgical procedures requiring
general, regional and monitored anesthesia care. Emphasis will be placed on the basic aspects of
general anesthesia and basic regional anesthetic techniques. The resident will be expected to
evaluate healthy patients (American Society of Anesthesiology physical status I, abbreviated as
ASA ps I), induce and maintain anesthesia (MAC, regional or general anesthesia by mask, ET
tube or LMA) for basic surgical procedures. The resident should be able to plan for and implement
appropriate monitoring, fluid management and post-operative pain management strategies for
ASA I patients.
Patient Care
Goal:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health.
1.
2.
3.
Provide a preoperative patient assessment, and suggest appropriate perioperative
interventions to ensure patient safety and reduce risk for ASA ps I patients
Formulate an anesthetic plan, emphasizing the different needs of the inpatient and
ambulatory patient and integrating general, neuraxial, and peripheral regional
anesthesia techniques to provide optimum patient outcome and satisfaction for ASA ps
I patients.
Provide peripheral and/or neuraxial blocks, sedation or general anesthesia in a
competent and safe manner, providing continuity of care in the operating room, and,
when possible, in the PACU or same-day surgery unit for ASA ps I patients.
Objectives:
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Preoperative Assessment and Preparation
1.
Perform preoperative assessments, utilizing appropriate consultations, to prepare ASA ps
I patients for surgery.
Prescribe appropriate preoperative medications for patients with diabetes or at risk for
aspiration pneumonitis.
2.
Airway Management
1.
2.
3.
Manage airways of normal patients utilizing face masks, laryngeal mask airways, oral
airways, and endotracheal tubes.
Perform elective fiberoptic intubation on patients with normal airways under general
anesthesia.
Perform awake intubations with assistance.
Anesthesia Equipment and Monitoring
1.
2.
3.
4.
5.
6.
7.
8.
Perform a checkout of the anesthesia machine and related equipment.
Assemble and organize appropriate equipment for general, regional or MAC anesthesia
for patients undergoing basic surgical procedures.
Determine and apply standard monitoring for healthy patients.
Obtain and maintain venous access.
Apply appropriate monitoring devices and describe the risks and benefits of invasive
monitoring.
Assemble equipment necessary for placement of arterial and central venous pressure
lines.
Insert arterial lines when indicated.
Prepare and position a patient for central line placement (IJ or SC) while developing the
skills required for placement of central lines via either route.
General Anesthesia
1.
2.
Induce and maintain general anesthesia in ASA ps I patients with direct staff
direction.
Conduct general anesthetics with inhalational, balanced and TIVA techniques for ASA ps
I patients.
Regional Anesthesia Techniques
1.
2.
Initiate spinal or epidural anesthetics and manage the patient intra-operatively.
Perform regional anesthesia to the upper extremity, correctly selecting equipment and
medications.
Sedation Techniques
1.
Manage deep sedation for brief surgical procedures for ASA ps I patients.
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Intraoperative Management
1.
2.
3.
4.
5.
6.
7.
8.
Maintain normal levels of O2 or CO2 through proper management of ventilation.
Assist in properly positioning patients.
Accurately complete the anesthetic record for ASA ps I patients undergoing basic surgeries
or procedures.
Demonstrate communication and teamwork in the operating room.
Select, modify and prepare the appropriate endotracheal tubes for laser surgery.
Appropriately manage intraoperative fluid and transfusion therapy.
Modify the anesthetic gas mixture to minimize the risk of fire in airway laser procedures.
Perform jet ventilation for laser cases performed without an endotracheal tube.
Post-operative Management
1.
2.
3.
Safely conduct the patient to PACU and communicate the patient’s condition to personnel
responsible for post-operative care of the patient.
Prevent or treat post-operative nausea and vomiting with appropriate doses of antiemetics.
Institute appropriate post-operative analgesia for patients undergoing surgery with
minimal to moderate pain.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of anatomy, physiology and basic pathophysiology
and the application of this knowledge to patient care.
1.
2.
3.
4.
Understand common medical diagnoses (e.g. congestive heart failure, chronic obstructive
pulmonary disease, diabetes, hypertension, etc.).
List important considerations for basic surgical procedures, and how anesthetics can be
tailored to meet these requirements.
Describe the use of multimodal analgesia, in particular the use of TIVA and regional
blocks, and how this technique contributes favorably to the goals of anesthesia.
Discuss complications of anesthesia that can lead to unplanned admissions, and strategies
to avoid or treat these complications.
Objectives:
Preoperative Assessment and Preparation
1.
2.
3.
4.
5.
6.
Describe the ASA classification system.
Describe appropriate pre-anesthetic medication for an ASA ps I patient.
Discuss methods of preparing patients with IDDM for anesthesia.
Describe implications of patients on steroids undergoing anesthesia.
Discuss the appropriate evaluation and management of patients with hypertension,
coronary artery disease or pulmonary disease presenting for surgery as per the
American Heart Association/American College of cardiology’s guidelines.
Assess and categorize patient’s airways into the appropriate classification.
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Airway Management
1.
2.
3.
4.
5.
6.
7.
Recognize indications for rapid sequence or awake intubations and discuss the methods
of each.
Describe the innervation of the upper airway, larynx and trachea.
Describe topical anesthesia of the airway for awake intubation.
Summarize the “ASA Difficult Airway Management Algorithm.”
Review the anatomy of the cricothyroid membrane.
Describe needle cricothyrotomy.
Compare the pressure required for transtracheal ventilation in adults and children using a
jet ventilator.
Anesthesia Equipment and Monitoring
1.
2.
3.
4.
5.
6.
7.
8.
List and describe the safety features found on modern anesthesia machines.
Describe the function and use of the components of an anesthesia machine, including
flow meters, vaporizers, and gas sources.
List and describe the components of an adult circle system and anesthetic ventilator,
identifying appropriate settings for an adult patient.
Identify the data available from noninvasive monitoring and the complications that can be
identified from such monitoring.
List the “Standards for Basic Anesthetic Monitoring.”
Identify the indications (patient conditions and surgical procedures) for invasive
monitoring, particularly arterial line and central venous line placement.
Describe the relative anatomy, techniques for placement and complications of CVP lines.
Describe the relative anatomy, techniques for placement and complications of arterial
lines.
Anesthetics and Adjuncts
1.
2.
3.
4.
Describe the basic pharmacology of commonly used inhalation anesthetics, local
anesthetics, muscle relaxants, and intravenous agents.
Discuss cost-benefit analysis of various narcotics, muscle relaxants and intravenous
drugs.
Describe the basic pharmacology of local anesthetics, including the properties
determining onset, duration, potency and toxicity.
Describe the basic pharmacology of commonly used vasopressors, antimuscarinics,
neuromuscular blocking agent antagonists, and B-blockers.
Regional Anesthesia Techniques
1.
2.
3.
4.
Plan and select equipment and local anesthetic agents for basic regional anesthetic
procedures; select and defend these choices for surgical procedures based on
duration, location and severity of illness of the patient.
Describe the anatomy pertinent to the performance of spinal, epidural or axillary block.
Describe the pharmacology and clinical use of common local anesthetics for spinal and
epidural anesthesia.
Describe physiological effects and treatment of side effects related to spinal and epidural
anesthesia.
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Sedation Techniques
1. Discuss safe management of minimal, moderate and deep sedation.
Intraoperative Management
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
List the purposes of an anesthesia record and discuss its use.
Describe physiologic effects of hypothermia and discuss methods of prevention in the
operating room.
Describe patient injuries related to anesthesia and methods of prevention.
Describe proper patient positioning and prevention of injuries in the supine, lateral and
lithotomy positions.
