Bayview Medical Center:
Residency Educational Objectives

A total of 4 residents rotate to the Bayview Medical Center each 4 week block. Residents are assigned as the “OB-Resident”, “Vascular-Thoracic Resident”, “Regional Anesthesia Resident”, or “General Operating Room Resident”.

Goals and Objectives for Residents in Anesthesia for Vascular-Thoracic Surgery

I. Define Rotation:

Residents on the 4 week Bayview Vascular-Thoracic rotation care for patients requiring major vascular surgery or a thoracotomy to treat intrathoracic disease.

II. Goals and Area of Knowledge:

The resident should acquire the skills necessary to for management of this high risk group of patients. This includes pre-operative assessment and optimization of their complicated medical issues, preparation for surgery, and intraoperative management. The degree of difficulty of the cases is graded to provide increasingly challenging cases as the level of training and skill progress.

III. Cognitive Objectives: The resident will be able to:

1. Describe the anatomy and discuss the physiology of the cardiovascular system and pulmonary system.
2. Explain and discuss invasive hemodynamic monitoring and make treatment decisions based upon the findings or derangements to maintain hemodynamic stability.
3. Safely and effectively manage medical problems frequently associated with vascular disease and pulmonary disease.
4. Recognize ischemic cardiac episodes intraoperatively and effectively treat and manage them.
5. Discuss the anesthetic implications for management of the patient with vascular disease and pulmonary disease.
6. Discuss preoperative anesthesia assessment for vascular and pulmonary patients, present the assessment to the staff anesthesiologist in a logical and organized manner and develop a reasonable and safe anesthetic plan which takes into account those implications peculiar to these groups of medically disabled patients.
7. Discuss regional as well as general anesthetic options for a given vascular and pulmonary surgical procedure and discuss the risks and benefits.
8. Discuss frequently used vasoactive drugs, their pharmacology, pharmacokinetics and appropriate usage.
9. Describe a ‘routine’ anesthetic plan for a given vascular and pulmonary surgical procedure.
10. Formulate a postoperative pain control plan for the vascular and pulmonary surgical patient.
11. Interpret blood gas analysis results and institute appropriate therapy.
12. Discuss issues related to anticoagulation.
    

IV. Skill Objectives: The resident will be able to:

1. Effectively communicate preoperative concerns or problems regarding preparation of the vascular patient for surgery.
2. Set-up equipment expeditiously for a typical vascular and pulmonary surgery case.
3. Execute simple vascular cannulations such as IV’s and arterial lines without difficulty and perform central venous and pulmonary artery catheter insertions with guidance.
4. Perform spinal and epidural regional anesthetics without difficulty.
5. Manage anesthesia for a routine vascular case fairly independently.
6. Recognize and treat intraoperative hemodynamic and pulmonary derangements and complications.

V. Curriculum:

Reading of related material in standard textbooks i.e. Millar or Barash, is mandatory. In addition, as part of their learning experience, residents are required to review the anesthetic assessment and discuss anesthetic plans with their staff anesthesiologist in advance on every case.

Goals and Objectives for Residents in Anesthesia for General and Colorectal Surgery

I. Define Rotation:

General/colorectal anesthesia rotation includes cases in general surgery, colorectal, plastic
and reconstructive surgery, and ophthalmology.

II. Goals and Area of Knowledge:

Primary Area of Knowledge: The general and colorectal anesthesia rotation is designed to allow the resident to build on the principles of basic anesthesia. The resident will also be assigned cases with increasing difficulty in general, plastic, eye and colorectal surgery.

Goals of the Rotation: To be able to evaluate, induce and maintain anesthesia for various surgical procedures in abdominal surgery, minor to intermediate difficulty plastic surgery, and eye surgery utilizing MAC or general anesthesia.

III. Cognitive Objectives: The resident will be able to:

1. Describe the ASA classification.
2. Describe components of an anesthesia ventilator and identify appropriate settings for an adult patient.
3. Identify patient conditions and surgical procedures in which invasive monitoring, particularly arterial line and central venous access, would be indicated.
4. Describe proper patient positioning for the supine, lateral and lithotomy position.
5. Describe position injuries possible with the lithotomy, lateral and supine position.
6. Discuss drug therapy available to use in an epidural catheter to achieve adequate postoperative epidural pain control in abdominal and plastic surgical procedures.
7. Assess patients airways accurately and categorize into the appropriate MP class.
8. Explain the types and quantity of fluids necessary for abdominal operations.
9. Describe indications for use of colloid solutions and possible risks of using various colloids.
10. List indications for blood transfusions and determine when blood transfusions are indicated or adult patients.
11. Discuss cost benefit analysis of various narcotics, muscle relaxants and intravenous drugs.
12. Describe physiologic effects of hypothermia and discuss various methods of prevention in the operating room.
13. Recognize indications for rapid sequence or awake intubations and discuss the methods of each.
14. Describe anatomy and techniques for placement of CVPs (internal jugular or external jugular) monitoring catheters. Discuss potential complications of placement of these catheters.
15. Describe technique and potential sites for arterial line placement. Discuss complications of arterial lines placement.
16. Discuss implications of TPN during anesthesia.
17. Discuss methods of preparing patients with IDDM for anesthesia.
18. Describe implications of patients on steroids undergoing anesthesia.

