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AMBULATORY
ANESTHESIA
NEUROANESTHESIA
OBSTETRIC ANESTHESIA
PEDIATRIC ANESTHESIA
Rotation:
Advanced Clinical Track - Emphasis in Ambulatory Anesthesia
Type: Elective
Duration: 6-9 months
Faculty: F. Kayser Enneking, MD
Prerequisite: Anesthesia training
during the CA1 year which includes the basic and fundamental aspects
of the management of anesthesia, as described by the ABA under "Subspecialty
Anesthesia Training."
In
addition to the core curriculum are the following goals and objectives.
1. Participate in ongoing research
projects.
2. Help develop a protocol for a
clinical research project and submit it to the IRB.
3. Submit a case report or clinical
study to a peer-reviewed journal.
4. Submit an abstract for presentation
at SAMBA's annual meeting.
5. Cultivate administrative responsibilities.
6. Participate in quality improvement
programs.
7. Develop experience in supervising
anesthesia administered by others.
8. Participate in health economic
and administrative decision-making purchases, budget planning, and committees.
9. Attend a seminar on establishing
an anesthesia practice in an ambulatory setting.
Core
Curriculum 6-9 months
The
following topics will be studied in depth by the resident choosing a
6-9 month rotation in ambulatory anesthesia.
Goals
and Objectives based on SAMBA Educational Guidelines
I.
Ambulatory Surgical Facilities: Study of design and function of ambulatory
surgical facilities.
II.
Preoperative Evaluation of the Ambulatory Patient
A. Modes of preoperative
screening and the
usefulness of preoperative patient contact
B. Laboratory
testing
C. Patient selection
1. Length of surgery
2. The need for transfusion
3. Adults with diseases and older patients
4. Children with diseases and the very young
III.
Preoperative Preparation and Premedication
A. NPO
status
B. Drugs
that reduce the risk of aspiration
C. Postoperative
nausea treated preoperatively
1. Overview, including the problem with certain narcotics
2. Treatment
3. Problems associated with treatment
4. Prevention by the choice of anesthetic
5. Reversal of muscle relaxation contributes to postoperative
nausea and vomiting
D. Anxiolytics,
sedatives, and opioids
1. Existence of anxiety
2. Treatment of anxiety, including the ncooperative
child
E.
Chronic medications
IV.
Anesthetic Management
A. What
type of anesthetic is appropriate: general,
regional,
sedation or local?
B. Intraoperative consideration of postoperative problems
1. Pain
a. Arthroscopy
b. Laparoscopy
c. Herniorrhaphy
2. Time spent in the PACU
a. Propofol
b. Desflurane
c. Narcotics
d. Regional/spinal/local
3. Postoperative nausea and vomiting
C. General anesthesia
1. Induction
2. Maintenance
3. Narcotics
4. Drugs used to relax muscles
5. Laryngeal mask
6. Special procedures
a. Laser surgery
b. Anesthesia outside the operating room,
including MRI and radiation therapy
c. Electroconvulsive therapy
d. Lithotripsy
D. Regional anesthesia
1. Upper extremity
a. Intravenous regional anesthesia (IVRA)
b. Brachial plexus block
2. Lower extremity
a. Compartment blocks (sciatic femoral, 3-in-1)
b. Intravenous regional anesthesia
3. Central neural blocks
a. Epidural
b. Caudal
c. Spinal, including continuous spinal
4. Retrobulbar/peribulbar eye blocks
5. Local infiltration
6. Local anesthetics
E. Monitored anesthesia care sedation techniques
V.
Postoperative Care
A. Defining and evaluating the discharge process
B. Phase one recovery (postanesthesia care unit (PACU)
1. Monitoring and equipment
2. Effects of minor preexisting conditions on the recovery profile
3. Postoperative pain management
4. Postoperative antiemesis management
5. Flumazenil
6. Complications
C. Phase two recovery
1. Discharge criteria
2. Discharge teaching and instructions
3. Complications
4. Psychometric testing
D. Postoperative follow-up
1. Outcome after ambulatory surgery
2. Unplanned admissions
3. Minor side effects
VI.
Faculty and Evaluation:
1. F. Kayser Enneking, MD (Chief)
2. Jill
Freedman, MD
3. Richard
Rogers, MD
4. Larry
Berman, MD
5. Sno
White, MD
6. Timothy
Morey, MD
Dr.