Discuss the following implications of lasers used in procedures:
a. Review the risks of laser energy.
b. Apply safety principles applicable to laser airway surgery.
c. List the advantages and disadvantages of different endotracheal tubes as they
pertain to laser surgery.
d. Formulate a safe anesthetic plan for airway laser surgery.
e. Summarize a plan of action for management of airway fires.
Plan the anesthetic management, including patient monitoring, for fiberoptic and rigid
bronchoscopy.
Explain the principles of venturi jet ventilation during laser airway surgery via a rigid
bronchoscope or laryngoscope.
Discuss apneic oxygenation and the subsequent rate of rise of PaCO2 during its use.
Discuss complications common during orthopedic surgery as pertaining to pneumatic
tourniquets, fat embolism, methylmethacrylate, and etiology of deep venous
thrombosis.
Discuss risks of anesthesia practice pertaining to anesthesiologists.
Describe the perioperative fluid management for an ASA I or II adult undergoing
abdominal and peripheral surgeries with minor to moderate blood loss.
List the indications for and complications of blood transfusions.
Describe the elements of autologous blood programs, including pre-operative autologous
pre-donation, acute normovolemic hemodilution, and cell salvage.
Describe the physiologic changes and complications associated with laparoscopic
surgical procedures.
Post-operative Management
1.
2.
List common problems in the PACU.
Compare and contrast post-operative pain control strategies, including patient controlled
analgesia (PCA) with different opioids, subarachnoid opioids, epidural analgesia,
continuous peripheral nerve catheters, intraarticular local anesthetic and opioid
injections, and non-steroidal anti-inflammatory drugs (NSAIDS).
Interpersonal Skills and Communication
Goal:
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Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
2.
3.
4.
5.
Discuss with patients the utility and advantages, as well as potential disadvantages, of the
different forms of anesthesia and analgesia for basic surgical cases.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
Articulate the anesthetic plan to the attending anesthesiologist and explain the rationale
for the plan.
Conduct post-operative visits for inpatients to evaluate patient satisfaction and determine
the incidence of undesirable effects of the anesthetic.
The resident must be sensitive to patient concerns about awareness and pain.
Professionalism
Goal:
Residents must demonstrate a commitment to fulfilling professional responsibilities, adherence
to ethical principles, and sensitivity to a diverse patient population.
Objective:
1.
2.
3.
4.
5.
Interact with staff anesthesiologists, CRNAs, PACU nurses, and operating room staff in a
manner that reflects interpersonal respect, integrity and commitment to excellence in
patient care.
Manage interpersonal conflict with dignity and in a manner that avoids offensive
behavior and reflects emotional maturity.
Protect patient confidentiality.
Maintain a respectable appearance.
Consult the surgical team and attending anesthesiologist when questions arise as to the
appropriateness of an anesthetic technique or about the nature of the planned
procedure, fostering an atmosphere of collegiality, facilitating the development of a
plan which best serves the interest of the patient.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care, evaluate scientific evidence,
and assimilate both to improve their patient care practices.
Objectives:
1.
Review the success of every anesthetic case performed and, should problems occur, use
appropriate resources to address those problems to improve the quality of care.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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2.
3.
4.
PAGE 229
Keep an accurate case log to document clinical experiences.
On a daily basis evaluate the shortcomings, complications and patient satisfaction of their
anesthetic care. Discuss these observations with staff and rotation directors to
develop a plan for improving the quality of anesthetic care provided.
Participate in simulated oral board scenarios, drawing upon knowledge gained from
clinical experience and the readings, and communicate safe pre-, intra- and postoperative management of all forms of anesthesia and their potential complications in
complex situations.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1. Analyze those factors that may optimize PACU throughput.
2. Assess causes of failure to achieve PACU discharge in less than 60 minutes, modifying
care to improve their success in this area.
3. Evaluate patient feedback to facilitate identification of problems in anesthesia care and
creation of potential solutions to improve both patient care and patient satisfaction.
4. Develop an understanding of the use of Anesthesia Coding guidelines as a measure of
productivity
III. REQUIRED READING
1.
1.
Clinical Anesthesiology, 4th edition, G. Edward Morgan, Maged S. Mikhail, Michael J.
Murray Ed. McGraw Hill, 2005.
IV. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and will be based on the review of evaluations from the faculty.
ROTATION EVALUATION
At the completion of the rotation, the residents will evaluate the training experiences. The
evaluation will include their assessment of:

Educational experience.

Caseload diversity and volume.

Strengths and weaknesses of the rotation.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
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Goals and Objectives
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PAGE 231
PROGRAM GOALS AND OBJECTIVES FOR
CA-1 RESIDENTS IN SURGICAL CRITICAL
CARE
I. ROTATION DEFINITION
The Surgical Critical Care rotation at the National Capital Consortium is designed to introduce
CBY/PGY1 residents to basic concepts in assessment and management in the ICU. This rotation
is at the Walter Reed National Military Medical Center. The critical care medicine rotation at
WRB provides an intensive introduction to the current practice of Critical Care Medicine in a
referral medical center. The Surgical Intensive Care Unit is both a pre and post-surgical care unit
with an average census of twelve to fifteen patients. Patients with a broad spectrum of pathology
and pathophysiology are treated here. Advanced physiologic monitoring techniques, mechanical
ventilation, nutritional support, clinical evaluation, and decision making are stressed during the
rotation. Residents assume graduated responsibility for patient care under the supervision of
credentialed critical care attending physicians. The successful completion of the CBY/PGY1
rotation should produce a physician familiar with basic aspects of ICU care.
The importance of having an anesthesiologist involved in the assessment and management of the
critically ill surgical patient has long been recognized. Indeed, the perioperative management
skills demonstrated by anesthesiologists lead to their initial involvement in the formulation and
directorship of early surgical intensive care units (SICUs). Recently, with the increasing amount
of fellowship training in this important area and the arrival of other physicians involved in the
delivery of critical care medicine, the role of the anesthesiologist in the SICU directorship has
diminished as multidisciplinary critical care medicine teams have evolved. Today, most SICUs
are under the directorship of board certified critical care specialists who trained from the base
specialties of anesthesiology, internal medicine, and surgery and have demonstrated both the
interest and expertise in the management of the critically ill patient. With the arrival at many
medical centers of dedicated trained critical care specialists, most departments of anesthesia have
relinquished the responsibility for SICU management to these specialists as the benefits of
having specific physicians dedicated to the delivery of such care is becoming more evident.
The need for anesthesiologists to acquire and to maintain their critical care expertise has never
diminished. The anesthesiologist's responsibilities in the operating room and recovery areas
demand an in-depth knowledge of such diverse topics as mechanical ventilation and weaning,
cardiovascular pharmacology, electrophysiology of the heart, metabolic response to stress, and
the pathophysiology of multi-system organ failure. In recognition of this, the Residency Review
Committee for Anesthesiology mandates that a minimum of four months training within the
environment of the intensive care unit (ICU) be provided as a portion of the core curriculum to
each resident in anesthesiology.
II. GOALS AND OBJECTIVES
The basic goals of the CBY/PGY1 rotation in surgical critical care medicine are to provide the
trainee with a framework of knowledge and skills to provide a rational basis to care of the
critically ill patient. The resident physician will rotate through the SICU under the direction of the
Chief, Surgical Critical Care Medicine Service. Teaching responsibilities and the delivery
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of the core curriculum didactic lecture series will be provided by the designated attending ICU
staff physician and critical care medicine fellow under the guidelines of the Chief, Surgical
Critical Care Service.
