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ANESTHESIA RESIDENT HANDBOOK
TABLE OF CONTENTS
SECTION 1: GENERAL RESIDENT GUIDELINES
Department Website .............................................................................................................. 5
Operating Room Assignments ............................................................................................... 5
Rounds/Seminars/Journal Club ............................................................................................. 5
Illness .................................................................................................................................... 5
Vacation ................................................................................................................................ 6
Procedure for Requesting Time Off ................................................................................... 6
Professional Leave ................................................................................................................ 7
Resident Travel Allowance ................................................................................................. 7
Statutory Holidays ................................................................................................................. 7
Salary and Benefits ............................................................................................................... 8
Library Resources and Locations .......................................................................................... 8
Recommended Textbooks ..................................................................................................... 8
Out of Southwestern Ontario Rotations ............................................................................... 10
SECTION 2: PROGRAM STRUCTURE
London Teaching Hospital Sites & Site Chiefs .................................................................... 12
Rotation Changeover Dates for 2014-2015 ......................................................................... 13
Subspecialty Rotations & Coordinators ............................................................................... 13
Anesthesia Residency Program 2014-2015 Administrative Structure ................................. 14
Mentor System .................................................................................................................... 15
Resident Research .............................................................................................................. 15
Resident Portfolio ................................................................................................................ 16
SECTION 3: POLICIES & PROCEDURES*
Anesthesia Resident Health and Safety Policy .................................................................... 18
Appeals Mechanism ............................................................................................................ 23
Guidelines for Elective Rotations ......................................................................................... 24
Harassment and Equity Policy ............................................................................................. 24
Journal Club ........................................................................................................................ 28
Leave of Absence Policy ..................................................................................................... 28
Ombudsperson Terms of Reference ................................................................................... 29
Operating Room Attire ......................................................................................................... 29
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Procedure for Requesting Time Off (Medicine/General Surgery) ........................................ 30
Resident OR Locker Policy .................................................................................................. 30
Resident Travel Allowance Policy ....................................................................................... 31
Resident Expenses .......................................................................................................... 31
Restricted Registration ........................................................................................................ 32
Senior Resident Duties ........................................................................................................ 33
Resident Call Scheduling Guidelines ............................................................................... 33
Guidelines for Call/Clinical Duties for Residents Registered for the Upcoming Royal
College Examinations in Anesthesiology .......................................................................... 34
SECTION 4: OBJECTIVES OF TRAINING
Overall Goals and Objectives of the Anesthesia Training Program ..................................... 38
Graded Responsibility for Anesthesia Residents ................................................................. 42
Objectives for the PGY-1 Year ............................................................................................ 43
Emergency Medicine Rotation (PGY-1 or electives for PGY-2 to 5) ................................ 44
Cardiology (PGY-1 or PGY-2 to 5) ................................................................................... 47
General Internal Medicine Rotation (PGY-1) .................................................................... 49
General Surgery (PGY-1) ................................................................................................. 51
Obstetrics & Gynecology (PGY-1) .................................................................................... 54
Pediatric Emergency Medicine (PGY-1) ........................................................................... 56
Introduction to Anesthesia Rotation (PGY-1 & 2) ............................................................. 59
Subspecialty Objectives
Acute Pain and Out of OR Anesthesia ............................................................................. 63
Airway .............................................................................................................................. 70
Cardiac Anesthesia .......................................................................................................... 72
Cardiac Surgery Recovery Unit ........................................................................................ 78
Chronic Pain ..................................................................................................................... 83
General Anesthesia (PGY-3 & 4) ..................................................................................... 89
Neuroanesthesia .............................................................................................................. 91
Pediatric Anesthesia......................................................................................................... 95
Pre-Admission Clinic ........................................................................................................ 98
Regional Anesthesia (St. Joseph’s)................................................................................ 101
Regional Anesthesia (UH) .............................................................................................. 103
Rural Regional Community Anesthesia Rotation ........................................................... 105
Thoracic Anesthesia ....................................................................................................... 109
Transesophageal Echocardiography .............................................................................. 116
Vascular Anesthesia....................................................................................................... 118
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Consolidation Anesthesia Block ........................................................................................ 125
Off-Service Rotation Objectives
Cardiac Care Unit (PGY-2 to 5) ...................................................................................... 129
Cardiac Electrophysiology (PGY-2 to 4) ......................................................................... 131
Consult Medicine ............................................................................................................ 138
Critical Care Medicine .................................................................................................... 141
Critical Care Ultrasound ................................................................................................. 145
Neonatal Intensive Care Unit ......................................................................................... 150
Palliative Medicine.......................................................................................................... 152
Pediatric Critical Care ..................................................................................................... 155
Respirology Rotation (PGY-2 to 5) ................................................................................. 157
Transfusion Medicine ..................................................................................................... 159
Research Rotation ............................................................................................................. 162
Anesthesia/Family Medicine Enhanced Skills Program ..................................................... 167
Royal College of Physicians and Surgeons of Canada
Objectives of Training in Anesthesiology ........................................................................ 179
Specialty Training Requirements in Anesthesiology ...................................................... 183
Specific Standards of Accreditation for Residency Programs in Anesthesiology ........... 186
*For further PGE policies and procedure, please refer to the Schulich School of Medicine and
Dentistry Resident/Fellow Handbook, available online at: http://www.schulich.uwo.ca/medicine/postgraduate/facultystaff/files/Residents/Resident_Handbook.pdf
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SECTION 1: GENERAL RESIDENT
GUIDELINES
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GENERAL RESIDENT GUIDELINES
These guidelines provide an overview of the basic responsibilities of the anesthesia resident
and the resources available during residency. For more detailed information, please follow the
links provided, or refer to the appropriate sections in this handbook.
DEPARTMENT WEBSITE
The Department of Anesthesia & Perioperative Medicine’s website can be accessed at:
http://www.schulich.uwo.ca/anesthesia.
Residents will find useful information about the Program, links to presentations and seminars,
login information for the Resident Log Book, Web Evaluations, and rotation and simulation
schedules here.
Residents can also find information about faculty research, news and events, useful links, and
contact information.
OPERATING ROOM ASSIGNMENTS
Daily attendance to assigned rooms is expected commencing at 0730 hours. If you have a
case assignment preference, it is your responsibility to advise the person responsible for the
daily assignments. Residents on subspecialty rotations will be assigned accordingly.
A preoperative assessment of all inpatients is mandatory. Please discuss assigned cases with
the assigned consultant preoperatively.
ROUNDS/SEMINARS/JOURNAL CLUB
Rounds and formal teaching sessions are a priority and time for attendance will be protected
from clinical duties. Your attendance at these activities, including Journal Club, is expected
and will be recorded.
For further information regarding the Journal Club, please refer to the policies and procedures
section of this handbook (Section 3).
ILLNESS
Please notify the Anesthesia Department Office and the On-Call anesthesiologist if you are
sick.
The site Anesthesia Department phone numbers are:
LHSC-UH: 519-663-3283
LHSC-VH: 519-685-8525
St. Joseph’s: 519-646-6100 Ext. 64219
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VACATION
The PARO Agreement entitles you to four weeks of vacation per year. This should be taken in
one week blocks every three months (if possible) for scheduling ease.
Vacation requests should be submitted via email to the Senior Resident, the Site Coordinator,
and Linda Szabo. This should be done at least one month in advance. Priority will be given on
a first-come, first-served basis. Professional leave has priority over vacation time. Vacation
time should not occur during the last two weeks of June or the first two weeks of July to ensure
the smooth turnover of outgoing and incoming residents.
Where possible, vacation should not be requested in April as a courtesy to the PGY-5
residents studying for exams. The Program will endeavor to give these residents some
protected time out of the OR during April for exam prep. As always, the Program will continue
to honor all vacation requests in accordance with the PARO Agreement and the above is only
a suggestion made out of courtesy for the PGY-5’s at this time of anticipated stress.
Requests for single day absences require a minimum of 7 days’ notice with the exception of
illness or emergency situations. PARO stipulates a minimum of one week blocks.
Procedure for Requesting Time Off
The following should be the procedure for vacation, lieu day requests, and professional leave
requests:
Step 1: The resident gives the request to the city wide resident call schedule organizer. If the
resident call schedule organizer agrees, then proceed to Step 2. If the request is
refused, then the process stops and alternate vacation arrangements will need to be
made.
Step 2: The resident then requests approval from the faculty site coordinator at the site they
are assigned to (UH, VH or St Joseph’s). If the request is refused then alternate
vacation arrangements need to be made.
Step 3: If approved, then the resident and the site coordinator should inform Linda Szabo, Val
Rapson and if at Victoria Hospital the site secretary. ([email protected] ,
[email protected] ).