Enneking is the responsible faculty member for this rotation. Evaluation
will occur as for the primary rotation in ambulatory anesthesia.
Rotation:
Advanced Clinical Track - Emphasis in Neuroanesthesia
Type: Elective
Duration: 6-9 months
Faculty: Michael E. Mahla, MD
Prerequisites: Successful completion
of clinical base year, CA-1 and CA-2 years, approval of neuroanesthesiology
faculty, the Departmental Education Committee, and the Assistant Chairman
for Education.
Six
to 9 months of an advanced curriculum in neuroanesthesia is available
to the CA3 resident. A resident may take 6 months of the neuroanesthesia
curriculum and combine that with an additional 6 months in another subspecialty
or in research relevant to the neurosurgical patient, or take 9 months
of neuroanesthesia.
Residents
with a particular interest in neuroanesthesiology may elect to do a
CST in neuroanesthesiology during their CA-3 year. The resident should
discuss their interest and long term goals with the attending neuroanesthesiology
faculty. Whenever possible without negatively impacting upon the neuroanesthesiology
experience of CA-2 residents on their basic neuroanesthesiology rotation,
the CST will be designed to meet the needs and long term goals of the
resident. This rotation will, with rare exceptions, be limited to those
residents either with academic career plans or to those residents whose
private practice plans involve a major medical center with a significant
neurosurgical load.
I.
Goals: In addition to those outlined for the basic rotation in neuroanesthesia:
A. Expand the knowledge base with regards to CNS physiology and
pharmacology and pathophysiology developed during CA-1 and CA-2 years.
B. Develop clinical judgement to provide anesthetic care for
complex neurosurgical procedures.
C. Develop technical skills necessary to conduct complex neurosurgical
cases.
D. Be able to instruct (under direct supervision of
neuroanesthesiology
faculty)
a junior resident
in the basics of a routine
neurosurgical
procedure. The resident will not
substitute for
the attending.
E. Design and carry out a clinical research project.
F. Participate actively in the management of most of the
complex neurosurgicalprocedures performed during their rotation.
G. Develop expertise in intraoperative neurophysiologic
monitoring.
H. It is expected that the CST resident will participate
in the late stay program in
place for the neuroanesthesia fellows. On the day when the resident
is assigned to late stay, he or she will help the attending physician
complete all late-running complex neurosurgical cases.
II.
Objectives: In addition to those outlined for the basic rotation in
neuroanesthesia:
A. Carry out preoperative evaluation and preparation,
and plan and carry
out an anesthetic
plan independently for routine neurosurgical procedures.
B. Understand important perioperative issues for complex neurosurgical
procedures, as well as plan and carry out an anesthetic for these procedures
with minimal assistance from attending neuroanesthesiologist. The CST
resident must understand the pathophysiology
of complex neurosurgical diseases, especially neurovascular disease,
and be able to anesthetize such a
patient with minimal intervention by the attending anesthesiologist.
The CST resident must display a greater understanding of the exact
nature of the planned surgical procedures and its implications
(e.g. when barbiturate coma
may be needed during aneurysm clipping or when awake intubation and
positioning is indicated for procedures on the cervical spine.
C. Consistently successfully insert and teach to junior
residents, all invasive monitors such as central venous cannulas (approaches
including long-arm, subclavian, internal jugular, femoral) and arterial
lines. Know the proper use and placement of the precordial Doppler and
transesophageal echo for
detection of venous air embolism.
D. Demonstrate competence in use of the fiberoptic bronchoscope in the
difficult Neurosurgical
airway and in patients with normal airways who require awake
intubation. Facility with light
wand intubation is also expected.
E. Interpret intraoperative neurophysiologic monitoring and perform
basic assessment of changes
with the guidance of the neuroanesthesia attending in
charge of the service each day.
III.
Evaluation
A. Perioperative management will be discussed daily
with attending neuroanesthesiologist.
B. Monthly, neuroanesthesiology attendings will evaluate
the CST resident's overall performance
and report to the resident by a letter.
C. Neuroanesthesiology attendings will complete Departmental
Resident Evaluation Forms.
D. You will complete a Departmental Rotation Evaluation
Form.
IV. Resources:
In addition to those described for basic Neuroanesthesiology Rotation
A. Rotations on Neurologic Monitoring Service.
B. Attendance at the weekly neurophysiologic monitoring
conference (Thursdays)
C. Attendance at weekly neurosurgical preoperative conferences,
particularly the neurovascular
conference
D. If the timing is correct, rotation as a teaching assistant
on the NeuroscienceCourse taught to first year medical students.