A broad perspective of Critical Care Medicine will be provided so that the anesthesiology
residents may achieve a basic understanding of:
1.
2.
3.
4.
5.
6.
The assessment and management of critically ill patients, including post-operative and
severely injured patients.
The use of life support equipment.
The use of vasoactive drugs.
The role of teamwork in the critical care setting.
The socioeconomic, ethical, and legal issues related to critical care.
The unique ethical and moral questions that arise in dealing with critically ill and dying
patients and their families.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
4.
5.
6.
Acquire skill for optimal care of the severely injured and critically ill patient.
Communicate effectively with and demonstrate caring and respectful behaviors when
interacting with patients and their families.
Gather essential and accurate information about their patients.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
Develop and carry out patient management plans.
Counsel and educate patients and their families.
Objectives:
1.
2.
3.
4.
5.
Perform complete histories and physicals on critically ill patients.
Coordinate the care of patients including admission, evaluation, and management
Perform the following procedures:
a. Arterial line placement (radial, femoral)
b. Insertion of a pulmonary artery catheter.
c. Endotracheal intubation.
d. Insertion of subclavian or jugular venous catheters.
Develop communication skills with patients and family members, colleagues, nursing
staff, respiratory therapists, administrative staff, and other support personnel.
Develop proficiency in the delivery of life support activities, including basic and
advanced cardiac life support guidelines as currently recommended by the
American Heart Association.
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Integrated Medical Knowledge
Goals:
Residents must demonstrate knowledge about established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care. Residents are expected to:
1.
2.
3.
4.
Understand new theories and principles of intensive care medicine and their impact upon
the future of ICU care.
List important considerations for surgical procedures, and how ICU care can be tailored
to meet these requirements.
Describe the use of multimodal analgesia and sedation, in particular the use of TIVA, in
the ICU.
Understand the theory and practice of advanced ventilatory management in the ICU.
Objectives:
The CBY/PGY1 resident should gain a basic understanding of the following areas:
Pulmonary
1.
Pulmonary Assessment
a. History.
a. Physical Examination.
b. X-ray interpretation.
c. Pulmonary Function
Testing.
d. ABG interpretation.
e. Pulse oximetry/capnography technology.
f. Bronchoscopy.
2. Respiratory Insufficiency secondary to:
a. Central Apnea.
b. Airway Obstruction.
c. Chronic Obstructive Pulmonary Disease.
d. Pneumonia.
e. Adult Respiratory Distress Syndrome.
f. Pneumo/hemo thorax.
g. Bronchopleural fistulae.
3.
Respiratory Therapy
a. Physical Therapy.
b. Chest physiotherapy.
c. Postural drainage.
d. Fiberoptic bronchoscopy.
e. Oxygen therapy.
f. CPAP.
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4.
Mechanical ventilation
a. CMV.
b. IMV.
c. SIMV.
d. Assist Control.
e. Pressure cycled and volume cycled ventilators.
f. Pressure support.
g. PEEP.
h. Pressure release ventilation.
i. Inverse ratio ventilation.
5. Pharmacologic therapy
a. Bronchodilators (β agonists, methyl xanthines, anticholinergics).
b. Mucolytics (N-acetylcysteine).
c. Antibiotics.
Cardiovascular
1.
2.
3.
4.
Assessment
a. Physical examination.
b. EKG interpretation.
c. Echocardiography interpretation.
d. Stress testing (adenosine/dipyrimidamole thallium testing).
e. Nuclear medicine studies.
Pathology
a. Dysrhythmia recognition and treatment.
b. Ischemia detection, recognition and treatment.
c. Management of hypo and hypertension.
d. DVT/PE prophylaxis, detection and treatment.
e. Congestive Heart Failure.
f. Low cardiac output states.
g. Pericardial tamponade.
h. Aortic aneurysm.
Techniques
a. Peripheral intravenous cannulation.
b. Central venous cannulation (IJ, EJ, subclavian, femoral).
c. Arterial cannulation (radial, brachial, axillary, dorsalis pedis, femoral, etc.)
d. Cardiac pacing (transvenous, transcutaneous).
Pharmacology
a. Antidysrhythmics.
b. Vasopressors (ephedrine, isoproterenol, metaraminol, dopamine, dobutamine,
epinephrine, norepinephrine, digoxin, inodilators, phenylephrine, methoxamine,
etc.).
c. Antihypertensives (nicardipine, sodium nitroprusside, nitroglycerin, hydralazine,
phentolamine, labetalol, propranolol, metoprolol, esmolol, etc.).
Central Nervous System
1.
Determinants of cerebral oxygen consumption, blood flow and intracranial pressure.
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2.
3.
4.
5.
6.
7.
8.
9.
10.
Management of closed head trauma.
Acute care of CVA patients.
Barbiturate-induced coma.
Pre and post-operative care of intracranial aneurysm patients.
Complications of stereotaxic and open neurosurgical procedures.
Glasgow neurologic rating scale.
SIADH.
Acute drug overdose.
Diagnosis of brain death.
Endocrine
1.
2.
3.
4.
5.
6.
Diabetes mellitus (DKA, hyperosmolar coma).
Diabetes insipidus.
Pheochromocytoma.
Addisonian crisis.
Malignant hyperthermia susceptibility.
Thyrotoxicosis.
Fluid, Electrolytes, Nutrition
1.
2.
3.
4.
Enteral nutritional formulae.
Parenteral nutritional formulae.
Determination of respiratory quotient (RQ).
Electrolyte disturbances (pathophysiology and therapy).
Integument
1.
2.
3.
4.
Histology.
Preservation of integrity.
Therapy for disruption of the integument.
Temperature regulation.
Hematologic
1.
2.
3.
4.
Appropriate use of blood and blood products.
Coagulopathies (pathology and therapy).
Disseminated intravascular coagulation (DIC)
Hemolysis (etiologies and therapy).
Renal
1.
2.
3.
4.
Causes, phases and prevention of acute renal failure (ARF).
Indications for renal dialysis.
Diuretics (thiazides, loop, osmotic etc.)
Complications of transurethral resection of the prostate (TURP).
Analgesia
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1.
2.
3.
4.
5.
Regional and neuraxial.
PCA.
IV/IM/transcutaneous opioids.
NSAIDS.
Other (tricyclic antidepressants [TCAs], carbamazepine, etc.).
Ethics
1.
2.
3.
4.
Physician-patient relationships.
Team approach to patient care.
Care of dying patients and their family.
Rational allocation of scarce and expensive resources.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, their patients’ families, and professional
associates.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Take part in discussions with patients and family members the advantages and potential
disadvantages of the different treatment options.
Demonstrate sensitivity to patient concerns about awareness, disability and pain.
Create and sustain a therapeutic and ethically sound relationship with patients.
Use effective listening skills and elicit and provide information using effective nonverbal,
explanatory, questioning, and writing skills.
Efficiently and accurately present patient data on rounds.
Write complete and legible notes in chart.
Effectively relate information to consultants.
Effectively relate information to patients’ families in lay terms, including end of life
discussions.
Work effectively with others as a member or leader of a health care team or other
professional group.
Effectively communicate with nursing, therapists and social workers.
Facilitate the education of medical students and junior residents which is lead by senior
residents and faculty.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
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1.
2.
3.
PAGE 237
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and, a commitment to excellence and on-going professional development.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of
clinical care, confidentiality of patient information, informed consent, and business
practices.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilties.
Practice-Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
1.
1.
2.
3.
4.
Locate, appraise, and assimilate evidence from scientific studies related to their patient’s
health problems.