This process allows an email trail of requests and approvals. If unclear as to the assigned
weekly protected academic time for senior residents, Linda Szabo will have this information.
Please submit all requests no later than the PARO final deadline.
If a resident’s request is denied, the resident will be contacted to make an alternative request
as stated in the PARO Agreement.
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Residents on Medicine or General Surgery Rotations will have to follow additional procedures
when requesting time off. For more information, please refer to the Procedure for Requesting
Time-Off (Medicine/General Surgery) Policy in Section 3 of this handbook.
PROFESSIONAL LEAVE
Residents are entitled to an additional paid leave for educational purposes. Although the time
is not specifically ear-marked for conferences, we encourage you to go to some conferences
during your residency. You are allowed to use professional leave as you see fit (for study,
etc.); however, conference stipends/funds can only be provided when you attend a conference.
You must request professional leave in the same electronic format that you request vacation.
We abide by the PARO Agreement, and it is recommended that you refer to this contract for
additional details.
Resident Travel Allowance
The Department of Anesthesia & Perioperative Medicine provides $800.00 per academic year
for travel to approved conferences, meetings, etc. Cash advances are not allowed. There is
also a one-time additional $800.00 allowed for travel to a major conference.
The annual amount may be carried over for one year with the approval of the Program
Director. You must receive prior approval from the Program Director to attend any conference
or meeting. Residents who are presenting at a meeting are entitled to reimbursement of
economy travel and accommodation (maximum 3 day stay) expenses in addition to the annual
conference allowance. If two residents are working on a research project together each
resident will get support to present at a conference (same conference or different
conferences). To receive support the resident must actually present at the conference in
question. Having their name as an author is not sufficient. It is expected that if a resident is
attending a conference where they are presenting with department support that they will make
an effort to support other residents who are presenting by attending those presentations.
For more information on Professional Leave and the PARO Agreement, please refer to Section
12 of the Agreement available at: http://www.myparo.ca/
STATUTORY HOLIDAYS
Statutory holidays will be taken on the day that they occur. The operating rooms run on an
emergency basis only on these days (as they do on weekends). If a statutory holiday occurs
when a resident is on call, then the resident receives the next day off as in normal call days.
The resident is also entitled to receive an extra day off for working the statutory holiday. This
does not apply to Christmas, Boxing Day, or New Year’s Day, which are covered separately by
the PARO contract.
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SALARY AND BENEFITS
The LHSC Medical Affairs Department sets up your payroll, including benefits. Your salary is
determined by the guidelines of the PARO contract and the amount is commensurate with your
training level.
Should you have any questions regarding salary and/or benefits, contact Monica McKay at
extension 75128 or by email at [email protected] .
LIBRARY RESOURCES AND LOCATIONS
There is an Anesthesia Library located at each of the 3 hospital sites:
University Hospital C3-107
339 Windermere Road London, ON N6A 5A5
Victoria Hospital D2-314
800 Commissioners Road East
London, ON N6A 5W9
St. Joseph's Health Care Main Library A1-604 268 Grosvenor Street London, ON N6A 4V2
Each location houses a collection of core anesthesia texts and provides study space and
resources for residents and other members of the department. If you would like to borrow
material from the library, please contact the Library Assistant and provide the title and library
barcode number (found on the inside of the back cover) of the book you are borrowing.
Contact information for the Library Assistant can be found at all three library locations.
The Department also has access to online resources through a subscription. For access,
please contact the Library & Information Coordinator, Brie McConnell, at extension 35134 or
by email at [email protected] . The Library & Information Coordinator is also
available to help you with any research concerns, medical literature and EBM searching,
citation formatting, bibliographies, and Refworks.
In addition to these resources, residents are able to access the materials at the clinical libraries
located in each of the hospitals, and the books and databases available through Western
Libraries. For information on how to access these resources, contact Brie McConnell.
RECOMMENDED TEXTBOOKS
Textbooks are usually very expensive. Most of the books listed below are available at one of
the hospital libraries, and you should review them before purchasing any. It is recommended
that each resident obtain ONE general anesthesia textbook at the beginning of the residency
as a reference and learning guide.
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General:
Miller RD, et al. Miller’s Anesthesia. Philadelphia: Elsevier.
Barash PG, et al. Clinical Anesthesia. Philadelphia: Wolters Kluwer.
Nimmo WS. Anaesthesia. Churchill-Livingston.
Anatomy:
Ellis H, et al. Anatomy for Anaesthetists. Massachusetts: Wiley-Blackwell.
Physiology:
Hall JE. Guyton and Hall Textbook of Medical Physiology. Philadelphia: Elsevier.
Barrett KE. Ganong’s Review of Medical Physiology. New York: McGraw-Hill.
(Both are classic textbooks)
Respiratory Physiology:
West JB. Respiratory Physiology: the Essentials. Philadelphia: Wolters Kluwer.
West JB. Pulmonary Pathophysiology: the Essentials. Philadelphia: Wolters Kluwer.
(Both texts are excellent, succinct reviews)
Lumb AB. Nunn’s Applied Respiratory Physiology. London: Churchill Livingston.
(Some points covered are of special value to anesthesiologists)
Medicine:
Longo DL. Harrison’s Principles of Internal Medicine. New York: McGraw-Hill.
Vickers MD. Medicine for Anaesthetists. Oxford: Blackwell.
Stoelting RK. Stoelting’s Anesthesia and Co-Existing Disease. Philadelphia: Elsevier.
Benumof JL. Anesthesia and Uncommon Disease. Philadelphia: Saunders.
Pharmacology:
R.K. Stoelting. Pharmacology and Physiology in Anesthesia Practice, Lippincott-Raven
Physics & Equipment:
MacIntosh R. Physics for the Anaesthetist. Oxford: Blackwell.
Mushin WM. Automatic Ventilation of the Lungs. London: Blackwell.
Dorsch JA. Understanding Anesthesia Equipment. Philadelphia: Wolters Kluwer.
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OUT OF SOUTHWESTERN ONTARIO ROTATIONS
As residents at Western University you are members of the SWOMEN network of teaching and
community hospitals. To maintain continuity of teaching and support your fellow residents who
are learning and working in the SWOMEN network (including the London hospitals) there
needs to be some limits in the numbers of “electives” or rotations outside of the SWOMEN
network.
Starting in July 1, 2015, residents will only be allowed two rotations out of this jurisdiction per
academic year (13 blocks). This includes anesthesia and “off service” rotations (medicine,
intensive care, etc…) For new residents starting in the program this restriction will also include
only eight rotations out of this jurisdiction for the entire residency.
The Residency Training Committee will need to grant specific approval for out of jurisdiction
rotations beyond the limits above.
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SECTION 2: PROGRAM STRUCTURE
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LONDON TEACHING HOSPITAL SITES & SITE CHIEFS
LONDON HEALTH SCIENCES CENTRE
LHSC-UNIVERSITY HOSPITAL (UH) 339 Windermere Road
London, Ontario N6A 5A5
Site Chief: Dr. Ramiro Arellano Phone:
Fax: Email: Pager:
519-663-3283 519-663-3079 [email protected] 18979
LHSC-VICTORIA HOSPITAL (VH) 800 Commissioners Roads East
London, Ontario N6A 5W9
Site Chief: Dr. George Nicolaou Phone:
Fax: Email: Pager:
519-685-5115 519-685-8275 [email protected] 17813
ST.JOSEPH’S HEALTH CARE LONDON (St. Joseph’s)
268 Grosvenor Street London, Ontario N6A 4V2
Site Chief: Dr. Bill Sischek Phone:
Fax: Email: Pager:
519 646-6100 Ext. 64218 519-646-6116 [email protected] 15974
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ROTATION CHANGEOVER DATES FOR 2014-2015 (Based on a 4 week educational block, 13 rotations in total)
Resident Orientation – Friday June 27, 2014
Block Start Date End Date
1 Monday, July 1, 2014 Monday, July 28, 2014
2 Tuesday, July 29, 2014 Monday, August 25, 2014
3 Tuesday, August 26, 2014 Monday, September 22, 2014
4 Tuesday, September 23, 2014 Monday, October 20, 2014
5 Tuesday, October 21, 2014 Monday, November 17, 2014
6 Tuesday, November 18, 2014 Monday, December 15, 2014
7 Tuesday, December 16, 2014 Monday, January 12, 2015
8 Tuesday, January 14, 2015 Monday, February 9, 2015
9 Tuesday, February 10, 2015 Monday, March 9, 2015
10 Tuesday, March 10, 2015 Monday, April 6, 2015
11 Tuesday, April 7, 2015 Monday, May 4, 2015
12 Tuesday, May 5, 2015 Monday, June 1, 2015
13 Tuesday, June 2, 2015 Sunday, July 30, 2015
Please note: Service call schedules should also reflect the same rotation block dates.
