Rotation-Specific Goals and Objectives

PEDIATRIC SURGERY - JUNIOR LEVEL

Competency-Based KNOWLEDGE Objectives

1. Demonstrate an understanding of normal pediatric fluid and electrolyte hemostasis.
2. Demonstrate the ability to recognize and correct fluid and electrolyte derangements.
3. Acid-Base Homeostasis
       a. Given values pH, PCO2 and HCO3
       b. Analyze the acid-base problem and its cause in pyloric stenosis.  Determine  an appropriate course of therapy.
4. Nutrition
        a. Discuss indications, contraindications, and benefits of enteral feedings.  Describe sites of delivery and potential complications and treatment.
        b. Discuss indications, contraindications, and benefits of parenteral feedings.
        c. Describe the details of initiating TPN, calculating caloric needs, monitoring delivery, and managing potential complications.

5. Summarize the basic approach to the diagnosis and management of more common surgical problems of infancy and childhood, such as:
        a. pyloric stenosis
        b. intestinal obstruction
        c. perforated appendicitis
        d. inguinal hernia
        e. umbilical hernia
        f.   gastroesophageal reflux

 6. Identify the technical aspects of the following procedures:

        a. excision of skin and subcutaneous lesions
        b. incision and drainage of abscess
        c. node biopsy
        d. chest tube placement
        e. gastrostomy
        f.  herniorrhaphy, inguinal and umbilical
        g. circumcision
        h. pyloromyotomy
        i.  placement of central venous line (percutaneous, cutdown, port)
        j.  appendectomy

 7. Describe the fundamental considerations in the pre-and postoperative care of infants and children in the above-listed cases.
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Achievement of competency-based KNOWLEDGE objectives will be assessed by oral examination in clinic, on the wards and in the OR
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PEDIATRIC SURGERY - SENIOR LEVEL

Competency-Based KNOWLEDGE Objectives:
1. Classify congenital malformations of the newborn by type, origin, and the need for surgical intervention.
            a. Gastrointestinal:  esophageal atresia, pyloric stenosis, malrotation, and duodenal
             imperforate anus.
            b. Pulmonary:  diaphragmatic hernia, sequestration, cystic defects, lobar
             emphysema.
            c. Abdominal wall defects:  umbilical and inguinal hernias, oomphalocele,
 gastroschisis.
            d. Head and Neck:  branchial cleft, thyroglossal duct cyst, cystic hygroma.

2. Explain the key steps in the following surgical procedures:
            a. Nissen fundoplication
            b. Bowel resection
            c. Repair of hepatic, biliary, and pancreatic injury
            d. Splenectomy
            e. Stoma closure
            f. Laparoscopic cholecystectomy
            g. Laparoscopic appendectomy

3. Analyze the pathophysiology, diagnosis, and management options in the treatment of short-gut syndrome.
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Competency-Based PERFORMANCE Objectives:
 1. Participate in preoperative, operative, and postoperative care of more complex problems in pediatric surgery such as:
            a. Integument
                        1) subcutaneous mastectomy
            b. Head and Neck
                        1) branchial cleft and thyroglossal duct cysts
                        2) cystic hygroma
                        3) thyroidectomy
            c. Thoracic
                        1) laryngoscopy, bronchoscopy, esophagoscopy
                        2) thoracotomy, thoracoscopy for biopsy, lung resection, and decortication
            d.Cardiovascular
                        1) peripheral arterial repair
                        2) resection of small vascular cutaneous lesions such as:  A-V malformation,
                            hemangioma, or lymphangioma
            e. Alimentary
                        1) flexible endoscopy
                        2) anti-reflux procedure, open and laparoscopic
                        3) Ladd procedure for malrotation
                        4) bowel resection, inflammation bowel disease, intussusception
                        5) colostomy
                        6) closure of enterostomy
                        7) Hodgkin’s staging
                        8) biopsy of tumor
                        9) splenectomy, splenic repair
                        10) laparotomy for abscess, adhesive obstruction
                        11) repair of hepatic injury
                        12) cholecystectomy, open or laparoscopic
                        13) laparoscopic appendectomy
4. Participate in the evaluation and management of pediatric trauma patients, including airway management, closed head injury, blunt injury to spleen, liver, pancreas, and small bowel.

Achievement of competency-based KNOWLEDGE objectives will be assessed by oral examination in the clinic, on the wards, in the OR and during M&M presentations.
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BURN SURGERY
PGY-2 Level
Dr. William Hickerson

Competency-Based KNOWLEDGE Objectives
Week One Objectives and Goals: Resuscitation
1. Describe basic criteria for pre-hospital care, first-aid and appropriate transport criteria.

2. Describe the pathophysiology of the burn injury with emphasis on: mechanisms of tissue death; the role of vascular thrombosis; capillary leak; osmolality and oncotic pressure; and hypovolemic shock without ongoing blood loss and its management.

3. Discuss the prognostic factors of a burn injury including depth and size of burn.

4. Review the role of various types of fluid in burn resuscitation including Ringer’s lactate, Plasmalyte and hypertonic lactated saline.

5. Discuss the formula used during burn resuscitation such as the Parkland formula, Brooke formula, and HLS protocol.

6. Describe the adequacy of various techniques to monitor the response to fluid resuscitation.

7. Discuss the initial evaluation and what diagnostic tests and relevant during the initial resuscitation.

8. Describe when fasciotomy and escharotomy are indicated in burn patients.  How are they defined and how are they completed?
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Week Two Goals and Objectives:  Initial Management

1. Describe the role of dressings in the burned patient vs. “no” dressings and how this relates to ambient temperature, risk of infection, and pain control.

2. Examine the risk of infection in the burn patient and differentiate between colonization and invasive infection.

3. Develop an understanding of clinical diagnosis of infection in the burn patient such as ileus, glucose intolerance, change in mental status or change in the temperature curve.

4. Describe the pathophysiology of the burn wound infection including the laboratory diagnosis of infection utilizing surface quantitative cultures vs. biopsy quantitative cultures vs. histology.

5. Discuss the various topical antimicrobials available, their pro’s and con’s, the principles of their use for the following:  silver sulfadiazine, mafenide acetate, Bactroban, Tribiotic solution, silver nitrate solution and Neosporin. 

6. Discuss the treatment of an infection involving the burn wound:  eschar vs. grafts.  These will include an understanding of different topical, increased frequency of dressing changes, wound debridement-OR vs. Unit, systemic antibiotics and subeschar antibiotics.

7. Describe adequate pain management techniques in the burned patient to include:  sources of pain-burn wound (i.e. partial vs. full thickness), dressing changes, OT/PT; the initial use of IV narcotics; alternatives to IV narcotics-IM, PO, transdermal, and sublingual; describe non-narcotic agents and their use to include anxiolytics and non-steroidal anti-inflammatories.

8. Describe the complications of pain management techniques (i.e. too much and too late).
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Week Three Goals and Objectives:  Surgical Management of the Burn Wound

1. Describe the various methods of removal of devitalized tissue to include:  spontaneous separation, tangential excision, and excision to fascia.

2. Discuss the various methods of wound healing:  spontaneous vs. split thickness skin graft vs. full thickness skin grafts vs. allografts vs. cultured epidermal autograft vs. artificial skin.  The student should be able to describe the mechanism and pathophysiology of each method.

3. Discuss the “timing factor” of wound closure as related to immediate excision, excision as donor site available, or delayed excision.

