To Anesthesia Department: ANESTHESIOLOGY ACADEMIC YEAR 2012-2013 The new first years are starting on Tuesday, July 2, 2012. For those that haven t been here for July before - or can t remember the process (or blacked it out) I have attached a copy of the CA1 first year orientation. In summary the new first years work through a 3-½ week orientation to anesthesia and the OR s. This year the first week starts July 9 th and runs through the end of July. All of the CA-1 class will accomplish orientation to call (baby call) with the senior residents. Some of the first years will start on call West or OB in August. The goal of the first 3-½ weeks is to have the residents work with a limited number of attendings on basic cases. First years for the most part will stay on the East Campus. Each first year resident has been assigned to a group of attendings or tutors, with whom they will work with regularly, schedule permitting. Evaluation is a very important part of the orientation. Each resident will be given a pocket sized evaluation booklet to keep with them during the first few weeks. They will fill in the number of procedures performed, topics discussed, etc. In addition, the attending needs to sign off each day in the booklet. This booklet will be returned to the residency office for review in the beginning of August. In early September we will have a staff meeting devoted to resident evaluation and will assess the first year s progress. By this time, it is expected that the CA1 s will have been on call at least 3 times. Please email me with suggestions/comments. Thanking you in advance for your help John Mitchell Page #32327-1-
RESIDENT LECTURES Resident Lectures: CC-439, West Campus Monday CA1 only, 3-5:00 pm Tuesday CA1 only, 3-5:00 pm In July and August there is no 4pm lecture, these resume in September Thursday 4-5:00 pm All residents (Simulation) Department Lectures: Wednesday 7-7:50 am Grand Rounds: Sherman Auditorium, East Campus Wednesday 7:50 8:30 am Clinical Conference ALL LECTURES ARE POSTED ON THE INTRANET ORIENTATION For the four weeks from July 9 th to August 3rd, first year residents will work one on one with attendings. CA1 residents will be scheduled in the Feldberg and Shapiro ORs, as much as possible. Each CA1 resident has been assigned 3-4 primary attendings for the first month. The floor managers will be asked to schedule these attendings and residents together as much as possible. Attendings have been chosen that are not on vacation and who have limited subspecialty commitments. Each resident has received an attendance booklet for the month. The CA1 curriculum is posted on the intranet. Assignments to ECT, cataracts and double rooms will be tracked. -2-
CA1 TUTORIAL Welcome to the Beth Israel Deaconess Medical Center and the Department of Anesthesia and Critical Care. Over the coming weeks and months, you will be introduced to a new city, a new hospital, and a new medical specialty. We understand that trying to learn so much about so many things can be difficult. In order to ease your transition into the operating room (and the hospital at large), we have developed a tutoring system. The tutors with whom you will work over the next four weeks will help guide you through some of the basics of anesthesia, will make sure that you have been taught and then evaluated on some essential skills (like how to put in an IV). It is hoped that after these few weeks all residents will have had a similar basic training, that you will be able to contribute constructively to the administration of a basic anesthetic, and that you will begin to feel comfortable in the operating room environment. Below is an outline of how we expect the tutor system to operate. The Chief Residents, as well as Dr. Bo Jachna (Tutor/Mentor Facilitator) are available to help with questions. BASIC STRUCTURE: During the month of July, each of you will be assigned to 3-4 attendings. While the tutors will likely teach you many things not outlined on the topics lists, it is your responsibility will be to come to work each day prepared to discuss at least those topics assigned for the week. The tutors will also be evaluating you on daily basis in your blue book. THE TUTOR S ROLE: The tutors have several important roles. First, they will introduce you to the basics of a few styles of anesthesia. Each of us has our own way of administering anesthesia, and so you will be introduced to a few styles over the first month. We also all have different teaching styles. Later in the year you will choose a mentor (see below). The exposure to the different teaching styles will help your choose a mentor to guide you through the remainder of your residency. The second role of the tutors is to get your through the topics for each week. These topics have been chosen because they are some of the real nuts and bolts issues that you should know by the end of your first month. While the schedule for each topic is not set in stone, you should help make sure that you get through all of the topics each week. If Thursday comes, and you find that there are still several topics that you have not covered, feel free to ask your tutor to cover them over the next two days. -3-