SUBSPECIALTY ROTATIONS & COORDINATORS
Residents scheduled for subspecialty rotations must contact the subspecialty coordinator prior to the
start of the rotation to receive instructions and materials specific to the rotation. If no subspecialty
coordinator is listed below, please contact the site coordinator for further information.
Rotation Location Coordinator Email
Airway VH Dr. Richard Cherry [email protected]
Airway UH Dr. Tim Turkstra [email protected]
Ambulatory SJH Dr. John Parkin [email protected]
Cardiac UH Dr. Ronit Lavi [email protected]
Neuro UH Dr. Miguel Arango [email protected]
Obstetric VH Dr. Indu Singh [email protected]
Pediatric VH Dr. Mohamad Ahmad [email protected]
Pain City Wide Dr. Kate Ower [email protected]
Pre-Admission Clinic VH Dr. Rooney Gverzdys [email protected]
Regional SJH Dr. Shalini Dhir [email protected]
Transplant UH Dr. Achal Dhir [email protected]
Vascular & Thoracic VH Dr. George Nicolaou [email protected]
Palliative UH Dr. Val Schulz [email protected]
Blood Conservation Program UH Dr. Fiona Ralley [email protected]
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ANESTHESIA RESIDENCY PROGRAM 2014-2015 ADMINISTRATIVE
STRUCTURE
Dr. Chris Watling Western University Associate Dean Postgraduate Medical Education
Dr. Davy Cheng Chief & Chair Department of
Anesthesia & Perioperative Medicine
Department Council
Dr. Arif Al-Areibi
Program Director
Postgraduate Education (PGE) Committee
Chair – Dr. Davy Cheng Program Director – Dr. Arif Al-Areibi
Associate Program Director – Dr. Jeff Granton Site Coordinator SJH – Dr. Pod Armstrong
Site Coordinator LHSC-UH – Dr. Peter Mack Site Coordinator LHSC-VH – Dr. Kevin Teague
Research Coordinator – Dr. Ronit Lavi SWOMEN Windsor Rep – Dr. Ed Roberts
IT Coordinator & RCPSC Examiner – Dr. Richard Cherry Community Rep – Dr. Nicole Campbell
Enhanced Skills Supervisor – Dr. Daniel Grushka Chief Resident – Dr. Farah Manji
Jr. Resident Reps – Dr. Nan Gai & Dr. Kyle Fisher Program Administrator – Linda Szabo
Duties of the PGE Committee
Resident Selection Resident Education
PARO Liaison Career Counseling
Resident Evaluation Program Evaluation Resident Research
Should you have any concerns regarding your educational experience or evaluation, please feel free to discuss this with any member of the PGE Committee
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MENTOR SYSTEM
The Department of Anesthesia & Perioperative Medicine has adopted a mentor system to ease
the transition of new trainees into the program and to provide guidance and support to each
resident throughout their training. Mentor groups are reviewed prior to the beginning of each
academic year. New trainees are assigned and additions/deletions to existing groups are
made.
If you have a preference for a mentor, or would like to discuss the mentor system, please
contact the Anesthesia Department Office at 519-663-3283.
Mentorship Program
In addition to the mentor system, there is a resident-run mentorship program for new PGY-1s.
Incoming residents are partnered with a PGY-2 resident based on interests, where they went
to school, where they’re doing their first anesthesia rotation, and sometimes, similar family
situations (i.e. kids, married). The PGY-2 resident will help the new resident navigate the
challenges of their first year. As the PGY-1s progress to PGY-2, they will become mentors for
the new incoming residents.
For information about the 2014-2015 mentorship program, please contact Dr. Nan Gai
([email protected] ).
RESIDENT RESEARCH
Anesthesia residents are actively encouraged to complete and present at least one research
project during their 5 years of residency training. Projects can include bench side research,
clinical research trials, quality assurance projects, systematic reviews, and case reports.
Research opportunities are available in all subspecialty areas of anesthesia. Residents are
encouraged to seek mentors and supervisors early. Protected time can be made available
during the residency for research activity.
Residents are encouraged to present at Anesthesia meetings and financial support is
available. Popular venues for presentation include Mac-Western Resident Research Day
Exchange, Canadian Anesthesiologists’ Society Annual Meeting, and the Midwest Anesthesia
Resident Conference (MARC) in the USA.
Mac-Western Resident Research Day Exchange
This is held yearly with McMaster University with the site alternating between the two
campuses. Research and academic projects are presented and judged, with the top three
receiving prizes. A recognized researcher is invited to speak and to be an assessor at the
Research Competition. A dinner and friendly anesthesia trivia challenge follow the presentations.
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For further information regarding resident research projects, please contact the Resident Research
Coordinator: Dr. Ronit Lavi ([email protected] ).
For support with:
Research study start-up
Funding opportunities
Research Ethics Board submissions and documents
Manuscript preparation, reviews, submission and revisions
Research training requirements
Poster/Oral presentations
Grant writing and/or reviews
Grant/study administration at Western, Lawson, LHSC/SJHC
or other research-related inquiries, please contact:
Erin Cecchini, MSc – Research Coordinator
Department of Anesthesia & Perioperative Medicine [email protected] , 519-685-8500 ext. 32092
RESIDENT PORTFOLIO
The Association of Canadian University Departments of Anesthesia (ACUDA) and the Royal
College of Physicians and Surgeons of Canada (RCPSC) have started to stress the need for
anesthesia trainees to track their progress in the CanMEDS roles beyond the focus of Medical
Expert. To help accomplish this, a portfolio was designed by members of ACUDA, which allows
residents to track courses, seminars, encounters, etc., that help fulfill CanMEDS. This portfolio has
been modified and is available from the Program Director in Excel format.
The CanMEDS roles beyond Medical Expert are each addressed in this modified portfolio.
Obviously there is going to be overlap between roles, and you can include material from one
encounter in several roles. The key to this process is the reflection aspect. In order to grow as a
physician you should reflect on how you have been impacted by new experiences. Within the
portfolio there are areas reserved for reflection. There is no need to write an essay, a few lines to
capture your thoughts should do.
Feel free to add additional sections or lines if needed. For example, if you take a course and it
does not seem to be represented in any area, then simply add a line. That is the advantage of the
electronic format. These are your forms and are confidential.
At your yearly meeting with the Program Director, we will ask to review a few of the forms each
time to help monitor your progress. The forms will also be reviewed at the end of the residency
when the Program Director will fill out your FITER. If a role is blank, it will make the FITER difficult
to complete. The RCPSC may also want to see them at some point, so it is to your advantage to
keep them up to date.
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SECTION 3: POLICIES &
PROCEDURES
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ANESTHESIA RESIDENT HEALTH AND SAFETY POLICY The Department of Anesthesia & Perioperative Medicine
PREAMBLE
The Department of Anesthesia & Perioperative Medicine recognizes that residents have the
right to a safe work environment during their training. The responsibility for promoting a culture
and environment of safety rests with the Schulich School of Medicine and Dentistry, Affiliated
Hospitals, the Department of Anesthesia & Perioperative Medicine, and with the residents
themselves. The concept of safety includes physical, emotional, psychological, and
professional security.
The Schulich School of Medicine and Dentistry Resident Health and Safety policy for
postgraduate trainees is found at: http://www.schulich.uwo.ca/medicine/postgraduate/policies
KEY RESPONSIBILITIES
For Residents:
To provide information and communicate safety concerns to the program and to comply with safety policies.
For the Residency Training Program:
To act promptly to address identified safety concerns and incidents and to be proactive in providing a safe learning environment.