4. Discuss the priorities of wound closure as they relate to survival, function and appearance of the burned patient.
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Week Four Goals and Objectives:  Inhalaional Injury

1. Discuss the pathophysiology of inhalational injury to include:  thermal vs. chemical injury.

2. Describe the systemic effects of an inhalational injury and how it relates to hypoxia, hypercarbia, carbon monoxide, and cyanide, etc.

3. Describe how the bacterial clearance from the airways and the blood are effected by an inhalational injury and burn injury.  How does this effect the risk of pneumonia?

4. Discuss the recognition of an inhalational injury as related to:  history of the accident and physical exam characteristics.

5. Review the phases of inhalational injury, from immediate to the development of ARDS, with a thorough knowledge of each phase and its makeup.

6. Describe the effects of smoke inhalation of fluid resuscitation, metabolic demand, prognosis.

7. Describe the treatment of smoke inhalation including:  high FiO2 vs. hyperbaric oxygen; and, conventional ventilation vs. percussive ventilation.
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Week Five Goals and Objectives:  Nutrition and Metabolism

1. Describe the pathophysiology of the hypermetabolic response.

2. What is the role of heat loss and environmental factors such as temperature and airflow?

3. What role do humoral mediators play such as: catecholamines, prostaglandins, cytokines, and others?

4. Describe the correlation of metabolic demand with wound size and time.

5. Describe the various forms of nutritional support (i.e. parental vs. enteral) and how they relate to timing of the initiation of feeds.

6. Discuss how to predict the nutritional needs of a burned patient, including equations and formulae, metabolic cart and protein needs.

7. Discuss the technical problems associated with gastric vs. transpyloric vs. transabdominal nutritional support.
8. Discuss how we monitor the patient’s response to nutrition including calorie counts, weights, nitrogen balance, visceral protein markers, and total lymphocyte count.

9. Discuss how wound closure, blocking agents (such as LPS), cyclooxygenase, and environmental factors modify the metabolic response to burn injury.
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Week Six Goals and Objectives:  Non-thermal Burn Injuries

1. Discuss electrical injuries comparing household current to high voltage injuries.

2. Describe high voltage injuries and their pathophysiology as it relates to heat generation, cardiac arrest, secondary trauma (falls and fractures), arc vs. flash, secondary flame burns, conduction of electricity in the human body, myoglobinuria, and fasciotomies.

3. Explain the diagnostic tests available to diagnose injury (i.e. CPK, ECG and nuclear medicine scans).

4. Describe the late sequelae of electrical injuries including cataracts.

5. Discuss the management of electrical injuries in the child who bites the electrical cord.

6. Discuss the pathophysiology of lighting burns.

7. Describe the pathophysiology for chemical burns:  acids vs. alkalis.

8. Discuss management techniques for chemical burns.

9. Discuss exfoliative and necrotizing skin diseases and their pathophysiology, diagnosis, and treatment for toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome, staphylococcal scalded skin, epidermolysis bullosa, meningococcemia and purpura fulminans.

10. Discuss special types of injury including frostbite, hot tar and molten metal burns.
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Week Seven Goals and Objectives:  Rehabilitation and Reconstruction

1. Describe wound healing and how it relates to scar formation including scar hypertrophy, keloid formation, neovascularization and scar maturation.

2. Discuss treatment options to modify the hypertrophic scar formation process such as pressure garment, face masks, silicone and steroids.

3. Discuss the surgical revision of burn scars such as regrafting and tissue expanders.

4. Describe the management of contractures including regrafting, full thickness grafting, rotational flaps, and Z-plasty, Y-V flaps and W flaps etc.

5. Discuss the OT/PT for the hand including the use of splints, position of the hand functional vs. passive use.

6. What is the role for active vs. passive range of motion?

7. Discuss the role of immobilization for grafting and when OT/PT therapy should resume.

8. What is heterotopic ossification and how is it managed?

9.Discuss the psychiatric and psychological issues as they relate to the burn patient.
·         Analyze the alcohol and drug abuse patient with attention to prevention and treatment of withdrawal.
·         Discuss the role of suicide attempts, depression and post-traumatic stress disorder and how they relate to burn injuries.

10. Understand, and treat, child abuse cases with ability to recognize them when they occur (i.e. story and injuries do not match) and, further evaluation to include long bone series, bone scans and the role of documentation in these cases.
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Week Eight Goal and Objectives:  Review and Oral Examination

Competency-Based PERFORMANCE Objectives

1. Provide emergency burn patient evaluation and monitoring to include the placement of intravenous access, foley catheters, nasogastric tubes, Swan-ganz catheters, arterial catheters, endotracheal intubation when indicated.

2. Implement fluid resuscitation for children and adults in a timely manner.  Direct clinical management and supervision of the Burn Team.

3. Select and apply appropriate dressings and topical antibacterials.

4. Manage inhalational injury as needed with flexible bronchoscopy and appropriate ventilator management.

5. Appropriate wound management in the OR including debridement of eschar by tangential excision or fascial excision with scalpel, electrocautery, Norsen Debriders, Goullian Knife or Dematome.  Harvesting graft from donor site with the dermatome and associated use of the mesher.

6. Evaluate electrical burns with the ability to identify entrance/exit wounds, identify cardiac, vascular, neurologic and opthalmologic effects and complications.

7. Institute appropriate treatment of chemical burns by identifying the chemical involved, management by dilution and treatment of the local and systemic effects of the chemicals involved.

8. Manage eschar contracture and edema formation with either escharotomy or fasciotomy. 

9. Proper placement of splints and face masks.
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CAVHS GENERAL SURGERY
(Including Surgical Endoscopy)
Central Arkansas Veterans Healthcare System

Supervisory responsibility for patient care statement:

All patients cared for on the CAVHS Surgical Service are cared for under the supervision of an identifiable surgical attending.  On occasion, attendings may cover supervisory responsibilities for other attendings.  The surgery chief resident is afforded overall responsibility for direction of the service, under the supervision of the Chef of Surgery and the attending staff.  Specific policies for resident supervision are described in VHA Handbook 1400.1 (3 May, 2004) available in the CAVHS surgical service offic 
Junior Resident Knowledge Objectives:(Note:  These objectives are applicable to junior residents assigned to the CAVHS General Surgery service.)

1. Demonstrate an understanding of basic principles of management of surgical emergencies, including perioperative cardiopulmonary arrest, bleeding, wound dehiscence/evisceration and pulmonary embolus.  

2. Demonstrate an understanding of basic principles of preoperative assessment of elective and emergency surgical patients including use of preoperative consultation and obtaining informed consent for surgical procedures.

3. Demonstrate an understanding of basic principles of preparation in the operating room, including sterile technique, use of preoperative antibiotic prophylaxis, the surgical prep, positioning/draping and management of anesthetic-related emergencies.

4. Demonstrate an understanding of basic principles of preoperative and postoperative care, including pain control, fluid and electrolyte management, wound management, nutritional support, DVT prophylaxis and antibiotic treatment.

5. Demonstrate an understanding of basic principles of prevention and treatment of withdrawal syndromes in surgical patients.

6. Demonstrate an understanding of basic principles of outpatient management and follow-up of surgical patients.
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Junior Resident Skill Objectives:
1. Perform an appropriate surgical history and physical exam and appropriate preoperative or postoperative ward visits.