The
faculty member responsible for this Track is Dr. Michael Mahla.
ROTATION:
Advance Clinical Track - Emphasis in Obstetric Anesthesia
TYPE: Elective
DURATION: 6 months
Faculty: Michael Froelich, MD
PREREQUISITES: Completion of clinical
base year, CA1 and CA2 years,
approval of the obstetric anesthesia
faculty, the Departmental Education Committee, and the Assistant Chairman
for Education
Six
to 9 months of an advanced curriculum in obstetric anesthesia is available
to the CA3 resident. A resident may take 6 months of obstetric anesthesia
curriculum and combine that with an additional 6 months in another subspecialty
or in research relevant to the obstetric patient, or take 9 months of
obstetric anesthesia.
Prerequisites:
Successful completion of the obstetric block rotations during the CA
1 AND 2 years. The resident must have an interest in obstetric anesthesia
and express that in a letter of preference that outlines the resident's
long range goals and how an extensive rotation on obstetric anesthesia
will aid in accomplishing those goals. To the extent possible, CST will
be tailored to meet those long range goals of the resident.
Those
applying for the Obstetric CST must meet with one of the obstetric anesthesia
faculty and develop a curriculum which will be presented to the Director
of Obstetric Anesthesia, the Education Committee, and the Assistant
Chairman of Anesthesiology for Education.
I.
Goals: In addition to those outlined for the basic rotation in Obstetric
Anesthesia, the
resident will:
A. Develop a body of knowledge built on but beyond that learned in the
CA1 and CA2 rotations.
In particular we will emphasize the physiological basis of
obstetric anesthesia.
B. Develop technical skills and judgement which lead to independent
conduct of complex
obstetric cases. In addition, we will provide an opportunity for the
resident to learn effects of anesthesia
on the neonate through scheduled time
in the neonatal intensive care unit.
C.
Be able to instruct (under the direct supervision of a obstetric anesthesia
attending) a junior resident in the basics of an ASA I or II obstetric
case. This is particularly relevant to those aiming toward an academic
career or a job
that entails teaching other care givers. The resident will never substitute
for the attending.
D.
Design and ideally complete a clinical study or write a review of an
obstetric subject chosen by the resident in consultation with an attending. In
most instances this material will also be given to the whole department
as a formal oral presentation.
E.
Participate in the administrative aspects of an obstetric anesthesia
service - by giving
in-service presentations for nurses, and by consulting with
obstetricians and neonatologists.
II.
Objectives: In addition to those outlined for the basic rotation
in Obstetric Anesthesia, the resident will:
A. Independently perform a preoperative evaluation,
anesthetize, and care
for postoperatively an ASA I obstetric patient for a surgical procedure
such a
exploratory laparotomy or cesarian section.
B. Understand the physiology of complex obstetrical
problems, such as a pregnant patient with congenital heart disease or
the patient with severe
preeclampsia, with minimal intervention by the attending anesthesiologist.
C. Understand and
administer neuroaxial blocks for regional anesthesia and/or postoperative
pain both in normal patients and in patients with complex
problems
such as heart disease or preeclampsia.
D. Demonstrate competence
in use of the fiberoptic bronchoscope in the obstetric difficult airway.
III.
Evaluation to Determine Goal Achievement
A. The faculty will evaluate the resident every 3 months.
The attending physicians complete a Departmental Resident Evaluation
Form, which will be
reviewed by the Clinical Competence Committee. The senior attending
on the service will inform the resident of any problem. Serious
problems will be discussed when they occur.
B. Understand and coordinate the medical care of ASA III
or IV patients
obstetric patient. This will include choice and use of monitors
appropriate to the medical situation.
C. The resident will complete a Departmental Rotation Evaluation
Form.
IV. Resources
Beyond Those Noted in the Goals and Objectives for the CA1 & CA2
Guidelines:
- Rotations on in the Neonatal ICU or High Risk Obstetric Clinic,
as appropriate -
Limited outside rotations in other obstetric units such as University
Hospital, as appropriate.
- In collaboration
with the anesthesia attending the high the CA3 resident will serve
as the anesthesia consultant for
high risk obstetric patients.
Responsibilities will
include evaluation of the patient,
researching the condition,
writing an appropriate consultation note and conferring with appropriate
representative of obstetric and nursing staff. The resident will
also take primary
initiative for arrangements for appropriate
post operative/delivery care in
collaboration with physicians and nursing
staff of the SICU.
