Introductory Anesthesiology (Blocks 1-3) Objectives

Transcription

1 Introductory Anesthesiology (Blocks 1-3) Objectives During the first three blocks of anesthesia training at the PGY3 level, residents will be introduced to the anesthesiologist s role in perioperative care. Residents will complete one block of introductory anesthesia in the OR, followed by two blocks incorporating on-call duties with the assistance of a senior buddy call. Family Medicine Expert 1. Clinical Anesthesia Objectives Patient Assessment The resident will be able to: complete an appropriate focused preoperative history and physical exam. correctly assign an ASA score to the patient. demonstrate a basic ability to assess a patient s airway, respiratory, and cardiovascular system during the preoperative, operative and postoperative periods. Perioperative Management The resident will be able to: demonstrate the ability to set up the OR in the morning (prepare drugs and IV s) and perform a satisfactory machine check before each case. demonstrate familiarity with a fundamental plan of anesthesia useful in ASA class 1-2 patients. demonstrate some knowledge of the limitations of various basic monitoring equipment. select and use appropriate monitors for the patient s intraoperative course. demonstrate familiarity with the indications and technique for a RSI. demonstrate an adequate knowledge of the action, dose, and problems associated with drugs commonly used in the resident s anesthetic practice. This will be similar to that knowledge required in the undergraduate course of medical pharmacology. Included should be: Sevoflurane, Desflurane, Isoflurane, Propofol, Fentanyl, Morphine, Hydromorphone, Naloxone, Succinylcholine, Rocuronium, Midazolam, Lidocaine, Bupivicaine, Neostigmine, Glycopyrolate, Atropine, Ephedrine, Phenylephrine, and those drugs required for resuscitation (to the level of ACLS). demonstrate some knowledge of the interaction of the above drugs with other medications and with common patient co-morbidities. demonstrate the ability to perform, with assistance, straightforward spinal, epidural or general anesthetics for ASA 1-2 patients. demonstrate an awareness of his/her limitations. Technical Skills The resident will be able to: demonstrate the ability to cannulate peripheral veins successfully (more often than not). demonstrate the ability to set up for and perform intra-arterial cannulation, but may not have perfected this skill. demonstrate the ability to maintain an airway with either mask, LMA or endotracheal tube most of the time, and to recognize problems that may occur with the airway.

2 perform a subarachnoid or an epidural puncture for the purposes of anesthesia/analgesia, and understand the indications, contraindications and potential complications of neuraxial blocks. Staff Intervention At this stage both direction and intervention by the staff (and/or senior resident) are expected as part of the normal teaching and learning experience. 2. On Call Objectives The resident will be able to: assess labouring patients who request an epidural. place a labour epidural in a safe manner. A success rate over 80% by the end of the third block with no more than one PDPH is expected. appropriately initiate and maintain a patient with a spinal anesthetic for a cesarean section. perform a SAB with a success rate over 80% by the end of the third block. know the main complications of anesthesia during pregnancy and take appropriate steps to minimize the risk to the patient. perform neonatal resuscitation consistent with the NRP protocol. respond to code 99s and cardiac arrests appropriately as well as being an effective member of the trauma team. run a code using ACLS guidelines. demonstrate familiarity with the indications for intubation and appropriate drugs for intubating in various settings. learn to trouble-shoot common acute pain management problems and scenarios safely and efficiently. The resident is expected to have completed the Competencies Required for Independent Anesthesia Call Duties checklist (reference: sthesia_call_duties.pdf) by the end of the third block before proceeding to independent call duties. 3. Airway Objectives Demonstrate basic knowledge and familiarity with the following concepts: airway assessment including risk factors for difficult laryngoscopy and intubation, difficult mask ventilation, difficult extraglottic airway insertion and difficult surgical airway. airway anatomy. the Mallampatti and Cormack-Lehane scoring systems. application of the most recent American Society of Anesthesiologists and Canadian Airway Focus Group difficult airway algorithms. optimization of mask ventilation and direct laryngoscopy. the laryngeal mask airway (LMA) and insertion techniques. the theory and techniques pertaining to common airway adjuncts, including but not limited to: lighted stylet, intubating LMA, gum elastic bougie, video laryngoscopy (e.g. Glidescope), other special laryngoscopy blades.