PART I: PHYSICAL SAFETY
These policies apply only to the activities that are related to the execution of residency
duties:
a) When residents are travelling for clinical or academic duties by private vehicle, it is
expected that they maintain their vehicle adequately, prepare for weather related
emergencies, have adequate supplies and contact information. It should be noted that
the Province of Ontario prohibits cell phone use (with the exception of hands free)
and/or text messaging while driving.
b) For long distance travel for clinical or academic duties, residents should ensure that a
colleague or residency office is aware of their itinerary.
c) Residents should not be required to drive with inadequate sleep. If required, alternate
means of transportation will be offered by the department after busy on call shifts. The
PGE Committee has agreed to offer taxi reimbursement for Anesthesia residents who
are post-call (on or off-service) who feel too tired to drive home safely. If a resident
decides it is necessary to take a taxi home for this reason, you may submit the receipt
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to Linda Szabo for reimbursement (maximum $20.00). If prolonged driving is required
with inadequate sleep, then alternate timing or travel arrangements should be made.
d) Residents are not expected to travel during inclement weather for clinical or academic
assignments. If such weather prevents travel, the resident must contact their supervisor
immediately. Assignment of an alternate activity is at the discretion of the Program
Director.
e) Electives, academic duties, or conferences that require international travel require
careful planning. Residents should have proper personal medical insurance, ensure
valid professional liability insurance, and valid medical licensure, proper Visa and
Passport, immunizations for travel to endemic countries, and safe travel and
accommodation.
f) Residents should not work alone after hours in health care facilities without adequate
security support.
g) Residents are not expected to make unaccompanied home visits.
h) Residents should only telephone patients using caller blocking.
i) Residents should not be expected to walk alone for any major or unsafe distances at
night.
j) Residents should not care for violent, intoxicated, or aggressively psychotic patients
without adequate security support, proper physical space and an awareness that this
danger exists.
The LHSC Workplace Violence and Prevention Program policies are available at:
http://www.lhsc.on.ca/priv/ohss/violence.htm
k) Residents should familiarize themselves with the location and services provided by
Occupational Health. This includes policies for needle stick injuries, work place injuries,
exposure to contaminated fluids (for example eyes, open sores, oral etc…) and
exposure to or contraction of reportable infectious diseases.
The LHSC and St. Joseph’s OHSS policies are available at:
http://www.lhsc.on.ca/priv/ohss/
https://intra.sjhc.london.on.ca/support-teams/occupational-health-and-safety/policies-
and-guidelines
l) Residents should be aware of the importance and availability of immunizations. This
includes, but is not limited to, Influenza, Hepatitis B, and Tetanus. (See links in section
k)
m) Residents should have a personal family physician and ensure immunizations are up to
date.
n) Residents must observe universal precautions and isolation procedures when indicated.
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o) Residents must follow hospital policy for the use of personal protective devices for high
risk procedures, including but not limited to, intubation, vascular access, and
procedures associate with splatter of bodily fluids. Intubations that occur in the
operating room are discretionary as to the need for a face shield or eye protection. If
concerned, then a face shield should be worn.
The Aerosol Generating Procedures are available at:
http://intra.sjhc.london.on.ca/depts/icontrol/pdfs/champslhsc/aerosol_generating_proced
ures.pdf
p) Call rooms and lounges provides to the residents should be smoke free, clean,
adequately lit and located in safe areas. Call rooms should have doors that lock.
q) Residents working in areas of radiation exposure must follow policies to limit intensity
and duration of radiation exposure, including the use of protective garments (aprons,
vests, and neck guards).
r) Pregnant residents need to be aware of specific risks to themselves and their fetus.
Residents should contact Occupational Health about these issues if they could be or
plan to become pregnant.
s) Residents should not suffer harassment, intimidation and/or sexual or physical violence
of any kind from faculty, allied health care workers, hospital support staff or peers.
The PARO Agreement (Section 10) regarding Discrimination/Harassment/Intimidation is
available at: http://www.myparo.ca/PARO-CAHO_Agreement
The LHSC employee code of conduct is available at: http://www.lhsc.on.ca/priv/conduct/
The Schulich School of Medicine and Dentistry code of conduct is available at:
http://www.schulich.uwo.ca/equity/index.php?page=CodeofConduct
Information about reporting an issue is available at:
http://www.schulich.uwo.ca/equity/index.php?page=ReportinganIssue
t) If a resident is suffering from a communicable illness that would put patients or staff at
risk they should be encouraged to stay home and seek medical assessment if needed.
PART II: EMOTIONAL & PSYCHOLOGICAL SAFETY
a) Learning environments must be free from intimidation, harassment and discrimination.
b) When a resident is affected by poor health, excessive stress or psychological issues
(including substance abuse), the resident shall be granted a leave of absence and have
access to the appropriate support. The resident should not return to work until these
issues have been resolved satisfactorily to ensure resident and patient safety.
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c) Intoxication while performing clinical duties will result in immediate suspension and
possible dismissal.
d) Residents should be aware of and have access to stress counseling, resources for
substance abuse, and a mechanism for dealing with harassment or inequity issues.
Information about the OMA Physician Health Program is available at:
http://php.oma.org/
Information about the PARO 24 Hour Help Line is available at:
http://www.myparo.ca/24_HOUR_Helpline
Information about the Associate Dean of Equity and Professionalism is available at:
http://www.schulich.uwo.ca/equity/index.php?page=AssociateDean
e) Residents should have adequate emotional support available after a severe adverse
event or critical incident. (See links in section d)
PART III: PROFESSIONAL SAFETY
a) Some residents may experience conflicts between their ethical, cultural or religious
beliefs and their professional and/or training obligations. Resources will be made
available to deal with such conflicts when these issues are brought to the attention of
the Program Director.
b) Residents are entitled to the vacation and professional days with the rules and
restrictions as set out in the PARO contract.
The PARO Agreement (Sections 11 & 12) regarding Professional Leave and Vacation
are available at:
http://www.myparo.ca/PARO-CAHO_Agreement
c) A culture of safety should exist to promote residents coming forward with concerns
regarding patient safety without fear of reprisal.
d) Residents must be members of the CMPA and follow CMPA recommendations in the
event of medico-legal issues.
e) Residents must ensure current and active licensure under the CPSO before any patient
contact.
f) Residents should have a system available that will allow honest, anonymous and timely
evaluation of supervisors, teaching faculty, and rotations.
g) Residents need access to neutral representatives at The University of Western Ontario
to advocate on their behalf. These individuals may at times be contacted with the
assistance of the Program Director or may be contacted directly by the resident if they
are not comfortable communicating with the Program Director.
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Information about the Associate Dean of Equity and Professionalism is available at:
http://www.schulich.uwo.ca/equity/index.php?page=AssociateDean
h) Residents should be encouraged to bring professional and personal issues to the
Program Directors attention. However, if patient safety or personal safety issues come
to light, (either through disclosure by the resident, complaint, poor evaluation, or through
other means) then immediate suspension or dismissal may be warranted.
See more links in Part IV
PART IV: MECHANISMS FOR DEALING WITH PERCEIVED LACK OF SAFETY
Any resident or faculty member that has concerns about the physical, psychological, or
professional safety of any individual resident, or group of residents, is required to bring this to
the attention of the Program Director immediately. If the Program Director is unavailable, then
the Associate Program Director or Chair of the Department needs to be made aware.
The Program Director will work with the appropriate administrative body (PGE, Medical Affairs,
CPSO, CMPA, Occupational Health, Department of Anesthesia and Perioperative Medicine
Executive) to address the concerns. No resident should be expected to learn or work in an
unsafe environment.
The following links are additional reading or source documents for the above policy:
PARO: http://www.myparo.ca
Office of the Associate Dean, Equity and Professionalism:
http://www.schulich.uwo.ca/equity/index.php?page=AssociateDean
OMA, Physician Health Program: http://www.phpoma.org/
CMPA: http://www.cmpa-acpm.ca/cmpapd04/index.cfm?index=1
CPSO: http://www.cpso.on.ca/
Occupational Health (St. Joseph’s and LHSC):
http://www.lhsc.on.ca/priv/ohss/
https://intra.sjhc.london.on.ca/departments/occupational-health-and-safety
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APPEALS MECHANISM The Department of Anesthesia & Perioperative Medicine
Residents that fail a clinical rotation or disagree with an evaluation have the right to appeal the
unsatisfactory evaluation. The steps needed to be taken are outlined below. All appeals must
occur within six weeks of receiving the evaluation. Each successive step must occur no later
than six weeks after the preceding step.
APPEALS PROCEDURE
Step 1: The resident must meet with the supervisor of the clinical rotation to better
understand the reasons for the results of the evaluation and to ascertain whether or
not the evaluation should be altered.
Step 2: If Step 1 does not come to a satisfactory conclusion for the resident, then they may
appeal in writing to the Appeals Committee of the Anesthesia Residency Training
Committee. This Committee consists of the Program Director, Associate Program
Director, one of the four Resident Representatives on the Residency Training
Committee, and a Site Coordinator from a site not involved in the evaluation in
question. The written appeal should include reasons as to why the evaluation is not
an accurate reflection of performance, and primarily focus on whether the proper
process was followed prior to an unsatisfactory evaluation. The committee will meet
with the resident in question and then the supervisor of the rotation. The resident may
also appeal to the Chair of the Department of Anesthesia & Perioperative Medicine if
this appeal is unsuccessful. Failures on rotations not core to anesthesia (internal
medicine, critical care, surgery, etc.), may require a direct bypass to Step 3.