Obtain and use information about severely ill patients and the larger population from
which their patients are drawn.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
Use information technology to manage information, access on-line medical information,
and support their education.
Facilitate the learning of students and other health care professionals.
Systems-Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
2.
3.
4.
5.
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, society as a whole, and vice versa.
Understand how medical practice and delivery systems differ, including methods of
controlling health care costs and allocating resources.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
Advocate for quality patient care and assist patients in dealing with system complexities.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and understand how these activities affect system
performance.
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III. REQUIRED READING
1.
The ICU Book, 3nd edition, Paul Marino, Williams & Wilkins, 2007.
2.
Distributed articles.
IV. EVALUATION
Final evaluation will be based upon clinical performance. Completion of an ICU rotation in the
CBY/PGY1 trainee requires performance at the level of reporter or greater.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
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GOALS AND OBJECTIVES FOR
CBY/PGY1 RESIDENTS IN ACUTE PAIN
MEDICINE AT WRNMMC
I. ROTATION DEFINITION
Acute Pain Medicine is an essential subsection perioperative care. It is based on the premise that
acute pain is much more than a symptom but rather collection of pathophysiologic processes that
can lead to persistent post-surgical pain. In a multidisciplinary fashion, an anesthesiologist led
acute pain medicine service utilizes a multimodal approach to perioperative pain through
interventional, pharmacologic, and other rehabilitative techniques (physical therapy, psychiatry,
etc). Such a service is extended to both surgical and non-surgical patients.
Regional anesthesia is one of the most power tools an Acute Pain Medicine service provides.
Regional anesthetic administration with local anesthetics prevents nociceptive impulses from
reaching the central nervous system before, during, and after surgical procedures. Advantages of
regional anesthesia include reduced physiologic derangements with surgery, less risk of pulmonary
aspiration (airway reflexes are not obtunded), and the provision of post-operative analgesia.
Preoperatively placed regional anesthetics reduce or prevent up-regulation of central nervous
system nociceptive signaling pathways. Perioperative regional anesthetics allow reduction or
avoidance of general anesthetics during surgery, reducing the toxicities of these systemic
medications. Neuraxial and peripheral anesthetic techniques extended into the postoperative period
reduce adverse anatomic and metabolic responses to surgery. Regional techniques may improve
surgical outcomes, including reducing wound infections and possibly cancer recurrence. For all
these reasons, anesthesiologists must be proficient in their ability to provide regional anesthetics.
This rotation provides an introduction to acute pain medicine and the use of regional anesthetic
techniques for both in- patient and ambulatory surgery. Residents will receive an introduction to
the approach to surgical and non-surgical patients via multimodal analgesic principles.
Residents will receive considerable exposure to the unique requirements of regional anesthesia.
Residents are expected to perform at least 40 peripheral blocks during their residency. While
some patients will only need to be followed until discharge from the PACU, residents will be
expected to follow some patients throughout the duration of their inpatient rehabilitation. This
ensures adequate clinical experience to develop both the motor skills necessary to perform
regional blocks and the cognitive skills to manage patients throughout the perioperative period.
A multidisciplinary approach to acute pain and the advantages of regional anesthetic techniques in
perioperative patient care will be stressed. These include reduction of nausea and vomiting, the
rapid emergence from anesthesia in order to qualify for PACU bypass, and improved perioperative
pain control. The pharmacologic rationale for the selection of local anesthetics, the role of regional
techniques in multimodal pain management, the complications and outcomes of regional anesthesia,
and specifics of many peripheral nerve blocks (including indications, contraindications, pertinent
anatomy and complications for each technique) will be emphasized during the rotation.
In this rotation, residents will focus on developing the necessary motor skills to place peripheral
nerve blocks and learning the principles of safe regional anesthesia. CBY/PGY1 residents are
expected to develop an understanding and familiarity with basic interventional strategies for acute
pain medicine such as include femoral block, sciatic block, popliteal fossa block, brachial plexus
National Capital Consortium Anesthesiology Residency
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blocks (interscalene block, supraclavicular, infraclavicular, and axillary), intravenous regional
anesthesia, and caudal block.
II. RESIDENT RESPONSIBILITIES
Residents will be responsible for evaluating patients who are candidates for regional anesthesia or
who require consultative medical pain care. Residents will be expected to take a history and
perform a pertinent physical exam. Residents are expected, with supervision from Staff
Anesthesiologist, to plan and execute the appropriate medical, interventional or combination
therapy for each patient on the acute pain service. Residents are required to document medical
care appropriately and to follow patients while on the acute pain service looking for benefit and
complication of therapy.
Daily assignment
7.
The resident will be assigned to the regional service for the day. The resident should
review the schedule for possible regional anesthesia candidates the day prior and
the morning of duty.
8. The resident will work closely with the regional staff anesthesiologist to coordinate
blocks. The resident may perform all scheduled OR peripheral blocks preoperatively
in the designated “regional block area.” Spinal, epidural, and combined spinalepidural blocks may be placed in the operating room, either by the regional resident
or by the OR room staff. Ultimately, the anesthesiologist supervising the anesthetic
case has final say regarding who does the block for that room.
9. The resident is responsible for reviewing the chart, interviewing and examining the
patient and discussing the anesthetic options with the staff anesthesiologist for each
case.
10. The resident will perform the block, document the procedure on the chart, follow the
patient in the operating room (noting any complications and checking for
effectiveness), follow-up with the patient in the recovery room, complete the
appropriate post-operative orders, and visit the patients post-operatively on the floor.
11. At the end of each day, the schedule for the following day should be reviewed by the
resident and the regional anesthesiologist.
12. The resident will participate in daily Acute Pain Service rounds and participate in the
management of perioperative pain and other aspects of perioperative care. Residents
will write daily notes, prescribe medications, and engage the primary admitting
surgical services in the care of operative patients.
While on the service, residents will keep a log of blocks, including the type of block, date,
indication, success or failure, and any complications. The resident should round on in-house
cases the next day after the regional procedure is performed, and follow up on any problems
identified when the APU staff calls outpatients the next day.
III. GOALS AND OBJECTIVES
Patient Care
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Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
Provide a preoperative patient assessment, and suggest appropriate perioperative
interventions to ensure patient safety and reduce risk, based on findings and
preexisting patient conditions.
Formulate an anesthetic plan, emphasizing the needs of the ambulatory patient and
integrating general, neuraxial, and peripheral regional anesthesia techniques to
provide optimum patient outcome and satisfaction.
Provide peripheral and/or neuraxial blocks, sedation or general anesthesia in a competent
and safe manner, and provide continuity of care in the operating room, and, when
possible, in the PACU or same-day surgery unit.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Preoperatively evaluate and identify patients that are candidates for regional anesthetic
procedures.
Perform brachial plexus, interscalene, intravenous regional, caudal, paravertebral, lumbar
plexus, sciatic and peripheral nerve blocks on appropriate patients under supervision
with minimal assistance and a high rate of success (>95%).
Provide regional techniques with sedation or combined with a general anesthetic in a
variety of surgical procedures.
Actively teach medical students and junior residents the pertinent anatomy and
techniques of the various regional anesthetics.
Perform upper extremity brachial plexus blocks (interscalene, supraclavicular,
infraclavicular, axillary).
Perform lower extremity plexus blocks (lumbar plexus, femoral, sciatic).
Properly plan and select equipment and local anesthetic agents for all regional anesthetic
procedures.
Provide sedation to create optimal conditions for performing a given block, as well as
patient comfort and blunting of adverse hemodynamic responses.
Demonstrate use of the peripheral nerve stimulator and ultrasound to assist in the
performance of peripheral nerve blocks.