3 trans-tracheal jet ventilation theory and technique (mannequin). cricothyroidotomy theory and techniques (anatomy labs). retrograde intubation theory and techniques (anatomy labs). flexible fiberoptic bronchoscope (FOB) assisted intubation. nasal intubation (with and without adjuncts). Knowledge of indications, contraindications, complications, assembly (where applicable), use, and care of airway adjuncts listed below: gum elastic bougie lighted stylets LMAs (classic, intubating, built-in gastric drain tube) straight blades articulating blades (e.g. McCoy) video laryngoscopes (e.g. GlideScope) Intubation of patients with normal and simulated difficult airways using at least two of the following techniques: gum elastic bougie trachlight intubating LMA straight blades articulating blades (e.g. McCoy) glidescope Communicator Residents will be able to effectively communicate with patients and their families prior to their anesthetic. Residents will be able to present cases to the attending staff in a clear, concise manner. Residents will treat patients with respect and courtesy in answering all questions and concerns they may have. Residents will be able to communicate effectively with all members of the operating room team. Charting will be clear, complete and legible at all times. Collaborator Residents will consult effectively and appropriately with other health care professionals to achieve suitable care for the patient and optimization prior to surgery. Residents will convey information to the necessary professionals to achieve optimal care for their patient. Residents will understand the importance of good working relationships within the anesthesia service, with other hospital-based services and with referring hospitals. Residents will effectively hand over to the oncoming resident any problems experienced during their night on call. Manager Residents will start to effectively manage their own operating rooms ie: setting up in the morning, checking the machine, preparing appropriately for each case, etc.

4 Residents will become aware of how the operating rooms are managed at the KGH. Residents will become aware of the interactions of the various OR personnel in a typical day. Residents will ensure that the C/S room and the emergency pack are stocked when they are on call. Residents will ensure that their attending staff is aware of any complications or delays. Health Advocate Residents will initiate appropriate education of patients/families regarding health related issues. Residents will ensure that the patient s safety is placed above all else. Residents will ensure that all standards of care are met when caring for each patient. Scholar Residents will demonstrate self-directed learning and will continue to read around cases, consult the literature, and improve their knowledge base. Residents will attend all rounds and teaching sessions. Residents will come to the hospital each morning having read up on the cases for the day, and having already reviewed the charts (or seen the patient). Professional Residents will demonstrate integrity and respect when interacting with patients, families and other health care professionals. Resident will conduct themselves in an honest, responsible manner at all times. Residents will demonstrate a strong sense of responsibility and ownership for their patients. Residents will act in an ethical manner consistent with the obligations of a physician. Residents will demonstrate that they are aware of their limitations at all times and ask for help/supervision appropriately.

5 Kingston General Hospital Rotation Objectives During the 3 blocks of core anesthesia training at the KGH, residents will continue to refine their knowledge and skills in general operative anesthesia. Expectations for performance will change depending on what quarter of the year residents are in. Residents will participate in regular oncall duties at the KGH without senior resident back-up. Family Medicine Expert During these rotations the resident is responsible for the following objectives: 1. Anesthesia for General Surgery Objectives 2. Anesthesia for Orthopedic Surgery and Trauma Objectives 3. Anesthesia for Gynecology Objectives 4. Anesthesia for Urology Objectives 5. Anesthesia for Plastic Surgery and Burns Objectives 6. Anesthesia for the Elderly Objectives Other clinical anesthesia objectives for the KGH rotations include: Patient Assessment The resident will be able to: complete an appropriate and efficient preoperative history and physical exam. demonstrate a strong ability to assess a patient s airway, respiratory, and cardiovascular system during the preoperative, operative and postoperative periods. Perioperative Management The resident will be able to: demonstrate the ability to set up the OR in the morning and perform a satisfactory machine check before each case. demonstrate the ability to troubleshoot equipment failures during the intraoperative period. demonstrate familiarity with a fundamental plan of anesthesia useful in ASA class 1-3 patients. select and use appropriate monitors for the patient s intraoperative course. demonstrate familiarity with the indications and technique for a RSI.