Dr.
Michael Froelich is the faculty member responsible for this track.
ROTATION:
Clinical Subspecialty Track (CST) in Pediatric Anesthesia
TYPE: Elective
DURATION: 6 months
Faculty member: Craig Weldon, MD
PREREQUISITES: Completion of clinical
base year, CA-1 and CA-2 years, approval of
the pediatric anesthesia faculty,
the Departmental Education Committee,
and the Associate Chairman for Education
Six
to 9 months of an advanced curriculum in pediatric anesthesia is available
to the CA3 resident. A resident may take 6 months of pediatric anesthesia
curriculum and combine that with an additional 6 months in another subspecialty
or in research relevant to the pediatric patient, or take 9 months of
pediatric anesthesia.
Prerequisites:
Successful completion of the pediatric block rotations during the CA
1 AND 2 years. The resident must have an interest in pediatric anesthesia
and express that in a letter of preference that outlines the resident's
long range goals and how an extensive rotation on pediatric anesthesia
will aid in accomplishing those goals. Whenever possible and in keeping
with the resident's long range goals and not impacting negatively on
the CA-1 and CA-2 rotations the CST will be tailored to meet those long
range goals of the resident. Thus each CST in pediatrics will have some
variability but fundamental goals must be met and body of knowledge
beyond the CA1 and CA2 level must be the end product. Those applying
for the pediatric CST must meet with one of the pediatric anesthesia
faculty and develop a curriculum which will be presented to the Director
of Pediatric Anesthesia, the Education Committee, and the Assistant
Chairman of Anesthesiology for Education.
I.
Goals: In addition to those outlined for the basic rotation in Pediatric
Anesthesia, the
resident will:
1. Develop a body of knowledge built on but beyond that learned
in the CA1 and
CA2 rotations.
2. Develop technical skills and judgement which lead to
independent conduct of complex pediatric cases.
3. Be able to instruct (under the direct supervision of
a pediatric anesthesia attending) a junior resident in the basics
of an ASA I pediatric case. This is particularly relevant to those aiming
toward an academic career or a job that entails teaching other
care givers. The resident will never substitute for the
attending.
4. Design and ideally complete
a clinical study or write a review of a pediatric subject of the residents
choice (with consultation with an attending).
5. Attend and participate
in all neonatal surgical cases. The resident is called for all neonatal
cases. After elective hours it is at the discretion of the resident
when not on a regular call as to whether he/she comes in for a case.
There are no repercussions
for electing to not participate when not on regular call.
II.
Objectives: In addition to those outlined for the basic rotation in
Pediatric Anesthesia, the resident will:
1. Independently perform a preoperative evaluation,
anesthetize, and care for postoperatively ASA I pediatric patients for
surgical procedures such a herniorrhaphy or tonsillectomy.
2. Understand
the physiology of complex neonatal surgical diseases, including congenital
heart disease, and be able to anesthetize such a patient with
minimal intervention by the attending
anesthesiologist.
3. Understand
and administer neuroaxial blocks for regional anesthesia and/or postoperative
pain.
4. Consistently
successfully insert invasive monitors such as central venous cannulas
(internal jugular approach) and arterial lines.
5. Demonstrate
competence in use of the fiberoptic bronchoscope in the pediatric difficult
airway.
III.
Evaluation to Determine Goal Achievement
A. You
are evaluated every 3 months by all attendings who worked with you.
The attending
physicians complete a Departmental Resident Evaluation Form
which is reviewed by the Clinical Competence Committee. Your advisor informs
you of any problems identified, and serious problems will be discussed
with you immediately after they occur. You will also be specifically
evaluated by the Director of Pediatric Anesthesia and the results of
your evaluation
will be discussed with you.
B. You
will complete a Departmental Rotation Evaluation Form.
IV.
Resources Beyond Those Noted in the Goals and Objectives for the CA1
& CA2 Guidelines:
A.
Rotations on EP/TEE Service
B.
Supervisory rotations on Pediatric Critical Care Medicine
C.
Rotation on the Cardiovascular Critical Care Medicine Service
D.
Limited outside rotations to other children's hospitals
E.
All resources listed under the P / P2 rotation described above.
Dr.
Weldon is the faculty member responsible for this track.
RETURN
TO INDEX FOR GOALS AND OBJECTIVES
Revised 6/25/02