Recognize the need for general anesthesia following an inadequate regional anesthetic
and convert to general anesthesia safely and efficiently with minimal disruption of
the planned surgery.
Recognize, evaluate and treat complications of regional blocks.
Recognize and evaluate the patient with a potential central neuraxial hematoma in a
timely and efficient manner.
Recognize and treat systemic local anesthetic toxicity.
Medical Knowledge
Goals:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
National Capital Consortium Anesthesiology Residency
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1.
2.
3.
4.
5.
List important requirements for ambulatory/inpatient surgical procedures and how
regional anesthetics can be designed to meet these requirements.
Describe the use of multimodal analgesia, in particular the use of peripheral blocks, and
its relationship to the goals of acute perioperatie pain medicine (inpatient and
ambulatory).
Discuss complications of peripheral blocks and their management.
List indications and contraindications of specific peripheral nerve blocks and their impact
upon the degree of post-operative pain expected from the planned surgery.
Describe the pharmacology (analgesic mechanisms and side effects) and utility of various
pharmacologic agents used for acute peiroperative pain and in the immediate
rehabilitative phase.
Objectives:
1.
2.
Identify indications and contraindications for regional anesthesia.
Understand and discuss the pharmacokinetics and pharmacodynamics of local anesthetics
and the differences among them.
3. Understand and discuss the benefits and risks related to the various additives used with
local anesthetic solutions.
4. Select and defend the choice of block and local anesthetic for surgical procedures,
depending on duration, location and severity of patient illness.
5. Display expert knowledge of anatomy pertinent to performing head and neck, upper and
lower extremity, plexus, sciatic, pleural, rib, spinal, epidural, and caudal anesthetic
procedures.
6. Demonstrate expert knowledge of the anatomic and physiologic differences of the
obstetric and pediatric patient population that may affect the implementation use
of a given regional technique.
7. Understand the benefits of a regional technique as it pertains to patient safety and
influence upon surgical outcome.
8. Discuss the peripheral nerve blocks of the upper and lower extremity, including
indications, contraindications, side effects, local anesthetic choice, needle type, the use
of indwelling catheters, patient positioning, monitoring and the
advantages/disadvantages of the various techniques and equipment used.
9. Discuss intravenous regional block (Bier block), including indications, side effects,
choice of local anesthetic, patient monitoring and its advantages/disadvantages.
10. Discuss peripheral nerve blocks of the head, neck and chest, including indications,
contraindications, side effects, local anesthetics, needle type, the use of
indwelling
catheters,
patient
positioning,
monitoring
and
the
advantages/disadvantages of the different techniques and equipment.
11. Discuss techniques for nerve localization; including peripheral nerve stimulation,
eliciting paresthesias, anatomic (e.g. bounce, pop, etc), and ultrasonic.
12. Discuss the mechanisms and side effects of various multimodal pharmacologic
agents used for acute perioperative pain.
Interpersonal Skills and Communication
Goals:
Residents must be able to demonstrate interpersonal and communication skills that result in
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effective information exchange and team-building with patients, their patient’s families, and
professional associates.
Objectives:
1.
2.
3.
4.
5.
Discuss with patients the advantages and potential disadvantages of various multimodal
analgesics including pharmacologic and regional anesthesia techniques.
Conduct the preoperative evaluation, explaining anesthesia options to the patient and
obtaining informed consent for the proposed anesthetic.
Articulate the anesthetic plan to the attending anesthesiologist and explain its
rationale.
Conduct post-operative visits for in-patients, and call-backs for ambulatory patients to
evaluate patient satisfaction and determine the incidence of undesirable effects of
the anesthetic.
The resident must be sensitive to patient concerns about awareness and pain.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
2.
3.
4.
5.
6.
Interact with staff anesthesiologists, CRNAs, PACU nurses, floor nurses, and operating
room staff in a manner which reflects interpersonal respect, integrity and commitment
to excellence in patient care.
Manage interpersonal conflict with dignity and in a manner which avoids offensive
behavior and reflects emotional maturity.
Protect patient confidentiality.
Maintain a respectable appearance.
Consult the surgical/medical team and attending anesthesiologist when questions arise
as to the appropriateness of regional anesthesia or about the nature of the planned
procedure, fostering an atmosphere of collegiality and allowing the development of
a plan which best serves the interest of the patient.
The resident must possess sufficient judgment and maturity to abort attempting regional
anesthetics when necessary.
Practice Based Learning
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care.
Objectives:
National Capital Consortium Anesthesiology Residency
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1.
2.
3.
PAGE 245
Collect and analyze post-procedure data from anesthetic cases performed.
Keep an accurate case log to document regional blocks performed, including the
following information: type of block, success of block, any complications
encountered, overall anesthetic plan, duration of block (from call-backs) and patient
satisfaction.
On a daily basis, report the information regarding block success and duration,
complications and patient satisfaction with the rotation directors, and provide
an assessment and plan for improving the quality of anesthetic care provided.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
2.
3.
4.
For each ambulatory anesthetic case performed, analyze those factors which may
optimize the likelihood of PACU bypass, communicate these to the attending in
the anesthetic plan, and conduct the anesthetic accordingly.
Assess causes of failure to achieve planned PACU bypass in ambulatory cases, and
suggest changes to improve success.
Evaluate patient feedback data, identifying problems in anesthesia care and creating
potential solutions to enhance patient satisfaction and facilitate more effective
care.
Evaluate the cost-effectiveness of acute pain medicine/regional anesthetic care,
including block techniques, medications, and perioperative analgesia options.
IV. REQUIRED READING
1.
Local Anesthetics, Chapter 30, Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2010.
2.
Spinal, Epidural, and Caudal Anesthesia, Chapter 51, Anesthesia, 7th edition, Ronald
Miller Ed. Churchill Livingston, 2010.
3.
Nerve Blocks, Chapter 52, Anesthesia, 7th edition, Ronald Miller Ed. Churchill Livingston,
2010.
V. REFERENCE MATERIALS
1.
2.
Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional
Anesthesia (New York School of Regional... by Admir Hadzic (Dec 7, 2011)
Atlas of Regional Anesthesia: Expert Consult - Online and Print, 4e (Expert Consult
Title: Online + Print) by David L. Brown MD (Aug 4, 2010)
National Capital Consortium Anesthesiology Residency
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3.
4.
5.
Atlas of Ultrasound-Guided Regional Anesthesia: Expert Consult - Online and
Print, 2e by Andrew T. Gray MD (Oct 8, 2012)
Ultrasound Guided Regional Anesthesia and Pain Medicine by Paul E. Bigeleisen
(Nov 20, 2009)
Acute Pain Management (Cambridge Medicine) by Raymond S. Sinatra, Oscar A.
de Leon-Cassasola, Eugene R. Viscusi and Brian Ginsberg (Apr 27, 2009)
6.
Anesthesia and Analgesia – monthly sections on regional and ambulatory
anesthesia.
7.
Web Sites:
www.nysora.com
www.dvcipm.org
www.usra.ca
www.neuraxiom.com
V. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and will be based on the written evaluations provided at the completion of this rotation. PGY
1/CBY residents must be determined to function at the level of interpreter or higher to receive
credit for a rotation in acute pain medicine. The summative monthly evaluation will be based
upon the following tools and information
1.
2.
3.
4.
5.
Resident case logs.
Tabulated QI data for the blocks and anesthetics performed by the resident.
Resident written self-assessment of their educational needs in regional anesthesia,
recommendations for changes in systems and bedside care based upon the QI data
and educational needs assessment.