2. Care for simple and complex wounds, including suturing and debridement.

3. Establish peripheral or central venous access and manage complications of central venous access.

4. Perform (under faculty or senior resident supervision) surgical procedures appropriate for the PGY-1 or PGY-2 surgical resident such as hernia repair, drainage of abscess, tracheostomy, placement of feeding or central venous access and less complex abdominal surgery.
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Endoscopy Resident Knowledge Objectives:

1. Demonstrate an understanding of indications of surgical endoscopy including esophagogastroduodenoscopy, sigmoidoscopy (rigid and flexible), colonoscopy, anoscopy and ERCP.

2. Demonstrate an understanding of the use of Surgical Endoscopy in surveillance for and management of gastrointestinal neoplasia.

3. Demonstrate an understanding of the use of Surgical Endoscopy in management of gastrointestinal bleeding.

4. Demonstrate an understanding of the use of Surgical Endoscopy in management of anorectal disease including fissure, fistula and hemorrhoids.
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Endoscopy Resident Skill Objectives:
1. Perform Surgical Endoscopic procedures, including sigmoidoscopy (rigid and flexible), colonoscopy, esophagogastroduodenoscopy and anoscopy.

2. Perform selected endoscopic diagnostic therapeutic procedures such as endoscopic biopsy, polypectomy and banding of hemorrhoids.

Senior Resident Knowledge Objectives:
(Note:   These objectives are applicable to the PGY-3 Assistant Chief Resident and the PGY-5 Chief Resident on the CAVHS General Surgery service.  The PGY-3 Assistant Chief Resident is expected to begin to develop the described knowledge and skills during this rotation.  The PGY-5 resident is expected to master the described knowledge and skills and is expected to develop a mentoring relationship with the PGY-3 resident, particularly in the areas of leadership and administration.

1. Demonstrate mastery of surgical knowledge required for the diagnosis and management of routine and complex problems in general surgery, especially to include surgical oncology, hernia disease, endocrine disease, surgical emergencies, benign gastrointestinal disease and biliary tract disease.  This knowledge should be sufficiently complete to enable evaluation and management of these problems in both the inpatient and outpatient setting as well as under emergency circumstances. 

2. Demonstrate mastery of surgical knowledge required for the diagnosis and management of surgical complications.

3. Demonstrate mastery of surgical knowledge required for the rational use of surgical literature.
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Senior Resident Skill Objectives:

(Note:   These objectives are applicable to the PGY-3 Assistant Chief Resident and the PGY-5 Chief Resident on the CAVHS General Surgery service.   The PGY-3 Assistant Chief Resident is expected to begin to develop the described knowledge and skills during this rotation.  The PGY-5 resident is expected to master the described knowledge and skills and is expected to develop a mentoring relationship with the PGY-3 resident, particularly in the areas of leadership and administration.) 

1. Demonstrate skills necessary for the operative management of routine and uncommon problems in general surgery. These skills should include complex abdominal surgery, head and neck surgery, surgery of the breast, complex hernia repair and minimally invasive surgery. 

2. Demonstrate mastery of administrative skills necessary for the management of a busy academic surgical service.

3. Demonstrate mastery of evaluation, negotiation and communication skills necessary for successful
practice as a surgical consultant. 

4. Demonstrate mastery of skills necessary for complete management of surgical patients in the intensive care unit.
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VASCULAR SURGERY
 (Applicable to both the CAVHS and UAMS Vascular Surgery Services)

Unit objectives for Junior and Senior Residents
 ·         Demonstrate knowledge of the anatomy, physiology, and pathophysiology of the vascular system, including congenital and acquired diseases.
 ·         Demonstrate the ability to surgically manage the preoperative, operative and postoperative care of patients with arterial, venous, and lymphatic disease.

JUNIOR RESIDENTS

1. Describe human arterial and venous anatomy

2. Describe basic arterial and venous hemodynamics

3. Discuss the anatomy, pathology, and pathophysiology of the arterial wall

4. Review and describe the basic clinical manifestations of the following vascular disorders:

a) obstructive arterial disease

b) aneurysmal arterial disease

c) thromboembolic disease—arterial and venous

d) chronic venous insufficiency and lymphatic obstruction

5. Assess patients’ vascular systems using appropriate skills in history-taking and clinical examination.

6. Describe the relationship of the following disorders/practices to atherosclerotic vascular disease:

a) diabetes mellitus

b) hypertension

c) renal failure

d) hyperlipidemia

e) smoking

7. Differentiate between the following diagnostic tools available for assessing vascular disease and explain the relative contributions of each:

a) angiography

b) computed axial tomographic (CAT) scanning

c) magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA)

d) duplex scanning (ultrasonography)

8. Summarize the etiology and therapeutic options of specific categories of vascular disease:

a) Venous disease

1) Varicose vein disease

2) post-phlebitic syndrome

3) thromboembolic disease

4) pulmonary embolism

b) Lymphatic disease

1) anatomy of lymphatic system and lymphatic return

2) congenital lymphatic anomalies

3) acquired lymphatic disease

c) Arterial disease

1) atherosclerosis and its related disorders

2) aortic and other vascular aneurysms

3) atherosclerotic vascular disease

4) arterial embolic disease

5) arteriovenous fistulas or malformations

6) extracranial cerebrovascular disease

7) visceral ischemic syndromes

8) renovascular hypertension

d) Miscellaneous

1) sympathetic nervous system

9. Outline the principles of non-invasive laboratory diagnosis; include a description of the role and limitations of the vascular laboratory

10. Discuss basic principles of Doppler ultrasound in preparation for performing bedside arterial and venous Doppler testing

11. Outline the principles of care for ischemic limbs

12. Describe the natural history of medically-treated vascular disease in the following categories:

a) carotid arterial stenosis

b) abdominal aortic aneurysm

c) chronic femoral artery occlusion

13. Summarize principles for the preoperative assessment and postoperative care of patients undergoing major vascular surgical procedures

14. Indicate the role of anticoagulant agents, including antiplatelet agents, in the management of patients with vascular disease

15. Analyze the role of the endothelium in atherosclerosis, thrombosis, and thrombolysis

16. Describe the hemodynamics and pathophysiology of:

a) claudication

b) transient ischemic attack (TIA)

c) stroke

d) mesenteric angina

e) angina pectoris

f) renovascular hypertension

g) arteriovenous (AV) fistula

17. Explain the concept of critical arterial stenosis

18. Differentiate between acute arterial and acute deep venous occlusion

19. Discuss the principles of and contraindications for anticoagulation and thrombolytic therapy

20. Discuss the mechanics of action and the therapeutic role of the following pharmacologic types of agents:

a) vasopressors

b) calcium channel blockers

c) anticoagulants

d) antiplatelet agents

e) thrombolytics

21. Determine a plan for assessment of operative risk in these categories:

a) cardiac

b) pulmonary

c) renal

d) metabolic

e) levels of anesthetic risk

22. Discuss the role of the following factors in maintaining homeostasis in the coagulation pathways:

a) Protein S

b) Protein C

c) Platelets

d) Platelet granules

e) Endothelial cell

f) Antithrombin III

23. Describe the use of adjunctive measures in the management of patients with vascular disease such as:

a) antibiotics

b) anticoagulants

c) thrombolytic agents

d) antiplatelet agents

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1. Evaluate patients for vascular disease

