In Residency News, Uncategorized

In Attendance: Drs. Caballero, Djalali, Ingrande, Kalra, Kan, Kelleher, Kulkarni, Macario, Newmark, Oakes, Sliwa, Tanaka (chair), Udani, Wagaman; Marissa David, Janine Roberts

Welcome to the Committee: Dr. Praveen Kalra.

New simulation program for Anesthesia and General Surgery housestaff: Dr. Udani is working with a small group from our department, as well Dr. Lau and the general surgery chief residents, on a simulation course to practice communication and teamwork skills between surgery and anesthesia personnel in the operating room. This multi-disciplinary simulation-based crisis resource management training will eventually involve nurses and others in the surgical team. The goal is to have 3-4 residents from each of the anesthesia and surgery departments participate in a half-day course with a projected March 2014 launch with one course this academic year to get started.

Echo track for residents interested in sitting for the Basic Perioperative Transesophageal Echocardiography Exam (PTExAM): By way of background, the Stanford Anesthesia vision is to provide the environment and resources to help fulfill the resident’s highest professional potential. The goal is to produce outstanding clinical anesthesiologists and leaders who also have additional areas of expertise such as Research via the FARM program, Global Health, Medical Education, Quality Improvement/Management/IT, combined clinical training in pediatrics and anesthesia, combined training in internal medicine and anesthesia, or indepth training in some clinical subspecialty.
CA2 Jan Sliwa and the cardiac anesthesia division are working on a 1-2 yr echo track for those residents specifically interested in sitting for the Basic Perioperative Transesophageal Echocardiography Exam (Appendix has summary). The preliminary curriculum includes completing 8 modules, use of online video lectures, dept provided book (Basic and Perioperative TEE by Savage and Aronson), monthly TEE lectures, and the TEE Simulator at LKSC. If curriculum completed, there may be an opportunity to attend the Annual Intraoperative TEE review course (Basic Session) and sit for the Basic PTE Exam (fees possibly covered in part or whole by the department). Residents will need to start on this early in their CA1 year to reach the required numbers for the exam: 50 Category 1 exams (TEE performed) and 100 Category 2 exams (TEE reviewed). The echo service currently is looking for more opportunities to teach and show the benefits of using echo for noncardiac cases. All Stanford attendings and trainees should feel free to contact the cardiac fellow or cardiac attending on call for echo service, even after hours and on weekends for echo consults. Several current CA2s are committed to finishing this echo track.

Stanford Anesthesia Medical Education Summit Meeting: The summit was held on September 26th, 2013 and was an opportunity for people to present different projects, receive feedback, and solicit participants and collaboration. The summit was one part of effort to help build a community of education scholarship in the dept. The plan is to have FNR session held every third Thursday of the mth 5pm to focus session on education and faculty development. Please contact Dr. Tanaka if interested in participating. Residents are invited to attend.

Rotation Milestones Update: Dr. Meredith Kan, orthopedics rotation director, has been working on the milestones for the rotation and she presented the milestones to the Committee. A planned piloting of rotation milestones will begin soon. This is also true for the bariatric rotation (Dr. Ingrande rotation director). The milestones should result in better direct teaching and assessment. Specific assessment forms customized to the learning goals and milestones are being developed such that by the end of 2014 each rotation will have a new resident evaluation form with questions specific to that rotation and level of training. Having a rotation specific evaluation on MedHub that addresses rotation specific milestones is part of the dept’s overall Milestones Program led by Dr. Adriano.

