Medical Students

 

Elective Fourth Year Rotation Goals
 

I.               Medical Knowledge

a.   Acquire an appreciation of the Anesthesiologist's considerations in preoperative  evaluation of the patient, including common preexisting conditions that may affect perioperative management.

b.   Understand which medications should be continued in the perioperative period

c.   Understand what medications are commonly used as premedications and their indications, dosages and contraindications

d.   Understand common induction agents and their relative benefits or drawbacks

e.   Understand what inhalational anesthetics do, including side-effects, and dosages

f.    Understand how neuromuscular blockers work, and their side-effects

g.    Understand basic airway anatomy, and airway management techniques

h.    Be familiar with ASA standard monitors, including how to apply them to a patient

i.     Know indications for invasive monitoring

j.     Understand how to interpret the findings of invasive monitors

k.    Understand which fluids are commonly used in the operating room and why they are  used

l.     Know common intraoperative complications and their possible etiologies

m.   Know local anesthetic pharmacology appropriate to the practice of general medicine

n.    Understand risks and benefits of regional anesthesia

o.    Be familiar with the types of patients and procedures that are appropriate for outpatient procedures, and the implications of ambulatory surgery on perioperative management

p.    Know how to assess postoperative pain and several modalities for treatment

II.               Patient Care

a.    Develop the ability to form a basic management plan for an anesthetic, including choice of  premedications, induction agents, monitors, and maintenance agents

b.   Develop the ability to prescribe a fluid management plan based on the patients history, procedure type and hemodynamics

c.   Develop the ability to perform basic airway management, including bag-mask ventilation and intubation

d.   Develop IV placement skills

III.            Practice Based Learning

a.   Examine and assess patient experiences for ways to improve patient care

IV.             Interpersonal and Communication Skills

a.   Function as a member of the anesthesia team, demonstrating effective communication skills with the attendings, residents and OR staff

V.             Systems-Based Practice

VI.           Professionalism

a.   Demonstrate care in developing an appropriate patient-physician relationship, and good bedside manner

FOURTH YEAR ROTATION OBJECTIVES.

I.            Preanesthetic Evaluation

A.      Conduct several preanesthetic assessments, including

1. Taking and recording a pertinent history

2. Performing an appropriate physical examination, including assessment  of:
                         airway
                         cardiovascular system
                         respiratory system
                         other systems as indicated

3. Reviewing pertinent laboratory data

4. Assigning appropriate ASA physical status

B.      Discuss how the following factors may influence the patient's course during the perioperative period:

1. Age

2. Nature of surgery, including minor versus major, peripheral versus central, and elective versus emergent, outpatient versus inpatient

3. Cardiovascular disorders, including but not limited to:
coronary insufficiency
hypertension
myocardial failure
dysrhythmias
 

4. Respiratory disorders
known or suspected difficult intubation
upper and/or lower respiratory infection
asthma
chronic obstructive pulmonary disease
lab work-up

5. Central nervous system disorders
increased intracranial pressure
convulsive disorders
cerebrovascular insufficiency
quadriplegia or paraplegia

6. Gastrointestinal disorders
    pulmonary aspiration risks:
        hiatal hernia/gastro-esophageal reflux/full stomach
        functional or mechanical bowel obstructions
        hepatitis, hepatic insufficiency, portal hypertension

7. Renal insufficiency

8. Hematologic disorders
anemias
coagulopathies
hemoglobinopathies

9. Personal or family history of unusual response to anesthesia
malignant hyperthermia susceptibility
abnormal succinylcholine metabolism

10. Lifestyle factors
obesity
substance abuse - tobacco, alcohol, chemicals

11. NPO status, including ASA guidelines for NPO status

C.     Discuss medication histories and the influence of chronic and current medications on the perianesthetic period, including:
         1.       Which drugs should be discontinued and why
         2.       The rebound phenomena resulting from abrupt discontinuation of some classes of drugs, notably beta blockers, and clonidine           