6 demonstrate an adequate knowledge of the action, dose, and problems associated with drugs commonly used in an anesthetic practice. demonstrate knowledge of the interaction of drugs used during anesthesia with other medications and with common patient co-morbidities. demonstrate the ability to perform straightforward and challenging spinal, epidural or general anesthetics for ASA 1-3 patients. demonstrate an awareness of his/her limitations. Technical Skills The resident will be able to: demonstrate the ability to cannulate peripheral veins successfully (more often than not). demonstrate the ability to set up for and perform intra-arterial cannulation, and by the end of the year to have mastered this skill. demonstrate the ability to set up for and perform central line insertions with and without ultrasound, and by the end of the year to have mastered this skill. demonstrate the ability to maintain an airway with either a mask, extraglottic airway or endotracheal tube and to recognize problems that may occur. By the end of the year the resident should have mastered these skills. demonstrate a solid approach to managing the difficult airway. This includes familiarity with and proficiency in using advanced airway aids to secure the airway. demonstrate the ability to perform an awake fibreoptic intubation. perform a subarachnoid or an epidural puncture for the purposes of anesthesia and understand the indications, contraindications and potential complications of neuraxial blocks. perform common peripheral nerve blocks with and without ultrasound guidance and understand the indications, contraindications and potential complications of regional anesthesia. Communicator Residents will be able to effectively communicate and present management plans with patients and their families prior to their anesthetic. Residents will be able to present cases to the attending staff in a clear, concise manner. Residents will inform patients of risks and benefits of various techniques used in such a manner that the patient can make an informed decision regarding treatment. Residents will treat patients with respect and courtesy in answering all questions and concerns they may have. Residents will be able to communicate effectively with all members of the operating room team. Charting will be clear, complete and legible at all times. Collaborator Residents will consult effectively and appropriately with other health care professionals to achieve suitable care for the patient and optimization prior to surgery. Residents will convey information to the necessary professionals to achieve optimal care for the patient. Residents will understand the importance of good working relationships with other staff at the KGH to ensure smooth patient care and safety.

7 Residents will maintain a collegial relationship with surgeons, consultants and family physicians. Residents will collaborate with the family physician to ensure optimal patient assessment and preparation (e.g., baseline test results, blood pressure management). Manager Residents will effectively manage their own operating room, ie: setting up in the morning, checking the machine, preparing appropriately for each case, etc. Residents will demonstrate the ability to organize anesthetic tasks efficiently without sacrificing standards of care. Residents will use health care resources wisely without sacrificing standards of care. Residents will be aware of the interactions of the various OR personnel in a typical day. Residents will demonstrates knowledge of the departmental guidelines for management of patients in the perioperative period (e.g., sleep apnea, sickle cell anemia, malignant hyperthermia, implantable cardioverter-defibrillator, ambulatory surgery, monoamine oxidase inhibitors, anticoagulants). Residents will ensure that their attending staff is aware of any complications or delays. Health Advocate Residents will initiate appropriate education of patients/families regarding health related issues. Residents will ensure that the patient s safety is placed above all else. Resident will ensure that all standards of care are met when caring for each patient. Residents will encourage patients to optimize their health status perioperatively. Scholar Residents will demonstrate self-directed learning and will continue to read around cases, consult the literature, and improve their knowledge base. Residents will continue to attend all rounds and teaching sessions. Resident will come to the hospital each morning having read up on the cases for the day, and having already reviewed the charts. Residents will continue to critically evaluate the literature and alter their anesthetic practice accordingly. Residents will become familiar with the Guidelines to the Practice of Anesthesia published yearly by the Canadian Anesthesiologists Society Professional Residents will demonstrate integrity and respect when interacting with patients, families and other health care professionals. Residents will conduct themselves in an honest, responsible manner at all times. Residents will demonstrate a strong sense of responsibility and ownership for their patients. Residents will act in an ethical manner consistent with the obligations of a physician. Residents will demonstrate on going self-assessment and insight. Residents will demonstrate that they are aware of their limitations at all times and ask for help/supervision appropriately.