2. Demonstrate skill in basic surgical techniques, including:

a. knot tying

b. exposure and retraction

c. knowledge of instrumentation

d. incisions

e. closure of incisions

f. handling of graft material

3. Participate in surgery for varicose vein disease, including:

a. ligation and stripping

b. management of venous stasis ulcers

c. management of venous thrombosis

4. Participate in amputations with specific attention to:

a. demarcation levels

b. control of toxicity

5. Demonstrate proficiency in venous access procedures

6. Demonstrate the ability to perform arterial access or arteriovenous access, including:

a. incisions

b. closure of incision

7. Obtain vascular control of diseased or traumatically occluded blood vessels using:

a. vascular clamp

b. Vessel loops

c. balloon occlusion

8. Participate in thromboendarterectomy and thrombectomy

9. Demonstrate appropriate vascular suture techniques

10. Perform the preoperative assessment and postoperative care of patients undergoing major vascular surgical procedures

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VASCULAR SURGERY
SENIOR RESIDENTS

Competency-Based KNOWLEDGE Objectives

1. Identify and describe vascular anatomy and regional anatomy related to vascular disease

2. Explain the physiologic and organic manifestations of vascular disease, such as renovascular hypertension, portal hypertension, and renal failure

3. Differentiate between the different operative approaches to the vascular system to include:
            a. incisions and exposure
            b. handling of vascular tissues
            c. principles of vascular bypass grafting
            d. emergency vascular surgery
            e. reoperative vascular surgery
            f. principles of endarterectomy

4. Illustrate the operative exposure of the major vessels, including:
            a. aortic arch
            b. proximal subclavian
            c. carotid artery
            d. descending thoracic aorta
            e. suprarenal aorta
            f. infrarenal aorta
            g. femoral artery
            h. popliteal artery

5. Outline the indications for operations for claudication, abdominal aortic aneurysm, carotid stenosis, an amputation

6. Describe the pathogenesis and complications of aneurysmal disease

7. Summarize the etiology, microbiology, and treatment of diabetic foot infection

8. Categorize the prevention and management of operative and postoperative complications, including graft infections, ischemic bowel, graft thrombosis, and extremity ischemia

9. Outline the manifestation of failing peripheral vascular grafts, contrasting angioplasty with reconstruction and amputation

10. Discuss the principles of reoperative vascular surgery

11. Outline procedures for managing vascular surgical emergencies such as acute tissue ischemia or major hemorrhage (traumatic or ruptured aneurysm)

12. Analyze the options for treatment of patients with chronic venous insufficiency and venous ulceration

13. Demonstrate a basic knowledge of the various types of graft and suture material available

14. Analyze alternative measures for the diagnosis and management of renovascular hypertension

15. Discuss alternative operative procedures for the management of portal hypertension

16. Summarize the surgical techniques available for managing the following vascular disorders:
            a. abdominal aortic bypass or aneurysmectomy
            b. carotid stenosis
            c. femoral-popliteal occlusion
            d. tibial artery occlusion
17. Apply the decision making process in analyzing complex vascular diseases, including the following:
            a. cerebrovascular problems
            b. mesenteric vascular disease
            c. renovascular disease
            d. aneurysmal disease
            e. lower extremity arterial occlusion
            f. venous disease
18. Outline the management of prosthetic graft infections, including:
            a. diagnosis
            b. use of alternate routes for revascularization
            c. use of alternative graft materials
19. Summarize complications of common major vascular procedures such as:
            a. carotid endarterectomy
            b. aortic reconstruction
            c. lower extremity vascular reconstruction
20. Describe principles, indications, practices and management of complications of selected endovascular procedures:
            a. diagnostic arteriography
            b. uncomplicated endovascular procedures

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Competency-Based PERFORMANCE Objective

1. Demonstrate the appropriate incisions and exposure of:
            a. abdominal aorta and its major branches
            b. portal venous system
            c. peripheral arterial system
            d. carotid arterial system
            e. arteriovenous fistula

2. Obtain vascular control of major vessels
            a. aorta
            b. vena cava

3. Participate in endarterectomy and bypass grafting

4. Demonstrate ability to manage graft and suture materials

5. Perform selected operative procedures or selected parts of the following operative procedures under supervision

            a. aortic aneurysm repair
            b. carotid endarterectomy
            c. aorta-iliac occlusive disease
            d. femoral popliteal occlusive disease
            e. correction of portal hypertension
            f. peripheral vascular trauma

6. Discuss and demonstrate the role of adjunctive measures in operative procedures including angioscopy, and thrombolytic therapy

7. Select and use proper advanced techniques in managing patients with a variety of vascular disorders such as:
            a. ruptured aortic aneurysm
            b. central vascular trauma
            c. suprarenal aortic aneurysm
            d. renovascular hypertension
            e. femoral tibial bypasses

8. Perform alternative methods of bypass grafting such as:
            a.  extra-anatomic bypass, principles and techniques
            b.  indirect revascularization
            c.   in situ techniques
            d.   sequential and composite techniques

9. Manage prosthetic graft infections to include:
            a. diagnosis
            b. selection of alternate routes for revascularization
            c. selection of appropriate graft materials
            d. timing

10. Manage complications of common major vascular procedures such as:
            a. carotid endarterectomy
            b. aortic reconstruction
            c. lower extremity vascular

11. Perform selected endovascular procedures, such as:
            a. diagnostic arteriography
            b. selected uncomplicated endovascular repairs

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THORACIC SURGERY - JUNIOR LEVEL
(These objectives apply to rotations at CAVHS and UAMS)

Objectives:  Demonstrate an understanding, and application, of basic anatomical, physiology, and pathological principles used in the treatment of patients with thoracic problems who will be managed by general surgeons.

Competency-Based KNOWLEDGE Objectives

1. Describe the components of thoracic anatomy, their physiology and functional relationship.
            a) muscles of respiration, diaphragm
            b) tracheobronchial tree, segments
            c) heart, great vessels, mediastinum

2. Describe the basic principles and critical factors involved in:
            a) respiration:  ventilation, perfusion
            b) control of respiration
            c)  lung ventilation, perfusion tests
            d)  respiratory failure
            e)  major lung disease categories
            f)   basics of oxygen therapy
            g)  postural drainage, respiratory toilet

3. Describe the indications for following procedures:
            a) endoscopy, thoracoscopy
            b) standard and special chest roentgenograms
            c) arteriography
            d) computed axial tomography (CAT)
            e) magnetic resonance imaging (MRI)
            f) nuclear medicine
            g) intubation, vent support
            h) central venous lines
            i) thoracentesis and/or chest tubes
            j) tracheostomy
            k) pacemaker

4. Discuss, and justify, diagnostic and therapeutic modalities for:
            a) pneumothorax
            b) hydrothorax, hemothorax, combination
            c) pulmonary infiltrate or mass
            d) abnormal cardiac, aorta configuration
            e) mediastinal masses
            f) neoplasms of the lung, esophagus, and mediastinum
            g) chest wall neoplasm

5. Describe the preoperative assessment of the thoracic surgery patient:
            a) operative risks:  history and physical
            b) diagnostic test of value for:
                        1) lung, heart and esophagus
                        2) nutrition
                        3) immune system
            c) operative choices for disease types
            d) potential complications
            e) informed consent and record
6. Recommend use of (and indications for):
            a) bronchoscopy:  flexible and rigid
                        1) laser bronchoscopy
                        2) alveolar lavage
            b) thoracoscopy
            c) thoracotomy, posterolateral
            d) pericardial window/pericardiocenteses
            e) fine needle aspiration (FNA) lung
            f)  pleural biopsy:  open or closed
            g) pulmonary resection
            h) esophageal cancer:  types of surgery
            i)  lung cancer TNM stage and treatment

7. Demonstrate an understanding of:
            a) different types of ventilators
            b) indication for ventilation
            c) management of ventilators
            d) weaning parameters from the ventilator
            e) different thoracic incisions
            f)  treatment of empyema, surgically
            g) esophagoscopy, dilatation

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THORACIC SURGERY - SENIOR LEVEL

Objectives:
Demonstrate an understanding, and application, of basic anatomical, physiological, and pathological principles used in the treatment of patients with thoracic problems who will be managed by general surgeons.