3.       Approaches to perioperative management of patients taking insulin or anticoagulants

 II.            Preoperative Medication

       A.         The student shall name effective preanesthesia medications and their indications for:          

                                     Relief of anxiety/Amnesia, specifically midazolam

1. Analgesia

2. Drying secretions, specifically glycopyrrolate

3. Reducing gastric acidity and volume, specifically H2 antagonists, metoclopromide, and antacids

4. Prevention of exacerbation of reactive airway disease, specifically beta-2 agonists

5. Preventing infection at the surgical site or for SBE prophylaxis

 III.       The Operating Room

            A.            Induction

1.   Identify several agents used on induction of general anesthesia and discuss their advantages and disadvantages:

            a.            Intravenous agents

            b.            Inhalation agents

            c.            Neuromuscular blocking agents

    2.     Observe and practice airway management during several uncomplicated intravenous inductions

    3.     Formulate a basic anesthetic plan for an ASA II patient undergoing a procedure

B.            Airway

1. Describe the indications, risks, and benefits of airway managment by mask or LMA versus intubation

2. Identify basic oropharyngeal and laryngotracheal anatomy

3. Identify and overcome upper airway obstruction with mask ventilation, using

            a.            Appropriate mask holding technique

            b.            Jaw thrust

            c.            Nasopharyngeal airway

            d.            Oropharyngeal airway

C.                 Intraoperative monitoring:

    1.      Identify ASA standard monitors for all anesthetics

    2.      Explain and demonstrate ECG lead placement and selection to optimize detection of dysrhythmias and ischemia

    3.      Explain indications and risks for invasive methods for monitoring arterial and central venous pressure

    4.      Correctly interpreting data from the following monitors of volume status:

             a.       Examination of the patient

             b.       Pulse and blood pressure   

             c.       Urine output

             d.      CVP

             e.      PCWP

    5.      Interpret results of arterial blood gas analysis in terms of

            a.            Oxyhemoglobin dissociation curve

                        b.            Acid-base status

D.            Fluid and electrolyte therapy:

    1.     Explain the rationales for establishing central and peripheral venous access

    2.     Identify the common sites for venous access and the contraindications and indications for each

    3.     Demonstrate skill at establishing venous access by:

            a.            Using sterile technique and universal precautions

            b.            Successfully inserting several peripheral catheters of various calibers

            c.            Protecting the venipuncture site and immobilizing the catheter

4.            Prescribe maintenance fluid and electrolytes

a.            Predicting how the following preoperative conditions will alter requirements for perioperative maintenance therapy:

                        1.            NPO
            2.            Bowel prep
            3.            NG suction
            4.            Fever

b.            Discussing intraoperative considerations which alter maintenance fluid and electrolyte therapy including:                       

                        1.            Blood loss
            2.            "Third space" loss     

c.          Discussing indications, drawbacks and benefits of crystalloid, colloid and blood product replacement therapies:

            1.            Regarding the functions of:
                blood volume
                oxygen carrying capacity
                coagulation

            2.            Regarding complications of each type of therapy

E.         Identify several position-related injuries that patients may sustain while unconscious

F.          Discuss methods of recognizing and treating various perioperative problems, including:

            1.         Dysrhythmias, including tachycardia or bradycardia

            2.         Hypotension

            3.         Hypertension

            5.         Low oxygen saturation

            7.         Endobronchial intubation

8.         Esophageal intubation

9.         High peak airway pressures

10.       Low urine output

G.         Identify risk factors for post-operative nausea and vomiting and several prophylactic interventions

 

IV.            Regional Anesthesia

A.         Local anesthetics:

            1.         Classify commonly used agents according to amide or ester linkage

            2.         List commonly used local anesthetics for:

                        a.         Topical use

                        b.         Local infiltration

                        c.          Peripheral nerve blocks

3.            List acceptable doses of at least two agents used for topical and local infiltration anesthesia

4.            Describe and identify signs of impending local anesthetic and/or vasopressor toxicity vs. "allergic reaction"

5.            Describe therapeutic steps necessary to prevent or treat local anesthetic toxicity in the event of an accidental intravascular injection

B.                  Neuroaxial (epidural or spinal) anesthesia:

1.        Describe basic anatomy of the spine

2.        Describe hemodynamic changes associated with neuroaxial anesthesia

3.        Identify contraindications to neuroaxial anesthesia

C.                 Peripheral Nerve Blocks:

1.        Describe advantages to peripheral nerve blocks for anesthesia or postoperative pain control

2.        Identify potential risks to peripheral nerve blocks

 

V.            Ambulatory anesthesia

A.         Identify the types of procedures and patients appropriate for ambulatory surgery

B.         Discuss assessment of the ambulatory patient with respect to:

            1.         ASA classification
2.         NPO status
3.         Appropriate lab work
4.         Nausea/vomiting prophylaxis
5.         Discharge criteria
6.         Pain management

 

VI.        Post operative pain management

A.         Compare and contrast the following treatments of postoperative pain:

            1.         IVPCA
2.         Epidural catheters
3.         Prn vs round-the clock dosing
4.         PO medications
            a.         Narcotics
            b.         Acetaminophen with or without codeine
            c.         Ketorolac/NSAIDs
            d.         COX-2 inhibitors

B.         Describe methods to evaluate pain including

            1.         Pain scales
2.         Visual analog scales

 

VII.           Professionalism

             A.           Patient Care:

1.      Introducing self to patient and as appropriate, patient family.

2.      Attending to patient concerns and questions

3.      Listening attentively

4.      Eliciting basic patient information

5.      Establishing rapport with patient

6.      Checking for patient understanding

7.      Maintaining patient confidentiality in verbal and written communications 

B.          The student will be prompt and dressed appropriately as becoming of a medical professional—As per OHSU clinical staff policy, available on web or in the education office

 

VIII.            Interpersonal and Communication Skills:

A.                  Attend to team activities, concerns, and issues respectfully

B.                  Exhibit polite inclusive language and behaviors.

C.                  Direct questions and concerns to appropriate team members and/or education faculty

D.                  Clarify questions and responsibilities in a timely manner

E.                   Know professional limitation and acting accordingly

F.                   Maintain ethical and professional boundaries with patients and team members