Step 3:
If Step 2 does not address the resident’s concerns, then they may provide a written
appeal to the Schulich School of Medicine and Dentistry’s Appeals Committee. The
process beyond this is outlined in the Postgraduate Medical Education Office
Appeals document.
The Postgraduate Medical Education Office Appeals document is available at:
http://www.schulich.uwo.ca/medicine/postgraduate/policies/files/Policies/2012Evaluat
ion-and-Appeals-Policy.pdf
If a resident does fail a rotation, a plan of remediation must be in place. This plan will be
organized by the Program Director, supervisor of the rotation in which the failure occurred, and
with the guidance of the Residency Training Committee.
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GUIDELINES FOR ELECTIVE ROTATIONS The Department of Anesthesia & Perioperative Medicine
In order to have a clear record of the proposed elective, the resident must provide the following
information (in writing) to the Anesthesia Program Director:
1. The location and dates of the elective.
2. The name of the supervisor.
3. The resident should also send the supervisor of the elective a letter, with a copy to the
Anesthesia Program Director, containing the following:
a) The objectives of the elective.
b) The arrangements for evaluation of the resident at the end of the elective period.
c) Details of service expectations, including days to be worked and on-call
expectations.
d) Any special arrangements which may be involved such as priority assignment of
the resident to individual preceptors or to specified types of cases.
e) Other special arrangements regarding such things as accommodation,
transportation, holiday, or professional leave.
The foregoing will serve to expedite approval for elective rotations by the Program Committee,
and help avoid unpleasant surprises during the actual elective rotation.
HARASSMENT AND EQUITY POLICY The Department of Anesthesia & Perioperative Medicine
Modified from the Schulich School of Medicine and Dentistry Policies found at: http://www.schulich.uwo.ca/medicine/postgraduate/policies
PREAMBLE
The teacher-learner relationship should be based on mutual trust, respect, and responsibility.
This relationship should be carried out in a professional manner in a learning/research/clinical
environment that places strong focus on education, high quality patient-care and, at all times,
ethical conduct.
In the past, the hierarchy and certain behaviors have been accepted, justified, and perpetuated
as behaviors in a rite of passage. In the current educational climate, some behaviors are not
acceptable and can no longer be condoned. Educators must be sensitive to the large power
imbalance that exists in the teacher/learner relationship and to the potential harm inflicted by
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inappropriate comments or actions. An interactive, informative, and respectful
teaching/learning environment must be established.
The Ontario Human Rights Code states that all individuals have the right to equal opportunities
in the workplace and to an educational environment free of harassment because of color, age,
sex, sexual orientation, ethnic origin, religion, and handicap, etc. Harassment is considered a
form of discrimination and is illegal under the Human Rights Code.
In the teacher-learner relationship, each party has certain legitimate expectations of the other.
For example, the learner can expect that the teacher will provide instruction, guidance,
inspiration, and leadership in learning. The teacher, on the other hand, can expect the learner
to make an appropriate professional investment of energy and intellect to acquire the
knowledge and skills necessary to become an effective professional, to develop a commitment
to service, and come to value the importance of responsibility in patient care and academic
responsibilities. Teachers have the responsibility to model and explicitly describe the behavior
they expect of students in their interactions with others. Students, in turn, have a responsibility
to extend the framework of collegial and respectful interaction to peers, staff, health-care
workers, and patients. Certain behaviors are inherently destructive to the teacher-learner-
researcher relationship and may, in fact, constitute a form of abuse. This may be operationally
defined as behavior by faculty, students, and staff which is consensually disapproved of by
society and by the academic community as either exploitive or punishing.
Concern regarding inappropriate behavior is not limited to the interaction between the teacher
(staff anesthesiologist) and student (anesthesia resident). It should also include the following:
All Physicians, Dentists and Midwives
Allied Health Care Professionals (RN, RRT, etc.)
Hospital Support Staff and Employees (cleaning staff, patient care associates, etc.)
Secretarial Staff
Industry Representatives on official business
Fellow Students (Residents, Fellows, Medical Students, etc.)
Patients and their relatives
It should be noted that demented, delirious (in particular patients under the influence of
anesthetic agents or emerging from general anesthesia), or patients with brain injuries may at
times behave in an inappropriate or violent manner. The primary focus should be the safety of
the patient and health care workers (resident) in this circumstance. Please refer to the
Anesthesia Resident Safety Policy for more information.
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COMMENTS OR BEHAVIOURS CONSIDERED UNACCEPTABLE
Perceived inappropriate comments directed at an individual related to the person's sex, sexual
orientation, racial background, religion, or physical ability. This may include:
a) Threat of/or actual physical contact of any kind when there is a perception of physical
violence. For example:
o Violent grabbing, pushing, or shoving.
o Throwing of instruments.
b) Sexual harassment of any kind. Types of conduct which may constitute sexual
harassment include but are not limited to:
o Sexual remarks or jokes causing embarrassment or offence after the person
making the joke has been informed that they are embarrassing or offensive or
that are by their nature reasonably known to be embarrassing or offensive.
o Sexual solicitation or advance made by a person in a position to confer, grant, or
deny a benefit or advancement where the person making the solicitation or
advance knows or ought reasonably to know it is unwelcome.
o Sexually degrading words used to describe a person.
o Sexually suggestive or obscene comments or gestures.
o Leering, touching, advances, propositions or requests for sexual favours.
o Derogatory or degrading remarks, verbal abuse, or threats directed towards
members of one gender or regarding one's sexual orientation.
o Inquiries or comments about a person's sex life, sexual prowess, or sexual
deficiencies.
o The display of sexually suggestive material in the workplace.
o Persistent unwanted contact or attention after the end of a consensual
relationship.
o Comments which draw attention to a person's gender and have the effect of
undermining the person's role in a professional or business environment.
o Comments regarding a person's physical appearance or attractiveness.
c) Assigning tasks for punishment rather than for educational benefit or denying equal
educational opportunities as a punishment.
d) Use of public humiliation or intimidation as a method of teaching or use of derogatory
terms when referring to another person.
e) Grading used to punish rather than as an objective evaluation of performance.
f) Preferential treatment, especially in the evaluation and admission process, as a result of
relationship (family, friend, donor, financial).
g) Initiating or maintaining intimate or sexual relationships between teachers and learners.
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h) Intimate or sexual relationships between clinical trainees and patients. (Please note that
the College of Physicians and Surgeons in Ontario has guidelines which focus on the
ethics of providing treatment for family members and in initiating an intimate relationship
with patients. Residents are expected to adhere to these professional guidelines).
While the literature focuses on the abuse of power (generally considered to reside in the hands
of the teacher or institution) it fails to articulate that students, especially in numbers, have
power also and can exercise that inappropriately under certain circumstances. An example
might be the organized effort to subvert or sabotage teaching sessions or evaluation
procedures for the purpose of punishing a teacher or for personal gain. From the point of view
of a code that applies to teacher and learner alike, it is important to recognize that the potential
to hurt and impair the functioning potential of another person exists within the domain of both
teacher and learner.
STEPS TO FOLLOW IF HARASSMENT, INTIMIDATION OR INEQUITY
REQUIRES REPORTING/ACTION:
1. The Anesthesia Program director should be informed immediately.
2. If possible, a written statement of the specifics surrounding the incident(s), behavior and
witnesses would be helpful.
3. At times residents may not be comfortable discussing these issues with the Program
Director. Alternate individuals or departments to inform:
o Chair of the Department of Anesthesia and Perioperative Medicine
o Associate Program Director for Anesthesia or member of Anesthesia PGE
committee
o Chief Anesthesia Resident or Junior Resident Representatives on Anesthesia
PGE Committee
o Office of Associate Dean of Postgraduate Medical Education
(http://www.schulich.uwo.ca/medicine/postgraduate/index.php)
o PARO (http://www.myparo.ca/)
o CMPA (http://www.cmpa.org)
o CPSO (http://www.cpso.on.ca/)
o Departmental Ombudsperson
Investigation, intervention, or disciplinary action taken will be at the discretion of the Schulich
School of Medicine and Dentistry, Affiliated Hospitals, CPSO, and supervisors of individual(s)
involved.
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JOURNAL CLUB The Department of Anesthesia & Perioperative Medicine
The Department of Anesthesia & Perioperative Medicine Journal Club is loosely based on the
McMaster Evidence Based Medicine approach, similar to the JAMA critical appraisal articles.
Journal Club is held bi-monthly from September to June. Each topic begins with a clinical
scenario requiring a literature search. The scenario is accompanied by a couple of articles for
review and questions for discussion.