Competency-Based KNOWLEDGE Objectives
 1. Integrate pathophysiology and management of:
            a) aortic aneurysms
            b) aortic dissections
            c)  occlusive disease
            d)  invasive neoplasms of the mediastinum
            e)  esophageal rupture
            f)   stages of lung neoplasms
            g)  esophageal neoplasms
            h)  esophageal motility problems
            i)   mediastinal masses and lesions
2. Describe the diagnosis and treatment of surgical complications such as:
            a) fistulae (BPF, TE, AV)
            b) esophageal leak
            c) loculated hemothorax
            d) postoperative bleeding
            e) air leaks
            f) empyema:  apical, basal, general
3. Indications for, and interpretation of, diagnostic modalities:
            a) plain and positional chest x-rays
            b) gastrointestinal contrast studies
            c) pulmonary function studies
            d) ventilator-perfusion studies
            e) nuclear medicine studies
4. Specify and justify the use of diagnostic studies for:
            a) rigid and flexible bronchoscopy
            b) esophagoscopy
            c) mediastinoscopy
            d) thoracoscopy
            e) laser bronchoscopy
5. Assess and recommend procedures in:
            a) thoracoplasty
            b) esophageal resection or replacement
            c) ant-reflux procedures
            d) sleeve resection of bronchus (cancer)
            e) chest wall reconstruction (flaps)
6.             Indications for and use of cardiopulmonary bypass (partial, complete) in thoracic surgery.

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Competency-Based PERFORMANCE Objectives

1. Perform, or supervise, all diagnostic or therapeutic endoscopic procedures
2. Resect ribs, treat empyema cavities, perform pleural and lung biopsies
3. Manage thoracic aortic aneurysms and dissections
4. Direct ventilator-dependent management
5. Perform lung, rib resection, mediastinoscopies and mediastinotomies
6. Provide surgical management of lung neoplasms
7. Provide surgical management of infections problems of lung and thorax
8. Manage cardiac arrhythmias
9. Perform, or supervise, pacemaker selection and placement
10. Manage pharmacotherapeutics associated with thoracic surgery
11. Treat medical conditions associated with thoracic surgical conditions

SURGICAL ONCOLOGY, BREAST and TRANSPLANT SURGERY

SURGICAL ONCOLOGY REFERENCE SOURCES:

Cancer Management:  A Multidisciplinary Approach by Pazdur, Coia, Hoskins, Wagman
The MD Anderson Surgical Oncology Handbook by Berger, Feig, Fuhrman
Atlas of Surgical Oncology by Bland, Karakousis, Copeland
Classics in Oncology by holleb, Randers-Pehrson
Cutaneous Melanoma by Balch, Houghton, Milton, Sober, Soong
The Breast by Bland, Copeland
Cameron Current Surgical Therapy.
Baker, Fischer Mastery of Surgery

• SURGICAL ONCOLOGY

JUNIOR RESIDENTS

(On completion of this rotation, junior residents should be able to…)

1. Evaluate a patient with a History and Physical and arrive at a tentative diagnosis and plan of management for common general surgery and surgical oncology clinical problems. (K,S)

2. Discuss evaluation, staging and management of common solid malignancies (K)

3. Provide preoperative and postoperative care on the ward with appropriate supervision. (K,S)

4. Recognize and provide initial management for common surgical complications. (K,S)

5. Place central lines and exchange lines on complex patients. (S)

6. Perform minor procedures in the operating room, including breast biopsy, excision of melanomas, wound closure, abscess drainage, hematoma evacuation, and related soft tissue procedures. (S)

7. Present case presentations to an audience and answer questions relative to those cases. (K)

8. Gather appropriate oncologic material from the literature utilizing Physicians Data Query (PDQ) and other computer sources. (K,S)
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BREAST ONCOLOGY OBJECTIVES

(On completion of this rotation, residents should be able to…)

1. Perform a breast examination and recognize common abnormalities (S)
2. Interpret a mammogram (S)

3. Perform ultrasound of the breast (S)

4. Describe the differences in management of a breast mass versus management of a mammographic abnormality (K)

5. Describe treatment options for DCIS, LCIS and invasive breast cancer (K)

6. Describe evaluation and treatment for gynecomastia and other benign breast conditions (K)

7. Describe the principles of and perform various image-guided biopsies of breast masses. (K,S)

8. Describe the indications and technique of, and perform under supervision, open breast biopsy, sentinel node biopsy, axillary dissection, simple mastectomy and modified radical mastectomy. (K,S)

9. Describe genetic implications and risk factors for development of breast cancer (K)

10. Describe the principles of, indications for and techniques of immediate versus delayed breast reconstruction. (K)
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GENERAL SURGERY and SURGICAL ONCOLOGY OBJECTIVES

SENIOR RESIDENTS

(On completion of this rotation, senior residents should be able to…)
1. Organize and run the service with multiple staff, residents, and a diverse patient population. (K,S)
2. Formulate treatment plans for complex general surgery and surgical oncology patients. (K)
3. See, evaluate and manage consultations for complex surgical oncology patients. (K,S)
4. Describe the indications for and perform the following procedures: (K,S)
            a. thyroidectomy
            b. parathyroidectomy
            c. partial mastectomy
            d. axillary node dissection
            e. sentinel node biopsy
            f. modified radical mastectomy
            g. groin dissection
            h. colectomy
            i. gastrectomy
            j. cholecystectomy
            k.  resection of sarcoma
            l.  resection of melanoma with complex repair
            m. liver resection
            n. cryosurgery of liver
            o. regional chemotherapy
            p. pancreatectomy and pancreaticoduodenectomy

5. Provide or direct the preoperative and postoperative care of patients requiring the above listed procedures (K,S)

6. Recognize and appropriately manage complications associated with the above procedures (K,S)

7. Interact with other disciplines, including Medical Oncology and Radiation Oncology, and arrive at treatment plans for complex patients. (K)

8. Present difficult problems at Conference and discuss diagnosis, management, prognosis, and complications. (K)
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TRANSPLANT SURGERY
  
DIALYSIS ACCESS (PGY-1, 2, 3)
Competency-Bases KNOWLEDGE Objectives:

1. Learn the indications and timing for dialysis
2. Learn the medical and surgical problems of renal failure patients
3. Identify the different types of dialysis:
            a. Hemodialysis
            b. Peritoneal dialysis
            c. Advantages and disadvantages of each