The tutors final significant role is to give you feedback and an evaluation daily. This is not meant to make you feel like you are working under a microscope, it is very important. It helps you (and us) know where your strengths are and where you need to improve. It helps the tutors communicate to each other, and thus maximize their role. Finally, since you come in with different backgrounds and learn at different speeds, getting early evaluations can help us give additional support to those who need it. EVALUATION BOOKLET: You will receive an evaluation booklet for the first 4 weeks (AKA The Blue Book ). This booklet contains list of procedures and topics that should be covered during the first month. Each time a procedure is performed e.g., an intubation or IV, then the resident should mark this in the booklet. The second half of the booklet is for the attending. There is a daily sheet with check-offs and space for comments. This booklet should be returned to the residency office (CC-470) at the beginning of August. A blank book or no book will be taken as an indication that the resident did not show up and the month will need to be repeated. If on the off chance your blue book is misplaced/washed/or lost, extra copies are available in the residency office (CC-470) GENERAL Professional Attitude Toward Patients: Your bedside manner can have a dramatic effect on the opinions that the patients (and your colleagues) have of you. In addition, since we generally do not have long-term relationships with our patients, the first impression that you make may be the only one that matters. To that end, some guidelines for interaction with patients include: Introduce yourself: State your name and your function (i.e. anesthesia resident). Address the patient as Mr./Mrs./Ms./Dr. unless told to do otherwise by the patient. Tell the patient what to expect, particularly when you are about to do something that might be painful. Say, This may sting a bit when placing an IV. Be mindful of the patient s experience. If he/she says that something hurts, acknowledge the statement and try to get rid of the pain. Maintain privacy when taking a history or performing a procedure (this can be difficult in the holding area), but making the effort can put the patient at ease). Keep the patient covered as much as possible when performing -4-
procedures. Acknowledge cultures that might be different from your own. Be mindful of beliefs/traditions/lucky charms that the patient wishes to bring to the O.R. Please remember that part of a patient s perception of how professional we are includes general appearance. Although for most it is second nature, please remember to come to work well-groomed and do not wear street clothes under your scrubs. This includes keeping your lab coat looking neat. Put your best foot forward for your patients. Professional Attitude Towards Colleagues: You should maintain a professional attitude towards your colleagues (including members of our department and other operating room personnel). When you work with someone for the first time, introduce yourself. You will find that most people at BIDMC are friendly and will welcome you here. ASSIGNED TOPICS: Below is a list of the topics/skills that should be covered each week. This is clearly not an exhaustive list of anesthesia topics. Rather, it is designed to be very practical, and to help you get through the first several weeks, and to prepare you to be on call at the end of the first month. Week 1: Week 2: Week 3: Week 4: Machine check Rapid sequence induction Pre-op assessment Local Anesthetics Standard Monitors Airway assessment Informed Consent Induction agents IV Placement Transducer set-up Co-existing disease basics Mask ventilation Intubation Level 1/Infusion pumps Difficult airway algorithm Invasive monitors POE entry Inhalation agents Vasopressors Opioids Charting LMA Muscle relaxants The expectation is that your tutors will formally evaluate you on each of these elements. This can help us document that you have begun to master these skills, and will also help you to know what areas still need improvement. If you find that at the end of one of the weeks you have not been taught one (or more) of these topics, please ask your tutor to do so. Below you will find a general description of -5-
each of these topics to help you (and your tutor) know what is expected each week. TOPICS OUTLINE WEEK 1: Machine Check: There is a description of the complete machine checkout procedure hanging from each anesthesia machine. Your tutors will take you through this, but you should familiarize yourself with this list. Many of us use the SOAP acronym to help remember an abbreviated version of this checkout. This stands for: S: Suction: Make sure the wall suction is working, within reach, and has enough tubing to reach the patient. O: Oxygen: Make sure the wall source is functioning and that the tanks are full. Check the low oxygen sensor, and calibrate it if necessary. A: This stands for several things: Airway: Make sure you have the airway equipment you will need, and that it is working (i.e. laryngoscope, endotracheal tube, etc). Also check that the emergency airway equipment that should be in the room is there (i.e. an LMA in the bottom drawer, a Bougie, an Ambu bag, etc). Apparatus: This is a general check of the ventilator and anesthesia machine itself, including alarms. P. Pharmacology: Make sure the drugs you need are available. IV Placement: This can be tricky. You should be able to successfully obtain intravenous access while maintaining aseptic technique. Mask Ventilation: Adequate mask ventilation includes the following: 1. Maintenance of a patent airway in an unconscious patient. 2. Recognize an inadequate or obstructed airway and take appropriate steps to correct it (e.g. repositioning head, jaw lift, airway adjuncts). 3. Recognize situation in which mask ventilation is contra-indicated. 4. Discuss potential complication of mask ventilation (facial nerve palsy, corneal abrasion, etc). Intubation: This is relatively obvious; resident should be able to successfully place an endotracheal tube in the trachea. Important steps include: choosing appropriate equipment -6-
