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APPENDIX ONE: NCC ANESTHESIOLOGY RESIDENCY GOALS AND OBJECTIVES PAGE 2 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 National Capital Consortium Anesthesiology Residency Goals and Objectives Pg # 4 8 9 13 17 21 25 33 39 45 53 60 67 72 77 82 88 93 97 102 106 113 120 127 134 142 150 158 166 172 178 184 190 196 JUL 2016 PAGE 3 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 Appendix National Capital Consortium Anesthesiology Residency Goals and Objectives Pg # 202 207 211 218 223 231 240 248 253 256 261 265 JUL 2016 PAGE 4 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 5 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 6 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 7 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 8 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 9 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 10 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 11 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 12 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 13 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 16. 17. 18. PAGE 14 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 Goals and Objectives JUL 2016 PAGE 15 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 16 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 17 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 18 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 20 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 21 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 22 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: National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 23 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, National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 24 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 25 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 26 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 27 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 28 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 29 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 30 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 31 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 32 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 JUL 2016 PAGE 33 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 JUL 2016 PAGE 34 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 JUL 2016 PAGE 35 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 National Capital Consortium Anesthesiology Residency 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 JUL 2016 PAGE 37 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 38 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 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 PAGE 41 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 PAGE 42 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. National Capital Consortium Anesthesiology Residency 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 47 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 PAGE 122 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 PAGE 124 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 JUL 2016 PAGE 126 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 JUL 2016 PAGE 127 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 Goals and Objectives JUL 2016 PAGE 128 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 JUL 2016 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 162 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 163 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 164 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 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 166 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 JUL 2016 PAGE 167 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 Goals and Objectives JUL 2016 PAGE 168 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 169 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 JUL 2016 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 JUL 2016 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 JUL 2016 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 JUL 2016 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 JUL 2016 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 6. PAGE 201 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 202 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. PAGE 203 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. PAGE 204 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 205 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 Goals and Objectives JUL 2016 PAGE 206 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 207 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: National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 208 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 209 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 211 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 212 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 JUL 2016 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 214 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 JUL 2016 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 Goals and Objectives JUL 2016 PAGE 216 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 217 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 218 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 8. 9. 10. 11. 12. PAGE 219 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, National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 7. PAGE 220 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 221 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 222 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 223 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: National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 224 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 225 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 226 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 227 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: National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 228 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 JUL 2016 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 JUL 2016 PAGE 230 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 232 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 233 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 234 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 235 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 236 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: National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 238 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 239 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 240 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 Goals and Objectives JUL 2016 PAGE 241 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 242 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 Goals and Objectives JUL 2016 PAGE 243 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 244 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 Goals and Objectives JUL 2016 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 Goals and Objectives JUL 2016 PAGE 246 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 247 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 248 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 PAGE 252 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 268 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. National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 269 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 National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 270 Appendix (a) WRNMMC Operating Room Assignment Template Deleted – See anesthesia share drive National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 271 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? National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016 PAGE 272 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: National Capital Consortium Anesthesiology Residency Goals and Objectives JUL 2016