4.          For each method of dialysis, know and define the different types of access:
            a. Hemodialysis
                        · Catheters:  temporary
                        · Catheters:  permanent
                        · Native fistula (Cimino)
                        · A V grafts
            b. Peritoneal Dialysis
                        · Catheters:  temporary
                        · Catheters:  permanent 

5. Hemodialysis
            a. Learn preoperative evaluations and postoperative management
            b. Learn operative techniques for the placement
            c.  Learn to evaluate and manage postoperative complications
6. Peritoneal Dialysis
            a. Learn the preoperative evaluation and postoperative management
            b. Learn operative techniques for the placement
            c.  Learn to evaluate and manage postoperative complications
            d.  Learn laparoscopic-assisted placement and repositioning
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Competency-Based PERFORMANCE Objectives:

1. Participate in the evaluation of potential dialysis patients. (PGY-1, 2, 3)
2. Participate in the pre- and postoperative surgical management of dialysis patients. (PGY-1, 2, 3)
3. Perform different operative dialysis procedures, including:
            a. Dialysis catheters:  temporary and permanent (PGY-1, 2, 3)
            b. Native fistula (Cimino) (PGY-2, 3)
            c.  Dialysis access grafts (PGY-2, 3)

4.  Participate in postoperative management (PGY-1, 2, 3)

5.  Participate in the evaluation and management of complications using radiologic and surgical techniques: (PGY-1, 2, 3)

6. Participate in laparoscopically placed (repaired) peritoneal catheters. (PGY-2, 3)V
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TRANSPLANTATION AND ORGAN DONATION (PGY-1, 2, 3)
Competency-Based KNOWLEDGE Objectives:

1. Understand basic transplant immunology including:

a. Tissue typing

b. PRA

c. ABO compatibility

d. Acute rejection

e. Chronic rejection

2. Kidney transplantation

a. Learn pretransplantation evaluation and appropriate medical, surgical, and psychological testing.

b. Learn preoperative evaluation and management.

c. Learn postoperative evaluation and management, including:

· Fluid management

· Hypertension

· Diabetes mellitus

· Nutrition

· Wound care

· Surgical complications

d. Learn immunosuppression management and the mechanism of action
and side effects of the current medications:

· Prednisone

· Cyclosporine

· Tacrolimus

· Imuran

· Cellcept

e. Learn the different phases of immunosuppression:

· Induction

· Maintenance

· Rejection

f. Learn postoperative follow-up, including clinics.

g. Define potential infectious complications.

h. Learn the management of rejection, including the rationale behind the use of:

· Steroids

· Polyclonal antibodies

· Monoclonal antibodies

i. Learn the use of CD3 levels

j. Learn how to evaluate an increasing creatinine.

k. Learn medication interactions.

3. Pancreas Transplantation

a. Understand the indications.

b. Learn to identify the appropriate patients (Type I vs. Type II diabetes mellitus).

c. Learn pretransplant evaluation and appropriate medical and surgical testing.

d. Understand immunosuppression management specific for pancreas transplants.

e. Understand basic pancreas transplant physiology.

f. Understand the pancreas transplant operation.

g. Learn postoperative management.

h. Learn management of surgical and medical complications following a pancreas

transplant.

4. Hepatic Transplantation

a. Understand general principles of management of hepatic failure.

b. Understand indications for hepatic transplantation.

c. Understand general surgical principles of cadaver and living related hepatic

transplantation.

d. Understand general principles of postoperative management of hepatic transplant patients, including management of complications.

5. Organ Donation

a. Understand the organ donation process.

b. Learn to differentiate between cardiac death and brain death.

c. Understand organ preservation and techniques.

d. Learn the preoperative evaluation of an organ donor.

e. Define the function of UNOS.

f. Know the advantages and disadvantages of cold versus continuous cold

perfusion of kidney transplants.

g. Understand the living donor process.

h. Define long-term living donation risks.

i. Understand operative and immediate postoperative risks of a living organ donor.

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Competency-Based PERFORMANCE Objectives:

1. Participate in the pretransplant evaluation of potential kidney and kidney/pancreas recipients. (PGY-1, 2, 3)

2. Participate in the preoperative management of transplant recipients. (PGY-1, 2, 3)

3. Assist, or perform, kidney/pancreas transplants and perform a ureteroneocystostomy. (PGY-2, 3)

4. Participate in pre-, intra-, and postoperative management of immunosuppressive medications including monitoring of:
            a. medication levels (PGY-1, 2, 3)
            b. toxicity (PGY-1, 2, 3)
            c. interactions (PGY-1, 2, 3)
            d. CD3 levels (PGY-1, 2, 3)
5. Participate in the evaluation and management of postoperative surgical complications, including:
            a. ureteral stenosis and leaks (PGY-2, 3)
            b. infections (PGY-2, 3)
            c. vascular stenosis and thrombosis (PGY-2, 3)
            d. lymphoceles (PGY-2, 3)
            e. wound complications (PGY-2, 3)
6. Participate in the long-term medical outpatient (clinics) management of:
            a. kidney and kidney/pancreas transplant recipients. (PGY-1, 2, 3)
7. Participate in the evaluation of organ rejection, including:
            a. laboratory and radiologic testing (PGY-1, 2, 3)
            b. organ biopsy (PGY-1, 2, 3)
            c. immunosuppressive rejection management (PGY-1, 2, 3)
8. Participate in the preoperative and operative management of:
            a. living organ donors (PGY-1, 2, 3)
            b. cadaveric organ donors (PGY-1, 2, 3)
9.Participate in the postoperative management of living donors and the management of complications. (PGY-1, 2, 3)
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GENERAL AND VASCULAR SURGERY (PGY-1, 2, 3)
Competency-Based KNOWLEDGE Objectives:

1. Learn the specific general surgical problems of:
            a.             renal failure patients
            b.             transplant
2.Learn the pre- and postoperative evaluation and management of general surgical problems in:
            a. renal failure patients
            b. transplant patients
3. Learn calcium/phosphorous metabolism and the different types of hyperparathyroidism:
            a. primary
            b. secondary
            c. tertiary
4. Understand the specific vascular and diabetic-related problems in:
            a. renal failure patients
            b. transplant patients
5. Learn the pre- and postoperative and management, along with complications of, vascular and diabetic problems in:
            a. renal failure patients
            b. transplant patients
6. Learn management of postoperative complications of vascular and diabetic-related problems.
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Competency-Based PERFORMANCE Objectives:
 
For both renal failure and transplant patients:
1. Participate in the preoperative evaluation, operative management, and postoperative management of general and vascular surgical problems. (PGY-2, 3)

2. Participate in the management of postoperative complications following general and vascular operations. (PGY-1, 2, 3)

3. Perform, or assist, in the surgical and medical management of parathyroid disease. (PGY-2, 3)

TRAUMA AND GENERAL SURGERY - JUNIOR RESIDENTS 
(S) skill
(K) knowledge

This includes trauma and the elements of general surgery that are not inherently parts of other services (Oncology, Thoracic, Plastics, Vascular, Dialysis management)
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I.  Trauma

A. Management of acute trauma: The resident will be able to assist the physician staff in the evaluation and management of the acute trauma patient with particular attention to potentially life threatening injuries.