proper head position taking care to avoid damage to lips, teeth and other tissue lifting laryngoscope appropriately (not torqueing) Charting: The resident should be introduced to the AIMS system, as well as paper forms used in our department. Specifically, the pre-procedure assessment, anesthesia consent and anesthesia record should be reviewed. The resident should complete the relevant documents in a professional, legible, and accurate manner. The following is taken from a recent addendum to departmental policy: It is expected that the anesthesia record provide a clear, accurate, and legible account of anesthesia related events in operating room. Heart rate and blood pressure must be documented at least every 5-minutes. Respiration and oxygen saturation should be documented at least every 30 minutes, but should be done more often at times when these are changing rapidly (i.e. during significant changes in anesthetic depth). WEEK 2: Rapid Sequence Induction: The resident should know basic indications, contraindications, and complications of RSI. In addition, he/she should know, and be able to perform the basic the basic steps of RSI. This should include: having appropriate equipment available adequate pre-oxygenation rapid laryngoscopy knowing how to give cricoid pressure Airway Assessment: The resident should demonstrate knowledge of the basic factors that might predict a difficult intubation (Mallampati class, mouth opening, thyro-mental distance, neck extension, history of difficult intuition, etc.). He/she should be able to accurately assess these factors in a patient. Transducer Set-up: The resident should know where the equipment for transducers is kept and how to set up, including zeroing the monitor. Level-1/Infusion Pumps: Level-1: The resident should know where to locate the pump and the accessories. Should be able to assemble the pump to a timely manner. Should know the risks associated with the use of a rapid infuser. Infusion Pumps: The resident should know the location of the pumps, tubing and electric cords. The resident should be able to program the pumps to deliver cc/hr, mcg/min, mcg/kg/min on the Bard and Baxter pumps. -7-
Failed Intubations Algorithm: The resident should be able to recite basic steps in the algorithm, including: Call for help Reposition head Try different blades Most experienced anesthesiologist attempt intubations What to do if you can/can t mask ventilate Location of the airway cart Location of adjuncts already in the room (Boogie, LMA, cricothyroidotomy kits) LMA: The resident should know where to find an LMA. The resident should be able to successfully place an LMA. Of course, this will depend on being assigned to a case that is appropriate for anesthesia under LMA. The hope is that all residents will have some experience with mask anesthesia and the LMA by the end of the first month. WEEK 3: Pre-Procedure Assessment: The resident should have the opportunity to observe their tutor perform a pre-procedure assessment. The tutor should then observe the resident (either accompany him/her to see an inpatient or observe in holding area for telephonic patient). The important elements of a pre-procedure assessment include: Pleasant and profession introduction of self to patient. Include name and role (e.g. My name is Dr. John Smith, and I am the anesthesia resident Confirmation of the patient s name (use Mr. Jones not Bob unless otherwise told by the patient) Confirmation of the procedure to be performed Careful past medical history, include review of systems (especially cardiac, pulmonary, GI/Reflux, endocrine, renal) Anesthesia/surgical history Medications and allergies Directed physical exam. Should include vital signs, airway, cardiac, lungs, other as indicated NPO instructions/orders Consent (see below) Appropriate documentation of the above Informed Consent: The resident should see consent obtained, and then be observed obtaining consent. Some important elements of obtaining informed consent include: -8-
Pleasant and professional introduction of self to patient. Include name and role (e.g. My name is Dr. John Smith, and I am the anesthesia resident. Confirmation of the patient s name (use Mr. Jones not Bob unless otherwise told by the patient). Confirmation of the procedure to be performed. Discussion of all relevant anesthetic option. Since conversion to general could be required during any procedure, it is prudent to always include this in the discussion. Discussion of relevant risks. While there are no absolute guidelines regarding what risks must be discussed, BIDMC policy on informed consent states, The physician should disclose in a reasonable manner all significant medical information that (a) the physician possess or reasonably should possess as a physician with appropriate knowledge a technical skill practicing in that specialty, and (b) is material to an intelligent decision by the patient. Documentation of the types of anesthesia discussed on the Pre-procedure Assessment form. Completion of the Anesthesia Consent. This should include: documentation of the name and date of procedure, writing in any additional risks relevant to the patient that are not covered on the form, patient signature, MD signature. Co-Existing Disease: While we cannot cover all of co-existing disease in one week, residents should be given an introduction to pre-operative assessment for, anesthetic implication of, and complications related to the following conditions: Ischemic heart disease Major Valvular heart disease Pulmonary disease Diabetes Hypertension Renal failure Post-op Nausea & Vomiting Know basic protocols to prevent PONV Identifying high-risk patients PACU/POE Orders: Know how to enter POE orders Invasive monitors Know where to find and set up including zeroing Scavenger Hunt You will be given a list of equipment to find on the East and West. -9-
WEEK 4 Pharmacology: You will be using many new medications throughout the month. During the fourth week you should review doses, pharmacokinetics, side effects, indications and contraindications of these classes of drugs. In addition, you should use this time to review topics that have not been covered during the previous 3 weeks. Be prepared to discuss: Muscle Relaxants Opioids Induction agents Inhalational agents Vasoactive agents Other topics must be covered Trauma room set up checklist Location ICU, PACU and holding area on East and West Know where work room is Know location of: a) Airway cart b) Emergency code cart c) Level 1 d) Omnicell machines e) MH cart f) Latex allergy g) Cart procedures Administrative Responsibilities: By the end of orientation phase, all residents must: 1. Know how to check email 2. Know how to use POE and computer to lookup patient information 3. Know how to remove drugs from pharmacy and the PYXIS machine 4. Know how to use PACS Date Created: Jul 2006 Review Date: Nov 2011 Review Due: Nov 2012-10-