Airway Workshop: This year’s workshop will be held November 16th and 17th, 2013

Appendix. Basic TEE Exam Content Outline (NBE Website)
1. Patient Safety Considerations
2. Echocardiographic Imaging: Acquisition & Optimization
3. Normal Cardiac Anatomy & Imaging Plane Correction
4. Global Ventricular Function
5. Regional Ventricular Systolic Function & Recognition of Pathology
6. Basic Recognition of Cardiac Valve Abnormalities
7. Identification of Intracardiac Masses in Non-Cardiac Surgery
8. Basic Perioperative Hemodynamic Assessment
9. Related Diagnostic Modalities
10. Basic Recognition of Congenital Heart Disease in the Adult
11. Surface Ultrasound for Vascular Access

Module 1: Ultrasound Physics, TEE Safety
• Key Topics: Patient Safety and Ultrasound (absolute/relative contraindications to TEE, infection control), Physics principles (Doppler shift, aliasing, Nyquist limits, pulsed wave vs. continuous wave Doppler & their applications, M-mode, gain, depth, wavelength/frequency/resolution/artifacts)
Module 2: The Probe & Standard views
• Key Topics: Probe capabilities (degrees of freedom), Recognizing normal anatomy & Imaging optimization in each view
• Toronto TEE website
• Intro to the exam with Simulator sessions
Module 3: Ventricular Function
• Key Topics: Recognizing normal/abnormal ventricular function (hypokinesis/akinesis/dyskinesis, quantification of systolic function), Ischemic changes (views for visualizing all 16 LV segments, recognizing ischemic segments), coronary blood supply, LVH/DCM/HOCM
• Pathology on Simulator sessions
• Archived TEE exam review
Module 4: Valvular Function
• Key Topics: Recognizing normal valve anatomy, Characterization of leaflet motion (normal, restricted, prolapsed, flail), recognizing severe valve lesions (regurgitant/stenotic), Nyquist limits
• Pathology on Simulator sessions
• Archived TEE exam review
Module 5: Great Vessel pathology/Intracardiac Masses/Pericardium/Pleural spaces
• Key Topics: Ao dissection/aneurysm, Normal vs Abnormal intracardiac masses (Chiari network, Eustachian valve, Crista terminalis, Lambl’s excrescences, Nodule of Arantius, Moderator band, LV bands, papillary mulscles, Abnormal masses eg. myxoma, fibroelastoma, IVC thrombus, pulmonary embolism), Pericardial effusion, Pleural effusion
• Archived TEE exam review
Module 6: Introduction to Hemodynamics
• Key Topics: Measuring CO (views for obtaining LVOT/RVOT VTI, calculation), techniques for monitoring volume status, RVSP, Qp/Qs
• Moodle lectures
• Moodle online quiz
• Archived TEE exam review
Module 7: Congenital Heart Disease
• Key topics: Recognition of ASD (PFO, Secundum ASD, Primum ASD, Sinus Venosus ASD, Unroofed coronary sinus), Performing a bubble study, Bicuspid Aortic Valve disease, Recognition of VSD (inlet, membraneous, intramuscular, supracristal), Coarctation of the Aorta, Patent Ductus Arteriosus
• Archived TEE exam review
Module 8: Surface Ultrasound for Vascular access
• Key topics: Surface anatomy of central venous access (IJ, femoral, subclavian/axillary long axis), arterial access (radial, ulnar, brachial, femoral), peripheral venous access (deep brachial), guiding IABP placement, confirming central line placement

Suggested Curriculum:
• 1-2 year track to complete all modules (starting as CA-1 or CA-2)
• 1-2 months per Module
• Online video lectures/course materials
• Book provided by department for residents starting TEE track
• Access to fellows’ TEE review course materials
• Access to archived TEE exams for review
• Attendance at monthly TEE lectures
• Attendance at TEE Simulator at LKSC
• Continuation of 2 week Cardiac/TEE rotation prior to 2 month Cardiac rotation
• Continuation of GOR/TEE rotation to get more exams
• If curriculum completed, an opportunity to attend the Annual Intraoperative TEE review course (Basic Session) and sit for the Basic PTE Exam. (Fees possibly covered in part or whole by the department).
• Basic Certification requires 50 Category 1 exams (TEE performed) and 100 Category 2 exams (TEE reviewed)

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