a. Primary survey: The resident will demonstrate the understanding and ability to successfully perform the primary survey with recognition and appropriate management of abnormalities disclosed during the primary survey.(K)

b. Secondary survey: The resident will demonstrate the understanding and ability to successfully perform the secondary survey with recognition and appropriate management of abnormalities disclosed during the secondary survey.(K)

c. Diagnostic studies: The resident will demonstrate the ability to interpret the workup for acute trauma patients. This will include plain film x-rays, CT scans, MRI, and laboratory studies, where appropriate.(K)

d. Emergency procedures: The resident will demonstrate knowledge and when appropriate, capability in performing with supervision, emergency procedures. These may include those listed below.(K)(S)

1. Central venous line

2. Arterial line

3. Chest tube

4. Diagnostic peritoneal lavage

5. Peripheral IV

6. Endotracheal Intubation with c-spine immobilization

7. Wound closure

8. Wound debridement with open care

9. Nasogastric tube placement

10. Bladder catheterization

e. Operative management: The resident will demonstrate an understanding of the principals of operative management of blunt and penetrating trauma. The resident will demonstrate the ability to perform appropriate procedures with supervision such as wound debridement/exploration, exploratory laparotomy and proctoscopy, as well as assist more senior physicians during complex procedures.(S)

B. Management of non-acute trauma: The resident will demonstrate the ability to provide appropriate continued care to the trauma patient following initial management. This will include patients transferred after stabilization, as well as patients admitted to our facility following initial workup. The resident will demonstrate adequate knowledge of late complications of trauma with the appropriate management. This will include both in-hospital management with appropriate discharge planning as well as out-patient follow-up.

a. Nutrition: The resident will demonstrate knowledge of the nutritional needs of the trauma patient and be able to assess and meet those needs.

b. Rehabilitation: The resident will demonstrate the ability to assess rehabilitation needs, obtain appropriate consults and direct rehabilitation care prior to and following discharge.(K)

c. Discharge planning: The resident will participate in discharge planning for the recovering injured patient.(K)

d. Chronic wound management(K)(S)

e. Complications: The resident will demonstrate an understanding of the common complications following trauma to include the following:(K)

1. Pneumonia

2. Pulmonary embolus

3. Hematoma/seroma

4. Infection

5. Non-union

6. Bowel obstruction

C. Burn management: The resident will demonstrate the skills necessary to assess and manage burn wounds as both inpatient and outpatient including operative treatment of burns and the management of burn in the multiply injured patient.(K)(S)

II. General Surgery

A. Emergency:  The resident will demonstrate adequate knowledge and skills to evaluate patients who present with acute complaints.  This will include the ability to perform an adequate history and physical exam, obtain appropriate diagnostic studies and formulate a differential diagnosis as well as to propose a management plan.(K)(S)

            a.  Acute abdomen
            b.  Vascular insufficiency
            c.  Spontaneous pneumothorax
            d.   Anal/Rectal complaints
            e.  Gastrointestinal bleeding
B. Non-acute General Surgery (Excluding Malignancy) :  The resident will demonstrate adequate knowledge and skills to evaluate patients who present with chronic complaints.  This will include the ability to perform an adequate history and physical exam, obtain appropriate diagnostic studies and formulate a differential diagnosis as well as to propose a management plan.(K)
            a. Biliary disease
            b. Hernia
            c. Chronic abdominal pain
            d. Venous access
            e. Endocrine (benign disease)
                        1.       Thyroid
                        2.       Parathyroid
                        3.       Adrenal
                        4.       Pancreas
            f. Gastrointestinal complaints
                        1.        Inflammatory
                        2.        Peptic Ulcer Disease
                        3.        Gastro-esophageal reflux
                        4.        Short-gut syndrome
                        5.        Bowel obstruction
                        6.        Anal/Rectal complaints
            f.    Benign skin and soft tissue masses and infections.
            g.  Wound management and closure

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TRAUMA AND GENERAL SURGERY
SENIOR RESIDENTS

Suggested Readings:
Current ATLS provider manual
TRAUMA. By Feliciano, Moore and Mattox

Knowledge Based Objectives:

1. Pathophysiology of hypovolemia:  including the mechanisms of acidosis, cellular swelling and the requirement for additional crystalloid.

2. Resuscitation of hypovolemia:  the relative roles of crystalloid and blood products.  The importance of hypothermia and coagulopathy and how they are managed.  Know the indications for resuscitative thoracotomy in the trauma patient.

3. Know the indications for surgical procedures in the trauma patient including;  cricothyrotomy, celiotomy, thoracotomy, neck exploration and extremity vascular repair for both blunt and penetrating trauma.

4. Understand the uses and misuses of standard trauma diagnostic procedures including:  CT scan, both abdomen, chest and head, peritoneal lavage, abdominal and pericardial ultrasound and angiography.  Know their indications, complications, weaknesses.

5. Know how to guide a referring physician through the appropriate transfer of a trauma patient including:  air verses ground, when to perform procedures prior to transfer, both diagnostic and therapeutic.

6. Be familiar with the common surgical options for the management of:  liver and spleen lacerations, pancreatic injuries, injuries to the kidneys, ureters, bladder and urethra, retroperitoneal hematomas, and abdominal vascular injuries and injuries to hollow viscera.

7. Know the management options for a hemodynamically unstable pelvic fracture.

8. Know the diagnostic approach to the mediastinum in blunt trauma including the role of CXR, CT, Angio and TEE, and understand the surgical approaches to the great vessels.

9. Be familiar with the more common complications of injury and their prevention and management:  infection, DVT, alcohol withdrawal, ARDS, renal failure.

10. Be able to coordinate multiple services carrying for the injured patient and have sufficient knowledge of orthopedic, neurosurgical, etc. injuries to be able to prioritize patient management.

11. Understand the rehabilitation needs of the trauma patient including:  fractures of weight bearing bones, spinal cord injuries, head injuries.

12. Know the impact of co-morbid factors on the management of the trauma patient;  including heart disease, diabetes, liver disease, extreme age, etc.

13. Understand the basics of injury prevention and the economic impact of injury in this country.
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Procedure Based Objectives:

1. Resuscitative thoracotomy for penetrating thoracic trauma.

2. Celiotomy for both penetrating and blunt abdominal trauma including the appropriate use of “Damage Control” techniques.

3. Expose and repair extremity vascular injury.

4. Manage critically injured patients in the ICU including those with multiple fractures, increased intracranial pressure, etc.

5. Supervise junior surgical residents in the performance of procedures such as:  central lines, chest tubes, peritoneal lavage, wound debridement and closure.

 SURGICAL INTENSTIVE CARE UNIT
GOALS AND OBJECTIVES

Knowledge Based Objectives:

The resident should be familiar with the following:

1. Central Nervous System

a) The pathophysiology of increased intracranial pressure; spinal cord injury and

brain death evaluation.

b)The effect of acid-base changes on ICP.

c)The concept of Cerebral Perfusion Pressure.

d)The use of agents such as diuretics; loop and osmotic; the use of blood

pressure and temperature control.

e)Principles of sedation, analgesia, neuromuscular blockade.

2. Cardiovascular

a)Basic physiology including concepts of preload, afterload, contractility,

ventricular compliance, etc.

b)Definition of shock and the classification into hypovolemic, cardiogenic,

neurogenic, septic, etc.

c) Appropriate therapy for each type of poor perfusion based on hemodynamic

principles. This includes monitoring of perfusion via oxygen delivery or

intracellular pH.

d)Management of cardiac arrhythmias.

e)Recognition and management of cardiac ischemia.