Monthly evaluations by staff anesthesiologists with emphasis on punctuality, maturity,
clinical competence, rapport with patients, and fundamentals of knowledge. “On the
fly” evaluations will be used to address daily concerns.
Resident evaluations of the staff and rotation.
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
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CBY/PGY 1 ROTATION IN INTERNAL MEDICINE (WARDS)
Residents will be expected to demonstrate competence in the six ACGME general competencies
as outlined below. Evaluations will be used to assess their progress in attaining these goals and
also to promote continuous learning.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
4.
5.
Perform an appropriate evaluation, including history, physical exam and laboratory
studies when needed.
Initiate diagnostic studies for acute care patients.
Demonstrate the basic skills necessary for the care of medical care patients.
Manage patients with acute or chronic conditions undergoing diagnostic workups
and medical or surgical management.
Provide safe, efficient, and compassionate care to patients.
Objectives:
1.
2.
3.
Demonstrate detail-oriented systems based management of medical patients.
Initiate and interpret diagnostic studies.
Consult other services as indicated.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care on the medicine wards..
1.
2.
3.
Apply relevant scientific knowledge and reasoning to the care of the medical patient.
Understand the pathophysiology of patients presenting for care.
Understand the principles management of common medical conditions.
Objectives:
1.
2.
3.
4.
Explain the principles of volume status assessment in medical patients.
Describe the common pathophysiologic states of patients who are admitted to the medicine
ward.
Compare and contrast the use of crystalloid (hyper and isotonic) and colloid fluids in
trauma resuscitation.
List transfusion criteria for blood and blood products with an emphasis on the application
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
5.
6.
7.
PAGE 249
in acute trauma.
Discuss and defend the management principles for cardiovascular, pulmonary and renal
failure on the ward.
Define the initial management principles infections on the medicine ward.
State the rational for transfer to the Intensive Care Unit.
Interpersonal Skills and Communication
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, patients’ families, and professional
associates.
Objectives:
1.
2.
3.
4.
Discuss with patients and family members the advantages and disadvantages of the
different diagnostic and therapeutic options.
Establish and sustain a therapeutic and ethically sound relationship with patients and
families, addressing patient and family concerns and anxieties.
Establish collaborative working relationships and effectively communicate with residents
and attendings.
Work as part of a team.
Professionalism
Goal:
Residents must demonstrate a commitment to professional responsibilities, adherence to ethical
principles, and sensitivity to diverse patient populations.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate responsiveness to the needs of patients and society that supersedes selfinterest as well as accountability to patients, society, and the profession.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate respect to patients, families, and operating room staff.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
Practice Based Learning
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 250
Goal:
Residents must investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices.
Objectives:
1.
2.
3.
4.
Use information technology to manage information, access on-line medical information
and support their education.
Locate, appraise, synthesize, and assimilate medical information from texts, lectures, and
journal articles, and apply this information to the care of trauma and critically injured
patients.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
2.
3.
4.
5.
Understand the integration of the health care system as it relates to care of the surgical
patient.
Understand the resources and patient flow from initial presentation, to diagnosis, through
the intraoperative period, and to the post- operative phase either in the ICU or on the
hospital ward.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
Practice within the context of the health care institution and in cooperation with other
health care professionals.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
1.
The ICU Book, 3nd edition, Paul Marino, Williams & Wilkins, 2007.
2.
Principles of Internal Medicine. Harrison.
IV. EVALUATION
Final evaluation will be based upon clinical performance. Completion of an internal medicine ward
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 251
rotation in the CBY/PGY1 trainee requires performance at the level of reporter or greater.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
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National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 253
CBY/PGY 1 ROTATION IN ADDICTION MEDICINE
Residents will be expected to demonstrate competence in the six ACGME general competencies
as outlined below. Evaluations will be used to assess their progress in attaining these goals and
also to promote continuous learning.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
4.
Perform an appropriate evaluation, including history, physical exam and laboratory
studies when needed.
Initiate diagnostic studies for patients seen in addiction treatment services (ATS).
Demonstrate the basic skills necessary for the care of ATS patients.
Provide safe, efficient, and compassionate care to patients.
Objectives:
1.
2.
3.
4.
Demonstrate detail-oriented systems based management of patients.
Perform initial assessment of ATS patients.
Initiate initial diagnostic studies.
Consult other services as indicated.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care in the ATS clinic.
1.
2.
3.
Apply relevant scientific knowledge and reasoning to the care of the patient.
Understand the pathophysiology of patients presenting for care.
Understand the principles of care.
Objectives:
1.
2.
3.
4.
5.
Explain the principles of assessment of patients.
Describe the common pathophysiologic states of patients who present to ATS.
Identify the priorities in care for patients.
Compare and contrast the use of inpatient or outpatient therapy for addiction.
Understand the rational and initiation of therapy with suboxone.
Interpersonal Skills and Communication
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 254
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, patients’ families, and professional
associates.
Objectives:
1.
2.
3.
4.
Discuss with patients and family members the advantages and disadvantages of the
different therapeutic options.
Establish and sustain a therapeutic and ethically sound relationship with patients and
families, addressing patient and family concerns and anxieties.
Establish collaborative working relationships and effectively communicate with clinic
members and consultants.
Work as part of a team.
Professionalism
Goal:
Residents must demonstrate a commitment to professional responsibilities, adherence to ethical
principles, and sensitivity to diverse patient populations.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate responsiveness to the needs of patients and society that supersedes selfinterest as well as accountability to patients, society, and the profession.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate respect to patients, families, and clinic staff.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
Practice Based Learning
Goal:
Residents must investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices.
Objectives:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 255
1.
2.
3.
4.
Use information technology to manage information, access on-line medical information
and support their education.
Locate, appraise, synthesize, and assimilate medical information from texts, lectures, and
journal articles, and apply this information to the care of patients.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
2.
3.
4.
5.
Understand the integration of the health care system as it relates to care of the surgical
patient.
Understand the resources and patient flow from initial presentation, to diagnosis, through
return from rehabilitation.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
Practice within the context of the health care institution and in cooperation with other
health care professionals.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
1.
Assigned readings.
IV. EVALUATION
Final evaluation will be based upon clinical performance. Completion of an addiction medicine
rotation in the CBY/PGY1 trainee requires performance at the level of reporter or greater.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 256
CBY/PGY 1 ROTATION IN GENERAL SURGERY
Residents will be expected to demonstrate competence in the six ACGME general competencies
as outlined below. Evaluations will be used to assess their progress in attaining these goals and
also to promote continuous learning.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
4.
Perform an appropriate evaluation, including history, physical exam and laboratory
studies when needed.
Demonstrate the basic skills necessary for the care of surgical patients.
Manage patients with acute or chronic conditions undergoing diagnostic workups
and medical or surgical management.
Provide safe, efficient, and compassionate care to patients.
Objectives:
1.
2.
3.
4.
5.
6.
Demonstrate detail-oriented systems based management of surgical patients.
Perform initial assessment of surgical patients pre and postoperatively.
Evaluate and interpret abdominal pain.
Evaluate and interpret oliguria and renal failure.
Evaluate massive bleeding and transfusion.
Evaluate and interpret shock, including hypovolemic, cardiogenic, neurogenic and
septic shock.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care.
1.
2.
3.
Apply relevant scientific knowledge and reasoning to the care of the surgical patient.
Understand the pathophysiology of patients requiring surgery or possible interventions.
Understand the principles and the endpoints of resuscitation in surgical patients.
Objectives:
1.
2.
3.
Explain the principles of volume status assessment in trauma patients.
Describe the pathophysiologic states that patients have who require or may require surgery.
Identify the priorities in acute resuscitation and define the end points of resuscitation.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
4.