8 Anesthesia for General Surgery Objectives 1. The resident will be able to perform thorough preoperative evaluations of the patient considering the necessary preparation and premedications for the patient. The patient s concomitant disease will be taken into consideration. 2. The resident will be able to outline the necessary considerations and demonstrate competency in delivering anaesthetics for patients needing: cholecystectomy appendectomy bowel obstruction and perforation bowel resection acute gastrointestinal bleeding operations for morbid obesity colorectal surgery herniorrhaphy breast surgery endocrine surgery 3. The resident will appreciate the implications, challenges and risks of anesthesia and surgery on obese patients. 4. The resident will be able to discuss the effects of abdominal surgery on pulmonary function intraoperatively and postoperatively. 5. The resident will be able to decide which patients are appropriate for consideration of laparoscopic surgical techniques. 6. The resident will be cognizant of the relative and absolute contraindications, and the risks/benefits of laparoscopic surgery. 7. The resident will be able to describe the physiologic implications of laparoscopic abdominal surgery including the effects of: positioning C0 2 pneumoperitoneum 8. The resident will describe the implications of conversion to an open procedure, and when an open procedure may be in the patient s best interest. 9. The resident will be able to describe the uses of various types of lasers in surgery, and be cognizant of the hazards of laser surgery. 10. The resident will be able to provide suitable postoperative management in the recovery room and will provide postoperative analgesia by a number of techniques including IV PCA opioids, continuous thoracic epidural analgesia and PCEA. Recommended Reading

9 Clinical Anesthesia. Barash (6 th ed) Chapter 46, 47, 48, 49 General Surgery in Anesthesiologist s Manual of Surgical Procedures. Jaffe (4 th ed) Chapter 7 Anesthesia for Orthopedic Surgery and Trauma Objectives 1. The resident will be able to perform a detailed preoperative assessment and preparation of the patient for Orthopedic Surgery including: the appropriate management of a patient s concomitant disease deciding when additional investigations are required optimization of the patient prior to surgery proper prediction and arrangement of post-operative care 2. The resident will be able to outline the pros and cons of various anesthetic techniques. The resident will know the risks/benefits of GA vs Regional, as well as how co-morbidities and DVT prophylaxis affect those techniques. 3. The resident will be able to perform a Bier block (IV regional anesthesia) and understand the related indications, management and risks. 4. The resident will be able to outline the anesthetic considerations in: major lower extremity arthroplasty surgery spinal surgery shoulder surgery fractures surgery under tourniquet use of cement 5. The resident will be able to select and perform the necessary procedures for appropriate postoperative pain management. 6. The resident will be able to recognize and initiate treatment of postoperative complications such as: fat embolism pulmonary embolism compartment syndrome 7. The resident will know the ATLS Trauma Protocol, and the role of anesthesia in the assessment and initial stabilization of the trauma patient. The resident will be expected to complete ATLS training before or during their PGY3 year of training. 8. The resident will know the assessment and management principles in acute trauma for the following problems: blunt trauma penetrating trauma Airway trauma/trauma requiring airway management

10 head and spinal cord injury thoracic trauma CVS trauma abdominal trauma major orthopedic trauma hypotension in the trauma patient 9. The resident will have a plan for the management of the acutely traumatized patient in the OR. 10. The resident will appreciate the alterations in anesthetic management required for a patient with a chronic spinal cord injury (quadriplegia) with a particular focus on the prevention of autonomic hyperreflexia in this patient population. Recommended Reading Anesthesia for Orthopedic Surgery inclinical Anesthesia. Barash (6 th ed) Chapter 53 Orthopedic Surgery in Anesthesiologist s Manual of Surgical Procedures. Jaffe (4 th ed) Chapter 10 Anesthesia for Gynecology Objectives 1. The resident will be able to perform thorough preoperative evaluations of the patient considering the necessary preparation and premedications for the patient. The patient s concomitant disease will be taken into consideration. 2. The resident will be able to outline the necessary considerations and demonstrate competency in delivering anaesthetics for patients needing: D&C Hysterectomy Surgery for pelvic malignancy Myomectomy Endometrial ablation Tubal ligation Urinary incontinence surgery Laparoscopic surgery 3. The resident will be able to decide which patients are appropriate for consideration of laparoscopic surgical techniques. 4. The resident will be cognizant of the relative and absolute contraindications, and the risks/benefits of laparoscopic surgery. 5. The resident will be able to describe the physiologic implications of laparoscopic abdominal surgery including the effects of: positioning C0 2 pneumoperitoneum