Dr. Craig Railton and Dr. Tim Turkstra coordinate the Journal Club. Please feel free to contact
either of them with a topic suggestion ([email protected] or [email protected] )
Jamie Allaer provides administrative support for Journal Club and can be reached at extension
33022 or by email at [email protected] .
Attendance at Journal Club is mandatory and is recorded.
LEAVE OF ABSENCE POLICY Schulich School of Medicine & Dentistry
For information regarding the Postgraduate Medical Education Policy on Residency Leaves of
Absence, and to access the Leave of Absence Form, please refer to the following links:
Postgraduate Medical Education Policy on Residency Leaves of Absence and Training
Waivers:
http://www.schulich.uwo.ca/medicine/postgraduate/policies/files/Policies/2012Leave-of-
Absence-and-Training-Waivers.pdf
Leave of Absence Form:
http://www.schulich.uwo.ca/medicine/postgraduate/forms/files/Forms/LeaveofAbsence.pdf
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OMBUDSPERSON TERMS OF REFERENCE The Department of Anesthesia & Perioperative Medicine
The purpose of the Ombudsperson is to provide Residents in the Department of Anesthesia &
Perioperative Medicine access to an impartial faculty member at the Schulich School of
Medicine and Dentistry. Residents, either individually or as represented by the Chief Resident,
may at times need to bring significant concerns regarding the training program, Schulich
Medicine & Dentistry faculty, or the Department of Anesthesia and Perioperative Medicine to
the attention of the Ombudsperson.
TERM
Two year renewable term.
SELECTION
Candidates for this position will be suggested by the resident members of the Anesthesia PGE
committee. Candidate must be a member of the faculty at the SSMD. Candidates must also be
acceptable to the faculty members of the PGE committee.
FUNCTIONS
1) Provide experienced educator outside of the Department of Anesthesia and
Perioperative Medicine to receive and assess resident feedback regarding issues of
significance in the Residency Training Program for Anesthesia.
2) The Ombudsperson has the authority to seek the assistance of the Postgraduate
Education Office, Office for the Associate Dean of Equity and Professionalism or
Student Support Services.
3) If required the Ombudsperson may need to act as a mediator in areas of disagreement
or conflict.
The Program Director of the Anesthesia Training Program will assist the Ombudsperson if
required. The Program Director should also receive communication from the Ombudsperson
about issues brought forward. Depending on the nature of the issues at hand this
communication may be delayed or made more anonymous in nature.
4) The Ombudsperson should be aware of and utilize the Anesthesia Training Program’s
policy regarding intimidation and harassment if appropriate.
OPERATING ROOM ATTIRE London Health Sciences Centre
For information regarding operating room attire, please refer to the LHSC Policy:
http://www.lhsc.on.ca/priv/periop/or/policies/attire.htm
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PROCEDURE FOR REQUESTING TIME OFF (MEDICINE/GENERAL
SURGERY)
PROCEDURE FOR REQUESTING TIME OFF OF MEDICINE ROTATIONS
The Department of Medicine uses an on-line system for no call, vacation, educational leave,
etc. requests. Their web-based system is available to all residents while on Medicine rotations.
A username and password are required. To obtain your username and password please call
extension 3511 or email [email protected]
The online portal is available at:
http://lhdomws.lhsc.on.ca/dom/callsch/logindex.asp
PROCEDURE FORE REQUESTING TIME OFF OF GENERAL SURGERY ROTATIONS
Effective July 1, 2007, all residents rotating through general surgery will have to complete their
vacation requests on-line at www.general.uwosurgery.ca under Vacation Module. Requests
must be made at least 4 weeks in advance of the requested start day of vacation (6 weeks is
recommended). Late submissions will not be accepted and the request will be declined.
Please note that requests are approved by the service chief resident on a first come basis.
Once they are approved, you and your program will receive notification of all leaves taken
while on surgery. Please allow 2 weeks for approval notification.
Off-call requests – you may request at any time using the online request form, but they
may not necessarily be granted.
Vacation requests – apply to week days only – if you require the weekend you must
either request as off-call or vacation.
Stat replacement requests – you have 90 days to use these days and this request
option will be available to use after the observed statutory holiday. It is our strong
preference that, whenever possible, you take your stat replacements day on the rotation
where these holidays occurred.
Your username and password can be obtained by contacting Christine Ward at
[email protected] .
RESIDENT OR LOCKER POLICY The Department of Anesthesia & Perioperative Medicine
Lockers must be vacated at the end of a rotation for others coming on-service to use. There
will be a grace period of 3 days only following completion of a rotation. If the locker is not
vacated, the lock will be cut and the contents removed. This policy applies even if you are
returning to the site later in the year.
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RESIDENT TRAVEL ALLOWANCE POLICY The Department of Anesthesia & Perioperative Medicine
The Department of Anesthesia & Perioperative Medicine provides $800.00 per academic year
from travel to approved conferences, meetings, etc. Cash advances are not allowed. There is
also a one-time additional $800.00 allowed for travel to a major conference. The annual
amount may be carried over for one year with the approval of the Program Director
Trainees are expected to complete their own travel expense report (forms are available from
Linda Szabo). Original receipts must be submitted with the expense report and Western
University requires that claims for air or train fare must be accompanied by the boarding
passes. Credit card statements (copies are acceptable) showing the completed transaction for
claimed expenses must also be submitted (unrelated personal information on the statement
should be blacked out). Expense reports and accompanying receipts/statements should be
forwarded to Linda Szabo for approval/signatures.
Trainees who are presenting at a meeting will be reimbursed for 3 nights hotel stay, meals for
3 days, economy travel, registration fees, and poster preparation. This coverage is not
deducted from the annual travel allowance. If two residents are working on a research project
together each resident will get support to present at a conference (same conference or
different conferences). To receive support the resident must actually present at the conference
in question. Having their name as an author is not sufficient. It is expected that if a resident is
attending a conference where they are presenting with department support that they will make
an effort to support other residents who are presenting by attending those presentations.
Resident Expenses
The following expenses are approved and can be claimed in a travel expense report:
Conference registration
Economy fare (i.e. air, train, bus, etc.)
Accommodation
Meals (based on Western University per diem of $45.00/day)
Textbooks/Educational apps
The following expenses are excluded and cannot be claimed:
MAC-Western Research Day
Paying for a second hotel room for accompanying family
No travel to Royal College Exam is eligible
No professional fees (i.e. license renewal, PGE fees, tuition, etc.)
Computers, software, and hardware
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Exam fees (i.e. Royal College, MCC I or II, etc.)
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RESTRICTED REGISTRATION The Department of Anesthesia & Perioperative Medicine
There is an ongoing pilot project involving limited licensure/restricted registration (RR). For
Anesthesia residents this would allow residents on a restricted license to do coverage as a
Critical Care Clinical Assistant/Associate in a supervised Intensive Care Unit.
The Department of Anesthesia and Perioperative Medicine cannot allow the RR program to
lead residents into situations for which they are unprepared, such as might occur if they were
allowed to practice anesthesia independently in a relatively unsupervised environment. There
is also concern about conflicts with clinical work related to their residency program and
excessive workload, possibly leading to a deterioration in academic performance or family
relationships.
There are also some advantages to the work experience, both academic and financial.
Working in the ICU should provide valuable experience and might be beneficial to the
resident’s academic development. Easing the debt burden might improve stress levels and
reduce strain on family relationships.
It was the Residency Training Committee’s decision, assuming the Committee has some
control over their experience, that we could sanction anesthesia residents providing coverage
in the ICU as Critical Care Clinical Assistant/Associate (CCCA). The following restrictions
would be operative:
1) The Program reserves the option to limit the number of shifts per month under a
restricted license. This will depend on the nature of the shifts and the work intensity of
the rotation that the resident is concurrently on within the training program.
2) The resident on the restricted license must have adequate backup and supervision.
However, policing this is not the role of the PGE Committee or the Program. All medical-
legal responsibility lies with the resident and the supervisor of the proposed work site.
3) Anesthesia call schedules cannot be disrupted.
4) There must be at least a 12 hour gap between CCCA shift and clinical work in the
residency program. Conversely, CCCA shifts must not be booked sooner than 12 hours
after the duty period in anesthesia.
5) The Program Director, with the agreement of the Residency Training Committee,
reserves the right to veto any resident from participating in extracurricular shifts if there
are concerns about academic or personal issues. Residents will not be eligible for RR if
they have received unsatisfactory or provisional evaluations on any rotation within the
previous year. RR privileges will be withdrawn upon receipt of an unsatisfactory or
provisional evaluation.