3. Pulmonary

a)Basic pulmonary pathophysiology including an understanding of shunt, dead

space ventilation, minute ventilation and cardiac effects on oxygenation.

b) Pulmonary vascular response to hyposix, hypercarbia.

c) An understanding of oxyhemoglobin dissociation curve.

d) Understand and be able to use the concepts of oxygen delivery and oxygen

consumption to regulate ventilator use.

e) Be familiar with the diagnosis, management and pathophysiology of

atelectasis, ARDS, pneumonia, embolus and increased intraabdominal

pressure.

f)Arterial blood gas analysis, acid base abnormalities and management.

4.Renal

a)Understand the basic physiology of the renal response to stress, hypovolemia,

acid-base changes, volume overload, etc.

b)Pros and cons of various renal monitoring tools’ including urine output, urine

Na, FeNa, osmolality, C1, et.

c)Be aware of the effects of renally active drugs such as lasix, mannitol,

dopamine, glucose, urea on urine output and renal perfusion.

d)Principles of drug dosing in renal failure.

e)Principles of dialysis/hemofiltration.

5. GI – GI bleeding; hepatic failure

a)Be familiar with common GI causes of admission to the ICU including GI

bleeding, ischemic bowel, obstruction and others.

b)Be familiar with gut motility problems in the ICU including both diarrhea and

ileus.

c)Understand the basic techniques of enteral feeding as well as the pros and

cons of enteral vs parental nutrition.

d)Understand the role of the gut in many of the infections, which arise in the ICU.

6. Infectious disease

a)Understand why critically ill patients are immunosuppressed

b)Learn the basics of infection control in the ICU; hand washing, mouth care,

ventilator care.

c)Be familiar with the appropriate used of antibiotics, antifungals, etc. to treat

infections in critically ill patients and why prophylaxis is so rarely successful.

d)Understand the concepts of suprainfection and resistance and unit specific

flora.

e)Understand the concepts of and indications for use of the newer agents for SIRS (i.e. Xigris)

7. Pharmacology

a) Know how to calculate drug doses and dosing intervals in patients with organ

dysfunction and altered volumes of distribution or unusual losses.

b)Know the difference between supportive agents and therapeutic agents

c)Understand the basic mechanisms of drug interaction

8.Metabolic/Endocrine

a)Hypoadrenal Crisis

b)Diabetes Ingipidus

c)Diabetes ketoacidosis

9.Hematologic

a)Acute management of bleeding patient

b)DIC

c)Use of novel agents for hemostasis such as recombinant factor 7

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Performance Based Objectives:

1.Neurologic

a)Monitor a patient with increase ICP and follow the effects of hyperventilation,

sedation, volume, and systemic blood pressure on the cerebral perfusion

pressure.

b) Monitor patients serially with altered mental status and calculate Glascow Coma Scores on them and correlate this with their progress.

2.Cardiac

a)Place CVP, arterial and Pulmonary artery catheters and correlate the data

generated with patient response.

b)Learn the appropriate use of noninvasive monitoring tools such as Doppler,

ECHO, Bioimpedience.

c)Manage patients with poor perfusion guided by the numbers generated above.

3. Pulmonary

a)Manage the airway of a variety of patients including the use of the oral airway,

the ET tube, Bag-Mask ventilation.

b)At least be familiar with the techniques for various surgical airways

c)Place chest tubes, place arterial line catheters.

d)Management of pneumothorax.

e)Manage patients with respiratory insufficiency on ventilators with volume controlled modes, pressure controlled modes, pressure support, BiPAP, CPAP, APRV 

f)Respiratory monitoring with pulse oximetry and tibal Co2.

g)Arterial blood gas analysis.

h)Weaning patients off ventilator.

4.Renal

a) Manage the fluids and electrolytes of patients requiring acute hemodialysis or

hemofiltration

5. DNR orders

a) Withholding/withdrawing of life support.

b) Informed consent.

c) Ethical/legal aspects of critical care.

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PLASTIC AND RECONSTRUCTIVE SURGERY
 GOALS AND OBJECTIVES

All general surgery and pre-ENT surgery interns rotate on plastic surgery for one or two months.  This is a crucial time for the residents to gain basic skills and knowledge in surgery.  The following will outline the rotational objectives for the residents, which includes a didactic curriculum as well as surgical skills goal.  Hopefully, this will provide some guideline so the residents know what to expect as well as know what is expected of them during their rotation from an academic standpoint.  From a practical patient care standpoint, please refer to the Plastic Surgery Rotation Residents’ Manual.

At the beginning of the rotation, the resident is expected to read though both this objective manual as well as the Plastic Surgery Rotation Residents’ Manual.  The main goal during this rotation from a patient care standpoint is, of course, to provide an excellent and cordial service.  From an academic standpoint, the resident is expected to learn some of the basic principles and skills of surgery, which can be applied to the rest of their career.  This manual will provide a check-off list of those objectives, separated into a didactic and surgical skills categories.  A reading list with accompanying reading materials will also be provided.  At the beginning of the rotation, a question session will be administered to the resident.  At the end of the rotation, a similar session will be given to ascertain the level of improvement gained from the service.

Didactic Objectives

Know the following:

1) Discuss the stages of wound healing.

2) Discuss the stages of skin graft take.

3)Discuss the basics of scar revision.

4)Discuss the basic principles of skin grafting.

5)Basic principles of flaps

a)Classification (types)

b)Indications

6) Different types, behavior, and treatments of skin tumors.

7) Discuss the treatment of Hidradenitis Suppurativa.

8) Discuss the treatment of keloids and hypertrophic scars.

9) Anatomy of the facial nerve.

10) Different types of facial fractures, their assessment and treatment:

a) Le Fort d) Nasal

b) Maxilla e) Orbital

c) Zygoma f) Maxilla

11) Discuss the basic principles and various methods of chest wall reconstruction.

12) Discuss the basic principles and various methods of breast reconstruction.

13) Discuss the principles and various methods of abdominal wall and groin reconstruction.

14) Discuss the basic principles and various methods of pressure sore repair.

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Skills Objectives
Learn the following:
1) Perform primary plastic closure of
            a) the face in general
            b) lip
            c) ear
            d) forehead
            e) scalp
            f) eyelid
2) Gentle handling of soft tissue with instruments.
3) Perform basic suturing techniques:
            a) Simple interrupted
            b) Continuous over-and-over suturing
            c) Interrupted inverted subcuticular sutures
            d) Running continuous subcuticular sutures
                        1) with non-absorbable sutures
                        2) with absorbable sutures
                                    i) buried knots
                                    ii) non-buried knots
            e) Horizontal mattress sutures
            f)  Vertical mattress sutures
            g) Half-buried horizontal mattress sutures
4) Perform basic dressing techniques.
5) Perform and explain basic steps of splint and cast application.
6) Evaluate a wound.
7) Assess a facial fracture.
8) Assess facial nerve function.
9) Evaluate circulation of an extremity, upper and lower.
10) Evaluate and categorize a pressure sore.
11) Prep and drape a facial wound or surgical field.
12) Perform facial regional anesthetic blocks:
            a) mental nerve
            b) infraorbital
            c) supratrochlear
13) Administer a digital nerve block in the hand.
14) Apply arch bars (can be applied to stabilizing avulsed teeth or fractured alveolar segments).
15) Perform skin grafting techniques:
            a) harvest split-thickness skin grafts
            b) harvest full-thickness skin grafts