11 6. The resident will describe the implications of conversion to an open procedure, and when an open procedure may be in the patient s best interest. 7. The resident should be able to indicate any specific hormonal effects of various gynecologic conditions on the anaesthetic considerations. Recommended Reading Obstetric/Gynecologic Surgery in Anesthesiologist s Manual of Surgical Procedures. Jaffe (4 th ed) Chapter 8 Anesthesia for Urology Objectives 1. The resident will be able to describe the innervation of the genitourinary system and indicate appropriate levels of neural blockade needed for surgical procedures on each component of the genitourinary system. 2. The resident will be able to define the landmarks for the blockade of ilioinguinal and iliohypogastric nerves. 3. The resident will be able to outline criteria for the diagnosis of renal insufficiency, acute renal failure (ARF) and chronic renal failure (CRF) 4. The resident will be able to discuss the impact of CRF on the pharmacokinetics of drugs used in anesthetic practice, and indicate which of the drugs commonly used in the perioperative period depend heavily on renal excretion. 5. The resident will be able to Identify which common anesthetic agents can be used safely in patients who are dialysis-dependent and which agents should be avoided. 6. The resident will be able to outline the necessary considerations and demonstrate competency in delivering anaesthetics for patients needing: TURP and TURBT circumcision/orchiectomy/orchidopexy placement/removal of ureteric stents/calculi percutaneous nephroscopy and nephrolithotripsy laparoscopic procedures extracorporeal shock wave lithotripsy perineal prostatectomy radical retropubic prostatectomy radical cystectomy and ileal conduit 7. In each of the above cases the resident will be able to discuss pros and cons of alternative anesthetic techniques, appropriate monitoring and perioperative pain management. 8. The resident will be able to identify the common, and rare but important intraoperative complications with the above procedures, and will be able to manage them.

12 9. The resident will be able to place a subarachnoid block using either midline or paramedian approach, having selected an appropriate drug dose and analgesic level, and will achieve successful surgical anesthesia 90% of the time. 10. The resident will demonstrate the ability to place an epidural catheter preoperatively, and use it for pre-emptive analgesia and combined regional/ga for major urologic procedures. Recommended Reading The Renal System and Anesthesia for Urologic Surgery in Clinical Anesthesia. Barash (6 th ed) Chapter 52 Urology in Anesthesiologist s Manual of Surgical Procedures. Jaffe (4 th ed) Chapter 9 Anesthesia for Plastic Surgery and Burns Objectives 1. The resident will be able to perform a detailed preoperative assessment and preparation of the patient for plastic surgery including: the appropriate management of a patient s concomitant disease deciding when additional investigations are required optimization of the patient prior to surgery proper prediction and arrangement of post-operative care 2. The resident will be able to outline the necessary considerations and demonstrate competency in delivering anaesthetics for patients needing: 8. abdominoplasty 9. panniculectomy 10. liposuction 11. skin grafts 12. pressure sore and wound reconstruction 13. repair of facial fractures 14. microsurgery flap procedures and reimplantation 15. breast surgery 16. cosmetic surgery 3. The resident will develop an appropriate management plan for the perioperative care of a patient who has sustained a major thermal injury. This management plan will address the following areas: initial assessment and cardiovascular resuscitation fluid management (crystalloid vs. colloid, application of Parkland Formula) assessment of airway injury and implications for management detection and management of carbon monoxide poisoning anesthetic management for operative excision and grafting procedures with attention to potential for massive transfusion