IV. Skill Objectives: The resident should be able to:

1. Assemble and organize equipment for general, regional or MAC anesthesia for an ASA I or II patient having surgery with the potential for significant blood loss.
2. Assemble equipment necessary for placement of an arterial and CVP catheter.
3. Improve skills in performing peripheral venous access using large gauge IVs.
4. Perform a rapid sequence intubation in an ASA I or II patient with supervision.
5. Manage the induction of general anesthesia with limited assistance in ASA I or II patients for major laparotomies and plastic surgery procedures.
6. Assist in patient positioning in the lateral and lithotomy position.
7. Complete an anesthesia record accurately and in a timely manner.
8. Organize equipment and drugs to allow a safe, but timely turnover of cases.
9. Perform arterial line in ASA I and II patients, when indicated.
10. Prepare and position a patient for central line placement (IJ or EJ). Begin developing skills at placement of central lines via either of these two routes.
11. Prepare devices to prevent and/or treat hypothermia during major abdominal surgery or plastic procedures.
12. Perform pre-anesthesia consult in ASA III patients with staff supervision.
13. Prescribe appropriate preoperative orders/medications for patients on steroids, TPN, and those with IDDM..

Goals and Objectives for Residents in Obstetrical Anesthesia

Requirement: Resident must have completed the basic Obstetrical Anesthesia Rotation requirement at Johns Hopkins Hospital prior to being considered for an elective rotation in Obstetrical Anesthesia at Bayview Hospital Center:

I. Manual skills development:

A. Goal: to master skills, with an emphasis on efficiency. Demonstrate mastery of basic skills by:

1. Epidural catheter placement:

a. most completed in less than 10 min
b. low epidural replacement rate
c. low rate of PDPH
d. high patient satisfaction rate
e. 80% success rate

2. SAB placement

a. time target 5 min,
b. success rate more than 90%

3. General anesthesia

a. rapid, safe initiation and conduct of care

II. Enhance ability to act as consultant

A. Goal: Formulate anesthesia plans for high-risk parturients,

a. prior to onset of labor
b. when patient is admitted to labor floor
c. for problems that arise following delivery of the infant

B. Goal: Presentation of lectures related to obstetric anesthesia at departmental conferences

III. Development of management & leadership skills

A. Goal: Demonstration of ability to be independent upon completion of training
B. Goal: Demonstrate ability to coordinate effective and safe care on a busy obstetrical anesthesia service
C. Goal: Development of appropriate communication skills with nurses and surgeons
D. Goal: Demonstration of effective and professional leadership and management

Goals and Objectives for Residents in Regional Anesthesia

I. Define Rotation:

The Regional Anesthesiology Rotation is a four-week rotation which primarily involves the placement of regional anesthetics for orthopedic and plastic surgery cases, which are isolated to a limb.

II. Goals and Knowledge Base for the Rotation:

The objective of the primary rotation in Regional Anesthesia will be to train the resident in modern anesthetic techniques for a variety of orthopedic surgical procedures. The resident will be assigned to operating room cases in a way to produce a reasonable cross-section of the surgical and anesthetic options. The surgical procedures are apt to include:

1. Total joint replacement of the lower extremity
2. Reconstructive shoulder surgery
3. Arthroscopy
4. Hand surgery
5. Hip fracture
6. Miscellaneous trauma
7. Orthopedic oncology

The anesthetic procedures will include:

1. Preoperative assessment and selection of a reasonable anesthetic technique for a given orthopedic procedure
2. Spinal anesthesia
3. Epidural anesthesia
4. Peripheral regional anesthesia blocks such as brachial plexus anesthesia, axillary and interscalene approaches, etc.

The goal of the rotation will be for the resident to be exposed clinically and didactically to the full spectrum of orthopedic surgical procedures and the anesthetic techniques that can be applied. This rotation will place a special emphasis on the learning of regional anesthesia and the pharmacology of local anesthetics because of the unique place of these agents in this subspecialty.

III. Cognitive Objectives:

At the conclusion of the Orthopedic Anesthesiology rotation, the resident will be able to:

1. Identify common preoperative issues in orthopedic patients, and explain how they impact on an anesthesia plan.
2. Create a reasonable anesthesia plan for most common, reconstructive orthopedic surgical procedures.
3. Identify and manage the common problems in orthopedic trauma.
4. Plan and select equipment and local anesthetic agents for most regional anesthetic procedures. Select and defend these local anesthetic choices for surgical procedures, depending on duration, location and severity of illness of the patient.
5. Describe the basic pharmacology of a local anesthetic including the characteristics that determine onset, duration, potency and toxicity.
6. Discuss the unique topics within orthopedic anesthesia, including pneumatic tourniquets, fat embolism, hemodynamic implications of methylmethacrylate and etiology of deep venous thrombosis.
7. Describe the preoperative implications of co-existing diseases in orthopedic patients, including hypertension, coronary artery disease and rheumatoid arthritis.
8. Explain and contrast postoperative pain control strategies including patient controlled analgesia (PCA) with various opiates, subarachnoid opiates, epidural analgesia, continuous peripheral nerve catheters, intra-articular local anesthetic and opiate, and non-steroidal anti-inflammatory drugs.
9. Describe the techniques of autologous blood programs, cell salvage, hemodilution and perioperative blood conservation.

IV. Skill Objectives:

At the conclusion of the Orthopedic Anesthesiology rotation, the resident will be able to:

1. Perform a spinal anesthetic with the correct equipment and agent and manage the patient intraoperatively with minimal staff intervention.
2. Conduct a similar case with an epidural anesthetic.
3. Perform an axillary block, with correct selection of equipment and agents.
4. Perform an interscalene block for shoulder surgery, with correct equipment and agents.
5. Provide appropriate, safe anesthesia for:
   a.total hip arthroplasty
   b.revision total hip arthroplasty
   c.total knee arthroplasty
   d.treatment of fractured hip
   e.anterior cruciate ligament repair
   f.ORIF of major long bone fracture
   g.hand surgery
   h.major skeletal tumor resection