5.
6.
7.
8.
9.
10.
11.
12.
PAGE 257
Compare and contrast the use of crystalloid (hyper and isotonic) and colloid fluids in
trauma resuscitation.
List transfusion criteria for blood and blood products with an emphasis on the application
in acute trauma.
List and justify the considerations for urgent (non-emergent) surgery.
Discuss and defend the management principles for cardiovascular, pulmonary and renal
failure in the ICU and OR.
Define the management principles of sepsis and sepsis syndromes in the ICU and OR.
State the principles and methods of routine prophylaxis for:
a. DVT.
b. Gastritis / stress ulceration.
c. Delirium tremens.
Formulate and justify a management plan for septic shock.
Define the nutritional goals and techniques for ICU patients.
State the rational for advanced ventilatory management and define the use of APRV,
noninvasive positive pressure ventilation and prone positioning
Interpersonal Skills and Communication
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, patients’ families, and professional
associates.
Objectives:
1.
2.
3.
4.
Discuss with patients and family members the advantages and disadvantages of the
different surgical vs. non-surgical options.
Establish and sustain a therapeutic and ethically sound relationship with patients and
families, addressing patient and family concerns and anxieties.
Establish collaborative working relationships and effectively communicate with operating
room staff, surgeons, residents and attending anesthesiologists.
Work as part of a surgical care team.
Professionalism
Goal:
Residents must demonstrate a commitment to professional responsibilities, adherence to ethical
principles, and sensitivity to diverse patient populations.
Objectives:
1.
2.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate responsiveness to the needs of patients and society that supersedes self-
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
3.
4.
5.
6.
7.
8.
PAGE 258
interest as well as accountability to patients, society, and the profession.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate respect to patients, families, and operating room staff.
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
Practice Based Learning
Goal:
Residents must investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices.
Objectives:
1.
2.
3.
4.
Use information technology to manage information, access on-line medical information
and support their education.
Locate, appraise, synthesize, and assimilate medical information from texts, lectures, and
journal articles, and apply this information to the care of trauma and critically injured
patients.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
1.
2.
3.
4.
5.
Understand the integration of the health care system as it relates to care of the surgical
patient.
Understand the resources and patient flow from initial presentation, to diagnosis, through
the intraoperative period, and to the post- operative phase either in the ICU or on the
hospital ward.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
Practice within the context of the health care institution and in cooperation with other
health care professionals.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 259
III. REQUIRED READING
1.
The ICU Book, 3nd edition, Paul Marino, Williams & Wilkins, 2007.
2.
Sabiston, D., Et al. Principles of Surgery.
IV. EVALUATION
Final evaluation will be based upon clinical performance. Completion of a general surgery rotation
in the CBY/PGY1 trainee requires performance at the level of reporter or greater.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 260
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 261
CBY/PGY 1 ROTATION IN EMERGENCY MEDICINE
Residents will be expected to demonstrate competence in the six ACGME general competencies
as outlined below. Evaluations will be used to assess their progress in attaining these goals and
also to promote continuous learning.
Patient Care
Goals:
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
6.
7.
8.
9.
10.
Perform an appropriate evaluation, including history, physical exam and laboratory
studies when needed.
Initiate diagnostic studies for acute care patients.
Demonstrate the basic skills necessary for the care of acute care patients.
Manage patients with acute or chronic conditions undergoing diagnostic workups
and medical or surgical management.
Provide safe, efficient, and compassionate care to patients.
Objectives:
5.
6.
7.
8.
9.
10.
11.
12.
Demonstrate detail-oriented systems based management of acute care patients.
Perform initial assessment of acute care patients.
Evaluate and interpret abdominal pain.
Evaluate and interpret oliguria and renal failure.
Evaluate massive bleeding and transfusion.
Evaluate and interpret shock, including hypovolemic, cardiogenic, neurogenic and
septic shock.
Initiate initial diagnostic studies.
Consult other services as indicated.
Medical Knowledge
Goal:
Residents must demonstrate knowledge of established and evolving biomedical and clinical
sciences and the application of this knowledge to patient care in the emergency room.
4.
5.
6.
Apply relevant scientific knowledge and reasoning to the care of the acute care patient.
Understand the pathophysiology of patients presenting for care.
Understand the principles and the endpoints of resuscitation.
Objectives:
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
8.
9.
10.
11.
12.
13.
14.
15.
PAGE 262
Explain the principles of volume status assessment in acute care patients.
Describe the common pathophysiologic states of patients who present to the emergency
room for care.
Identify the priorities in acute resuscitation and define the end points of resuscitation.
Compare and contrast the use of crystalloid (hyper and isotonic) and colloid fluids in
trauma resuscitation.
List transfusion criteria for blood and blood products with an emphasis on the application
in acute trauma.
Discuss and defend the management principles for cardiovascular, pulmonary and renal
failure in the ER.
Define the initial management principles of sepsis and sepsis syndromes in the ER.
State the rational for initiating advanced ventilatory management and define the use of
APRV, noninvasive positive pressure ventilation and prone positioning
Interpersonal Skills and Communication
Goals:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building with patients, patients’ families, and professional
associates.
Objectives:
5.
6.
7.
8.
Discuss with patients and family members the advantages and disadvantages of the
different diagnostic and therapeutic options.
Establish and sustain a therapeutic and ethically sound relationship with patients and
families, addressing patient and family concerns and anxieties.
Establish collaborative working relationships and effectively communicate with operating
room staff, surgeons, residents and attending anesthesiologists.
Work as part of a team.
Professionalism
Goal:
Residents must demonstrate a commitment to professional responsibilities, adherence to ethical
principles, and sensitivity to diverse patient populations.
Objectives:
9.
10.
11.
12.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate responsiveness to the needs of patients and society that supersedes selfinterest as well as accountability to patients, society, and the profession.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate respect to patients, families, and operating room staff.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
13.
14.
15.
16.
PAGE 263
Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
Practice Based Learning
Goal:
Residents must investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices.
Objectives:
5.
6.
7.
8.
Use information technology to manage information, access on-line medical information
and support their education.
Locate, appraise, synthesize, and assimilate medical information from texts, lectures, and
journal articles, and apply this information to the care of trauma and critically injured
patients.
Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value.
Objectives:
6.
7.
8.
9.
10.
Understand the integration of the health care system as it relates to care of the surgical
patient.
Understand the resources and patient flow from initial presentation, to diagnosis, through
the intraoperative period, and to the post- operative phase either in the ICU or on the
hospital ward.
Practice cost-effective health care and resource allocation that does not compromise
quality of care.
Practice within the context of the health care institution and in cooperation with other
health care professionals.
Partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
III. REQUIRED READING
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 264
nd
1.
The ICU Book, 3 edition, Paul Marino, Williams & Wilkins, 2007.
2.
Clinical Emergency Medicine. Sherman, S. Et al. Lange. 2014.
IV. EVALUATION
Final evaluation will be based upon clinical performance. Completion of an emergency medicine
rotation in the CBY/PGY1 trainee requires performance at the level of reporter or greater.
V. ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:



Educational experience
Caseload diversity and volume
Strengths and weaknesses of the rotation
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 265
PROGRAM GOALS AND OBJECTIVES FOR
PGY 1/CBY RESIDENTS RESEARCH ROTATION
I. ROTATION DEFINITION
A one month block during PGY 1 focused on clinical reaserch.
II. GOALS AND OBJECTIVES:
Patient Care
Goal:
Residents will investigate topics pertinent to patient care in order to grow as physician scientists.
Objectives:
1.