13 development of a multimodal analgesic regimen for postoperative pain management for the burn patient analgesic management of burn dressing changes References: Anesthesia for Trauma and Burn Patients in Clinical Anesthesia. Barash (6 th ed) Chapter 36 Plastic and Reconstructive Surgery in Anesthesiologist s Manual of Surgical Procedures. Jaffe (4 th ed) Chapter 11 Hotel Dieu Hospital Rotation Objectives During the block of anesthesia training at the HDH, residents will be introduced to the anesthesiologist s role in a smaller community hospital with a focus on ambulatory procedures. Family Medicine Expert During this rotation the resident is responsible for the following objectives: 1. Ambulatory Anesthesia Objectives 2. Anesthesia for Otolaryngology Objectives 3. Anesthesia for Ophthalmology Objectives 4. Anesthesia for Dental and Orofacial Objectives Other clinical anesthesia objectives for the HDH rotation include: Patient Assessment The resident will be able to: complete an appropriate and efficient preoperative history and physical exam. demonstrate a strong ability to assess a patient s airway, respiratory, and cardiovascular system during the preoperative, operative and postoperative periods. Perioperative Management The resident will be able to: demonstrate the ability to set up the OR in the morning, become familiar with the anesthetic equipment at the HDH and perform a satisfactory machine check before each case. demonstrate familiarity with a fundamental plan of anesthesia useful in ASA class 1-3 patients. select and use appropriate monitors for the patient s intraoperative course. demonstrate familiarity with the indications and technique for RSI. demonstrate an adequate knowledge of the action, dose, and problems associated with drugs commonly used in an anesthetic practice. demonstrate knowledge of the interaction of drugs used during anesthesia with other medications, and with common patient co-morbidities.

14 demonstrate the ability to perform straightforward spinal, select regional or general anesthetics for ASA 1-3 patients. demonstrate an awareness of his/her limitations. Technical Skills The resident will be able to: demonstrate the ability to cannulate peripheral veins successfully (more often than not). demonstrate the ability to perform intra-arterial cannulation, and set up for same. demonstrate the ability to maintain an airway with mask, LMA or endotracheal tube, and to recognize problems that may occur with the airway. perform a subarachnoid for the purposes of anesthesia, and understand the indications, contraindications and potential complications of neuraxial blocks. perform common peripheral nerve blocks with and without ultrasound guidance, and understand the indications, contraindications and potential complications of regional anesthesia. Communicator Residents will be able to effectively communicate and present management plans to patients and their families prior to their anesthetic. Residents will be able to present cases to the attending staff in a clear, concise manner. Residents will communicate risks and benefits of various anesthetic techniques in such a manner that the patient can make an informed decision regarding treatment. Residents will treat patients with respect and courtesy in answering all questions and concerns they may have. Residents will be able to communicate effectively with all members of the operating room team. Charting will be clear, complete and legible at all times. Collaborator Residents will consult effectively with other health care professionals to achieve suitable care for the patient and optimization prior to surgery. Residents will convey information to the necessary professionals to achieve optimal care for the patient. Residents will understand the importance of good working relationships with other staff at the HDH to ensure smooth patient care and safety. Residents will maintain a collegial relationship with surgeons, consultants and family physicians. Residents will collaborate with the family physician to ensure optimal patient assessment and preparation (e.g., baseline test results, blood pressure management), and necessary follow up for any issues identified perioperatively. Manager Residents will effectively manage their own operating room, ie: setting up in the morning, checking the machine, preparing appropriately for each case, etc. Residents will demonstrate the ability to organize anesthetic tasks efficiently without sacrificing standards of care. Residents will use health care resources wisely without sacrificing standards of care.