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6) Academic projects must not suffer for the resident to qualify for privileges to engage in
RR.
7) Attendance at academic activities (academic day on Wednesday, journal club, rounds,
etc.) must be maintained.
8) Residents will not be eligible to work in the ICU until they have completed at least 2
months of adult ICU training (not including PGY-1), and 12 months of anesthesia at
PGY-2 or higher.
SENIOR RESIDENT DUTIES The Department of Anesthesia & Perioperative Medicine
The following is a list of duties to be undertaken by the Senior Resident:
Prepare and publish the resident call schedule according to the Resident Call
Scheduling Guidelines by the 15th of the month prior. Including a summary of all
resident time off on the schedule.
Meet with all new residents starting an anesthesia rotation at their site to:
o Review resident duties and responsibilities
o Provide a tour of the facility if necessary, including: clinical supplies, resuscitation
charts, library location, resident computer, call room.
o Make appropriate introductions to consultants and support staff
o Assist with obtaining locker space
o Inform new residents of the senior’s role as a resource person
Liaise with the PGE Site Coordinator
o Approve (via email) resident requests for time off
o Weekly rounds and teaching sessions
o Resident daily OR assignments
o Act as intermediary in communicating concerns between residents and
consultant staff
Resident Call Scheduling Guidelines
This is a set of guidelines for the designated scheduler maker to use when developing the call
schedules.
1) Find out about academic days, professional leave, education days, simulator days, and
holidays (including Christmas or any significant holiday). This often involves some legwork,
phone calls well ahead of time, etc. The onus is on the individual resident to let the senior
know of their request, but it will save some headaches if you prompt them. At changeover
time, find out who is on call the last night on their previous rotation. They will not be
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available to do the first day of the new rotation. Be sure you know the changeover date so
days are not missed or duplicated.
2) Fill in these holidays or weekend requests first.
3) Fill in ALL the weekends. Add up the weekend days to ensure that they are evenly
distributed. Try to avoid more than two successive weekends for any one person. Make
sure that people are not assigned with weekends during their holiday.
4) Fill in the Thursdays, try to keep them balanced.
5) Fill in the remaining days.
6) Keep a chart where you indicate the total number of days for each person, as well as the
total number of Thursdays, Fridays, Saturdays, and Sundays. Try to balance any negative
(extra day of call compared to others) with a positive (less weekend call, or more
Thursdays).
7) Review each person’s schedule and make sure you think it is livable, i.e. it doesn’t have a
long series of 1:2 call.
8) Duty roster should include surnames (not just given names) plus PGY level beside name.
9) Be prepared to make changes.
Special Guidelines:
PGY-1 residents will be booked at St. Joseph’s Hospital for the first block of
anesthesia they are assigned. During this time the site co-ordinators will assign
the PGY-1 resident buddy call at either University or Victoria Hospital. The site
will be determined by whichever site the resident is booked next block.
The “buddy call” should commence in the second week of introductory
anesthesia and should include at least one Friday night until 9pm, one Saturday
(8 - 4pm) and one Sunday (8am - 4pm). Two other weekday calls should also
occur.
Off service residents are assigned call only at the discretion and prior approval of
the site coordinator.
Special Instructions for UH Call Schedules:
Schedule to include names of residents available for the OR each day.
When the on-call resident is working off-site and taking call at 1700 hours, pre-
assign a resident to carry the pager during the daytime and note on the call
schedule.
CALL SCHEDULE MUST INCLUDE A SUMMARY OF ALL TIME OFF (FOR ANY REASON)
FOR EACH RESIDENT AND MUST BE DISTRIBUTED TO THE SITE COORDINATOR,
SITE SCHEDULING SECRETARY AND LINDA SZABO, AS WELL AS THE RESIDENTS
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Guidelines for Call/Clinical Duties for Residents Registered for the Upcoming Royal College Examinations in Anesthesiology
This is a set of guidelines for the designated scheduler maker to use when developing the call
schedules. The ultimate responsibility for the final call schedule at any given site rests with the
faculty site coordinator.
With all the guidelines below, if at any time PARO call guidelines are compromised by
excessive PGY-1 to PGY-4 call, then senior residents will have to increase call commitments.
It will be made clear to residents entering the Anesthesia training program at Western
University that the call expectations from PGY-1 to PGY-4 may be higher than PGY-5.
Guidelines are as follows:
Maximum call in 4 week block is 4 calls
Weekend call will be Friday/Sunday (not Saturday, unless requested)
Weekend call is to be shared by all (PGY-1 to PGY-5) residents (with the exception of
specific times below:
o No weekend call for 3 weekends before written exam date
o No weekend call for 2 weekends before oral exam date
o No weekend call one week before oral or written exam date
Residents sitting the upcoming exams in any given year will be scheduled to leave their
daily assignments at 1700 hours at the latest at any site (unless an emergency or
patient safety prevents this)
1 weekday study day preceding the written exam (beyond the usual
academic/vacation/professional day)
Reduced call frequency/no Saturday call ends after the oral exam each year
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SECTION 4: OBJECTIVES OF
TRAINING
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OVERALL GOALS AND OBJECTIVES OF THE ANESTHESIA
TRAINING PROGRAM The Department of Anesthesia & Perioperative Medicine
MISSION
First and foremost our mission is to train residents to become highly skilled and knowledgeable
anesthesiologists. The program will adhere to the CanMEDS competencies which are
expanded upon below. In addition to outstanding clinical competency, the training will focus on
giving the trainee the skills and opportunities to excel in research, quality assurance, teaching,
and leadership.
The objectives for any specific rotation will be describes in a documents specific for that
rotation.
Medical Expert/Clinical Decision Maker
The role of medical expert is the base that all other CanMEDS roles are supported upon. The
anesthesia training program at Western University expects that the acquisition of the medical
knowledge and skills of a specialist will gradually progress as a trainee moves through the
program.
PGY-1:
The aim of the PGY-1 year is for the trainee to gain a wide exposure to many fields of
medicine. The goal is to allow the resident to gather a variety of information and skills and
become a well-rounded physician.
PGY-2 and PGY-3:
Junior residents will continue to build upon the clinical exposure they gained in PGY-1. The
Introduction to Anesthesia rotation will continue from PGY-1 into PGY-2, allowing the resident
to gain the basic skills and knowledge expected of an anesthesiologist. In addition, a wide
variety of subspecialty anesthesia rotations will be undertaken after the Introduction to
Anesthesia rotation is complete. This will allow the resident to further understand and gain
experience with the depth and breadth of anesthesia practice. Internal medicine and critical
care rotations will begin to help fulfill the requirements of an anesthesiologist to provide
advanced perioperative medical intervention to patients. Overall the residents should have a
working knowledge of anatomy, pharmacology, physics, pathology, and physiology as it
pertains to anesthesia.
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PGY-4 and PGY-5:
Senior residents will continue to engage in a variety of subspecialty rotations and round out
their internal medicine and critical care rotations. It is expected by the end of PGY-4 that
residents will have an in-depth understanding of the scope of anesthesia practice. PGY-5
(consolidation) will focus on areas that may require additional work or exposure. In addition,
residents will be expected to have the clinical responsibilities (with appropriate back-up) of a
junior consultant and be able to apply knowledge of anatomy, pharmacology, physics,
pathology, and physiology in daily practice without excessive guidance. PGY-5 procedures
should for, the most part, be performed at the level of expertise of a junior consultant.
Communicator
PGY-1:
Residents will gain experience communicating as a physician. The skills involved with history
taking and documentation will also be stressed. Being able to gain skills delivering, either
written or verbally, a patient’s history, physical, investigations, and management plan will be
stressed in the varied clinical rotations.
PGY-2 and PGY-3:
Residents will continue to build on the skills mentioned in PGY-1. Clear communication with
the perioperative team (anesthesiologist, surgeon, nurses) will also be stressed. Complete and
adequate documentation in the form of the anesthesia chart will be an expectation.
PGY-4 and PGY-5:
Residents will be expected to communicate as leaders in the perioperative setting. In
particular, sound communication during emergencies will be an objective of training.
Collaborator
PGY-1:
As residents are rotating through a wide variety of clinical environments they should gain an
appreciation of the varied and important roles of the allied health care professionals and be
exposed to the concept of a multidisciplinary team.
PGY-2 and PGY-3:
Residents should be able to utilize the knowledge and skills of members of the multidisciplinary
team both inside and outside of the operating room. Interaction with the perioperative team,
supervisors, peers, patients, families, and allied health care should at all times be collaborative
and for the benefit of the patient.