Actively participate in the design, approval, and implementation of at least one clinical
or animal research protocol, which includes the detailed development of the
methodology, participation in the power analysis and statistical plan and involvement in
the budget development.
Medical Knowledge:
Goals:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Research Administration - Understand the administrative, logistic, fiscal, and ethical
issues related to the development and implementation of clinical and animal research
protocols.
Research Design – Understand the design of research studies from the simple to the
complex, ranging from case-control studies to fully randomized double blind placebo
controlled studies.
Statistical Analysis – Explain the appropriate statistical approach to empirical data
analysis, including an a priori data configuration that is appropriate to planned statistical
approaches, the differences between inferential and descriptive statistical methods, and
the differences between parametric and nonparametric statistics.
Research Technology – Describe the principles of data acquisition, including
digital/analog data acquisition, sensor development and placement, and computer
acquisition of data.
Writing – Acquire skills in technical writing that facilitate completion of scientific
abstracts and manuscripts suitable for publication.
Human subjects – Describe the principles and design of a human subject participation
protocol and its submission to an Institutional Review Board.
Animal Subjects – Describe the principles and design of an animal research protocol and
its submission to an Institutional Animal Care and Use Committee.
Learn and participate in the techniques used in the research project.
Participate in screening and consenting patients, data collection, and analysis.
Participate in animal management, data collection and laboratory analysis.
Prepare drafts of abstracts, manuscripts and protocols.
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
12.
PAGE 266
Conduct Medline searches for research literary support and the national patent database
for support of new technology transfers.
Objectives:
1.
2.
3.
4.
5.
6.
Describe differences, advantages, and disadvantages of different research designs.
Compare and contrast descriptive and inferential statistics and defend the choice of
applicable statistical tests.
Describe the content and outline of a scientific manuscript.
Appropriately chose and explain the benefits of analytical methods chosen for the
research project.
Explain the process of animal and human protocol approval.
Design and implement a data management plan for a research protocol.
Interpersonal Skills and Communication
Goal:
Residents must demonstrate interpersonal and communication skills that result in effective
information exchange and team-building.
Objectives:
1.
Establish and maintain a therapeutic and ethically sound relationship with patients
and families, addressing patient and family concerns and anxieties.
Professionalism
Goal:
Residents must demonstrate a commitment to their professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Objectives:
1.
2.
3.
4.
5.
6.
7.
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development.
Demonstrate a commitment to excellence and on-going professional development.
Demonstrate a consistent level of respect to patients, families, and operating room staff.
Demonstrate sensitivity and responsiveness to patients‟ culture, age, gender, and
disabilities and display the integrity expected of a medical professional.
Demonstrate a consistent work ethic.
Demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patient’s culture, age, gender and disabilities.
Practice Based Learning
National Capital Consortium Anesthesiology Residency
Goals and Objectives
JUL 2016
PAGE 267
Goal:
Residents must be able to investigate and evaluate their patient care practices and appraise and
assimilate scientific evidence to improve patient care. Residents may use a research rotation to
investigate a question relate to a problem or perceived problem in patient care.
Objectives:
1.
Residents may design a problem based educational/research project.
Systems Based Practice
Goal:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
healthcare and the ability to effectively call on system resources to provide care that is of optimal
value. During a research rotation residents may elect to investigate a topic related to systems based
practice.
Objectives:
1.
Use scientific evidence to determine the most effective use of medical resources.
V. CONFERENCES AND LECTURES
RESEARCH DESIGN
1. The Research Question
2. Choosing a Study population
3. Planning Measurements
4. Designing Studies – Cohort Studies
5. Designing Studies – Cross-sectional and Case-control Studies
6. Designing Studies – Experimental Studies
7. Designing Studies – Diagnostic Tests
8. Estimating Sample Size: Hypothesis and Underlying Principles
9. Estimating Sample Size and Power
10. Data Management and Analysis Plan
11. Institutional Review Board and Human Subject Issues
STATISTICS
1. Types of Variables
2. Probability and Normal Distribution
3. Describing Data
4. Exploratory vs. Confirmatory Data Analysis
5. Parametric Statistical Methods
6. Non Parametric Statistical Methods
7. Analysis of Frequency Data
8. Regression Analysis
WRITING DEVELOPMENT SKILLS
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1.
2.
3.
4.
5.
6.
7.
8.
Abstracts
Introduction
Methods
Results
Statistical Methods
Conclusions
References
Tables and Graphs
REVIEW COMMITTEE MEETINGS
1.
2.
3.
4.
Attend monthly Clinical Investigation Committee Meetings.
Attend Institutional Review Board Meetings.
Attend Institutional Animal Care and Use Committee Meetings.
Review specific protocols to be discussed at the monthly meetings.
VI. REQUIRED READING
1..
Zeiger, M. Essentials of Writing Biomedical Research Papers, McGraw Hill, 1991.
2.
Glantz, S.A. Primer of Biostatistics, 4th Ed, New York, McGraw-Hill, 1997.
3.
Hulley, S.B, Cummings, S.R. Designing Clinical Research, Williams and Wilkins, 1988.
4.
Bailar, J.C., Mosteller F. Medical Uses of Statistics, NEJM Books, 1992.
5.
Sackett D.L., Haynes B.R. Clinical Epidemiology, Little, Brown and Co, 1991.
VII. AVAILABLE RESOURCES
LABORATORY INSTRUMENTATION
1.
HPLC
2.
GC
3.
Blood Gas Analysis
4.
Spectrophotometry
5.
Chemiluminescence
6.
ELISA
7.
PCR
8.
Southern Blot
9.
Western Blot
10.
Scintillation Counting
RESEARCH RESOURCES
The National Capital Consortium has complete accredited research facilities and administration
available to support the conduct of human, animal and basic science research. Departmental
facilities available include 500 sq. ft of space for animal instrumentation and experimentation
and 1000 sq. ft of shared laboratory space with instrumentation listed above.
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PARTICIPATING FACULTY
Saiid Bina, PhD
John Capacchione, MD
Richard R. Kyle, MS
Sheila Muldoon, MD
Pushpa Sharma, PhD
Ryan J Keneally, MD
VIII. EVALUATION
Successful completion of this rotation will be assessed by the Clinical Competence Committee
and will be based on the written evaluations provided at the completion of this rotation.
IX.
ROTATION EVALUATION
At the completion of the rotation, residents will complete an end of rotation evaluation. The
evaluation will include their assessment of:

Educational experience

Caseload diversity and volume

Strengths and weaknesses of the rotation
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Appendix (a)
WRNMMC Operating Room Assignment Template
Deleted – See anesthesia share drive
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Appendix (b)
I PASS THE BATON
Introduction: Introduce yourself at the beginning of the hand-off process
Patient: Name, IDs, age, gender, location
Assessment: Chief complaint, diagnosis, vital signs, symptoms
Situation: Current status, recent changes,
Safety: Critical lab values, allergies
Background: Co-morbidities, medications
Actions: taken, required, anticipated
Timing: level of urgency of actions
Ownership: Who is responsible?
Next: What happens next?
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Appendix (c)
PUTS PATIENT FIRST Hand-off Tool
1.
Patient
2.
Underlying diagnosis/procedure
3.
Technique/anesthetic
4.
Status of procedure
5.
Past medical history
6.
Allergies
7.
Timing/expected duration of the procedure
8.
Immediate expected events in the next 30 minutes
9.
Emergency plan
10.
Noteworthy aspects of case
11.
Treatment plan for post-op care
12.
Fluids/EBL
13.
Induction events
14.
Records available for review
15.
vital Signs
16.
Transfer care to:
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