15 Residents will be aware of how the operating rooms are managed at the HDH. Residents will be aware of the interactions of the various OR personnel in a typical day. Residents will demonstrates knowledge of the departmental and facility guidelines for management of patients in the perioperative period (e.g., sleep apnea, sickle cell anemia, malignant hyperthermia, implantable cardioverter-defibrillator, ambulatory surgery, monamine oxidase inhibitors, anticoagulants). Residents will ensure that their attending staff is aware of any complications or delays. Health Advocate Residents will initiate appropriate education of patients/families regarding health-related issues. Residents will ensure that the patient s safety is placed above all else. Resident will ensure that all standards of care are met when caring for each patient. Residents will encourage patients to optimize their health status perioperatively. Scholar Residents will demonstrate self-directed learning, and will continue to read around cases, consult the literature, and improve their knowledge base. Residents will continue to attend all rounds and teaching sessions. Resident will come to the hospital each morning having read up on the cases for the day, and having already reviewed the charts. Residents will continue to critically evaluate the literature and alter their anesthetic practice accordingly. Residents will begin to critically evaluate the medical literature pertaining to ambulatory anesthesia. Professional Residents will demonstrate integrity and respect when interacting with patients, families and other health care professionals. Residents will conduct themselves in an honest, responsible manner at all times. Residents will demonstrate a strong sense of responsibility and ownership for their patients. Residents will act in an ethical manner consistent with the obligations of a physician. Residents will demonstrate on going self-assessment and insight. Residents will demonstrate that they are aware of their limitations at all times and ask for help/supervision appropriately. Anesthesia for Otolaryngology Objectives 1. The resident will be able to describe the basic anatomy of the nose, mouth, larynx and neck. 2. The resident will understand the hazards, scientific principles, and anesthetic approaches to laser surgery on the larynx. This includes an approach to an airway fire.

16 1. The resident will list the anesthetic problems anticipated in a patient presenting for tracheostomy. 2. The resident will discuss the determinants of pressure in the middle ear and will be able to list the effects of, and contraindications to, the use of N The resident will discuss the physiological effects of chronic upper airway obstruction. 4. The resident will manage patients with a variety of upper airway pathology. This must include knowledge (and practical experience if possible) of the following conditions: congenital anomalies affecting the upper airway (for example, Treacher-Collins and Pierre-Robin syndromes) tracheal stenosis epiglottitis croup cancer affecting the upper airway post-tonsillectomy bleeding tonsillar abscess trismus mechanical dysfunction in the jaw 5. The resident will be able to describe the anesthetic considerations for the following surgery: nasal surgery tonsillectomy/adenoidectomy myringotomy/mastoid and middle ear surgery including cochlear implant laryngoscopy/laryngeal surgery foreign body inhalation bronchoscopy (rigid, flexible, jet ventilation, apnea technique) ENT tumors ENT infections maxillo-facial trauma temperomandibular joint surgery tracheostomy 6. The resident will have a plan for the postoperative pain management for patients having ENT surgery. 7. The resident will have an approach to the traumatized upper airway. Recommended Reading: Anesthesia for Otolaryngologic Surgery in Clinical Anesthesia. Barash (6 th ed) Chapter 50 Anesthesia for Ophthalmology Objectives

17 1. The resident will be familiar with the preoperative assessment and preparation necessary for patients presenting for ophthalmic surgery. In particular the resident will be familiar with: 17. ocular anatomy and physiology 18. concomitant diseases 19. considerations re: intraocular pressure 20. effects of ophthalmologic medications 21. effects of anesthetic agents on the eye 22. anticoagulation and eye surgery 2. The resident will develop the communication skills necessary to engage and secure the cooperation of the elderly ambulatory care patient. The resident will correctly identify patients for whom a general anesthetic is necessary. 3. The resident will be familiar with the anatomy, technique of and complications of retrobulbar and peribulbar blocks. 4. The resident will know the implications and cardiovascular management of the oculocardiac reflex. 5. The resident will be able to list the anesthetic considerations in: open eye injuries cataract surgery retinal surgery strabismus surgery IOP measurements in childhood glaucoma 6. The resident will be able to outline the anesthetic implication of the instillation of SF 6 (sulfur hexafluoride) into the eye. 7. The resident will demonstrate a technique for achieving smooth emergence from GA without bucking and coughing. 8. The resident will be familiar with common postoperative ocular complications. Recommended Reading: Anesthesia for Ophthalmologic Surgery in Clinical Anesthesia. Barash (6 th ed) Chapter 51 Ophthalmic Surgery in Anesthesiologist s Manual of Surgical Procedures. Jaffe (4 th ed) Chapter 2 Ambulatory Anesthesia Objectives 1. The resident will be familiar with, and be able to demonstrate the appropriate preoperative assessment, preparation and premedication in an ambulatory setting to include consideration of: NPO status Drugs that reduce the risk of aspiration

18 Multimodal analgesia Postoperative nausea and vomiting prophylaxis and treatment Anxiolytics, sedatives, and opioids Chronic medications 2. The resident will be able to appropriately select patients suitable for ambulatory anesthesia including the following considerations: Length and nature of surgery Need for transfusion Concomitant disease Extremities of age Morbid obesity Anticipated post-operative analgesia requirements Anticipated post-operative monitoring requirements 3. The resident will be familiar with the salient features of the design and management of a facility catering to efficient ambulatory anesthesia. 4. The resident will be able to describe appropriate anesthetic techniques for ambulatory anesthesia including: Appropriate selection of general, regional, sedation, or local anesthesia Intraoperative consideration of potential postoperative problems Postoperative pain management Time in PACU Prophylaxis and treatment of postoperative nausea and vomiting Appropriate selection of muscle relaxants, narcotics, local anesthetics Airway intervention Considerations for regional anesthetic techniques Postoperative arrangements following central neuraxial blocks and plexus blocks Monitored anesthesia care techniques 5. The resident will be able to describe: Discharge criteria and patient instructions Criteria for hospital admission 6. The resident will have a plan for postoperative complications. Recommended Reading: Ambulatory Anesthesia in Clinical Anesthesia. Barash (6 th ed) Chapter 32 Peterborough Rotation Objectives

19 During the block of anesthesia training in Peterborough, residents will continue to refine their knowledge and skills in general operative anesthesia while gaining exposure to anesthesia in a regional community hospital. The expectations for performance will change depending on what quarter of the year residents are in. Residents will also participate in on-call duties while in Peterborough. Family Medicine Expert During this rotation the objectives will fall under the appropriate subspecialty objectives for the list that is assigned. This will include adult and pediatric cases. The resident will be able to outline the necessary considerations and demonstrate competency in delivering anesthetics for the various anesthetic subspecialties as practiced in Peterborough. The resident will practice within the confines of the policies and procedures of the Peterborough facility. Communicator Residents will be able to effectively communicate and present management plans to patients and their families prior to their anesthetic. Residents will be able to present cases to the attending staff in a clear, concise manner. Residents will communicate risks and benefits of various anesthetic techniques in such a manner that the patient can make an informed decision regarding treatment. Residents will treat patients with respect and courtesy in answering all questions and concerns they may have. Residents will be able to communicate effectively with all members of the operating room team. Charting will be clear, complete and legible at all times. Collaborator Residents will learn about regional practice patterns in the delivery of safe anesthetics. Residents will consult effectively with other health care personnel to achieve suitable care for the patient and optimization prior to surgery. Residents will collaborate with other services, particularly ICU and PACU, regarding preand post-operative care of patients. Residents will maintain a collegial relationship with surgeons, consultants and family physicians. Residents will collaborate with the family physician to ensure optimal patient assessment and preparation (e.g., baseline test results, blood pressure management), and necessary follow up for any issues identified perioperatively. Manager Residents will effectively manage their own operating room, ie: setting up in the morning, checking the machine, preparing appropriately for each case, etc. Residents will be aware of how the operating rooms are managed in Peterborough. Residents will be aware of the interactions of the various OR personnel in a typical day. Residents will experience different departmental and facility procedures, practices and policies.

20 Residents will ensure that their attending staff is aware of any complications or delays. Health Advocate Residents will initiate appropriate education of patients/families regarding health related issues. Residents will ensure that the patient s safety is placed above all else. Resident will ensure that all standards of care are met when caring for each patient. Residents will encourage patients to optimize their health status perioperatively. Scholar Residents will demonstrate self-directed learning and will continue to read around cases, consult the literature, and improve their knowledge base. Residents will continue to critically evaluate the literature and alter their anesthetic practice accordingly. Professional Residents will demonstrate integrity and respect when interacting with patients, families and other health care professionals. Residents will always be professional when working with the surgical services, recognizing differences in personal opinion, methods of practice and communication styles. Residents will conduct themselves in an honest, responsible manner at all times. Residents will demonstrate a strong sense of responsibility and ownership for their patients. Residents will act in an ethical manner consistent with the obligations of a physician. Residents will demonstrate on going self-assessment and insight. Residents will demonstrate that they are aware of their limitations at all times and ask for help/supervision appropriately.