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PGY-4 and PGY-5:
Residents should demonstrate the ability to lead members of a multidisciplinary team during
emergent and non-emergent situations.
Manager
PGY-1: Residents will learn how to manage the balance between being a learner, and a physician with
patient care responsibly.
PGY-2 and PGY-3:
Residents should begin to appreciate the unique aspects of the manager role as an
anesthesiologist. This includes, but is not limited to, on call urgent/emergent case prioritization,
OR call schedules, hospital systems to care for patients before, during, and after a procedure,
and the anesthesiologist’s role in equipment/medication acquisition.
PGY-4 and PGY-5:
Residents should be able to independently demonstrate the ability to prioritize cases and the
distribution of anesthesia resources (human and equipment). At this stage all anesthesia
residents will have been expected to have organized and administered call schedules.
Health Advocate
PGY-1: As residents rotate through multiple clinical rotations they should gain appreciation of the
importance of patient safety in the hospital environment. The concept of preventative medicine
should also be understood and implemented when appropriate.
PGY-2 and PGY-3:
Residents will be able to describe, identify, and implement preoperative optimization. The
resident will also learn to provide care in the safest manner possible by minimizing risk and
discomfort for patients. Residents will be able to implement appropriate pain control measures
perioperatively, particularly for the patient with chronic pain issues.
PGY-4 and PGY-5:
The senior resident should build upon and carry out, with minimal supervision, the health
advocacy objectives mentioned in PGY-2 and PGY-3. Residents will also be able to assess
and arrange the safest postoperative location for any individual patient.
Scholar
PGY-1:
Residents will learn to apply evidence based medicine to the care of patients.
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PGY 2 and PGY-3:
Residents will learn how to develop a scholarly project, and undertake to present this
academic endeavor as a poster, abstract, or manuscript. Residents will also endeavor to
improve their ability to critically appraise medical literature.
PGY-4 and PGY-5:
Residents will be expected to teach and mentor more junior trainees in anesthesia, internal
medicine, and critical care rotations. This progression should have begun as a junior resident.
Professional
Throughout their residency, residents are expected to fulfill the obligations of an anesthesia
resident. In particular the CanMEDS Portfolio, Resident Log Book, safe patient care,
documentation practices, careful tracking of narcotics, completion of required evaluations,
attendance at academic rounds, and the completion of a scholarly project.
PGY-1:
Residents will begin to appreciate professional obligations of being a physician in Canada.
PGY-2 and PGY-3:
Residents will continue to develop the duties expected of a medical professional, including
leadership, patient safety, promotion of the specialty of anesthesia, and the advancement of
health care locally and Canada-wide.
PGY-4 and PGY-5:
Residents will consolidate their role as a leader for a given patient’s care, and on a wider
scope solidify their professional obligations as an educator, scientist, clinician, and
administrator.
Reviewed: June 2013, Dr. Granton
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GRADED RESPONSIBILITY FOR ANESTHESIA RESIDENTS The Department of Anesthesia & Perioperative Medicine
As residents progress through their training it is expected that they should gradually have a
greater degree of independence. The graded responsibility is a balance between ensuring
patient safety and allowing the resident to gain confidence with independent practice.
Residents that are PGY-3 or higher are expected to supervise and educate more junior
trainees, including medical students. In the final year of training (PGY-5) it is expected the
resident should be able to function independently, with faculty back-up.
DEFINITIONS OF LEVELS OF SUPERVISION
Close:
Supervisor attends induction, emergence and any significant intraoperative event
Supervisor is immediately available
Intermediate:
Supervisor in close proximity, but not necessarily in room
Plans for induction, maintenance and emergence need to be discussed
Independent:
Supervisor in hospital and aware case or cases are progressing
Supervisor is available to consult with trainee and attend OR if urgently needed
In all independent cases, supervisor should be made aware if there are significant
anesthesia related concerns prior to induction
Independent epidural insertion only allowable after site coordinator satisfied that
resident has achieved appropriate level of skill.
EXPECTED LEVEL OF SUPERVISION BY PGY TRAINING LEVEL
TRAINING
YEAR ADULT CASES OBSTETRIC CASES PEDIATRIC CASES
PGY-1 Close C-section - Close
Epidural - Independent Close
PGY-2 ASA 1 or 2 = intermediate
ASA 3 or greater = close
C-section - Close
Epidural - Independent
ASA 1 or 2 = intermediate
ASA 3 or greater = close
PGY-3
ASA 1 or 2 = independent
ASA 3 or greater =
intermediate
C-section intermediate
Epidural - Independent
ASA 1 or 2 = intermediate
ASA 3 or greater = close
PGY- 4
ASA 1, 2 or 3 = independent
ASA 4 or greater =
intermediate
ASA 1 or 2 = independent
ASA 3 or greater = intermediate
ASA 1 or 2 = independent
ASA 3 or greater =
intermediate
PGY-5 Independent Independent Independent
Reviewed: June 2013, Dr. Granton
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OBJECTIVES FOR THE PGY-1 YEAR
The practice of anesthesia requires knowledge and skills from several disciplines. The PGY-1
year has been designed to provide a broad understanding of medicine and to facilitate success
on the LMCC Part II Examination, a current requirement of all Canadian Licensing authorities.
Residents not entering anesthesia residency immediately following medical school are advised
to apply for credit for the PGY-1 year promptly upon acceptance to the program. For basic
clinical training, the RCPSC Credential Committee will accept: rotating, transitional, mixed or
straight internships; residency training in family medicine; and/or basic clinical training that is
integrated into specialty residency programs.
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EMERGENCY MEDICINE ROTATION (PGY-1 OR ELECTIVES FOR PGY-2 TO 5)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
The goal of the Emergency Medicine rotation for trainees in anesthesia is consolidation of the
trainee’s knowledge of acute medical and surgical illnesses. In addition, development of an
approach to the assessment and management of the trauma victim and critically ill patient (eg.
evolving myocardial infarction, status asthmaticus, severe pulmonary embolism, etc.) will be
emphasized.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
Specific Knowledge Requirements
The resident will be able to:
List the common acute and chronic disease processes presenting in the emergency
department.
Describe the pathophysiology of these diseases.
Describe the usual therapeutic measures used to treat these diseases.
Recognize disease processes that require urgent/emergent medical or surgical
intervention.
Be able to describe the ACLS and ATLS protocols for patient intervention.
Specific Skill Requirements
The resident will be able to:
Complete a history and physical assessment of the patient presenting in the emergency
room with special emphasis on the presenting complaint.
Request and interpret appropriate investigations required to assess the patient’s
complaint.
Present a stratified differential diagnosis of the patient’s illness.
Prescribe initial management of the patient’s condition, including resuscitation of the
acutely ill patient.
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Demonstrate basic technical skills such as skin suturing, fracture casting, etc.
Demonstrate an understanding of the approach to and rationale for arterial and central
line insertion and intubation.
Understand the ACLS approach to assessment and resuscitation of the patient with a
critical cardiac illness where appropriate.
Understand the ATLS approach to assessment and resuscitation of the trauma victim.
Communicator
The resident will be able to:
Obtain and document the relevant medical history and physical examination thoroughly
and efficiently.
Develop communication skills with other members of the health care team to benefit the
patient.
Describe patient information and outline management plans to the attending emergency
consultant in a professional and intelligent manner.
Explain care management plans for discharge to patients in a clear, concise, easy to
understand manner.
Collaborator
The resident will be able to:
Describe the importance of the role of each of the members of the emergency
department team, and support them in fulfilling their roles.
Describe emergency room conditions warranting consultation with other health care
providers (i.e. general surgeon, internist, cardiologist, etc.).
Review management plans and courses of action with the attending emergency
department consultant.
Manager
The resident will be able to:
Consider health care resources when determining the patient’s emergency department
management plan.
Acknowledge the difficulties and decision-making involved in utilization and allocation of
finite health care resources.
Become proactive in ensuring appropriate discharge from emergency department, or
referral for consideration of admission to hospital for their patients.
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Health Advocate
The resident will be able to:
Understand the complex emotional effects of the illness on the patient and their family.
Provide appropriate education to ensure patients are well informed and well prepared
for discharge from the emergency department, or possible admission to hospital.
Encourage patients to optimize their health status.
Professional
The resident will be able to:
Demonstrate integrity and honesty when interacting with patients, families, and other
health care professionals.
Be punctual, efficient, and respectful at all times.
Reviewed: June 2012, Dr. Granton
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CARDIOLOGY (PGY-1 OR PGY-2 TO 5)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
Anesthesia residents may undertake at an elective rotation in in-patient Cardiology at University
Hospital.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
The resident is expected to:
Demonstrate knowledge of cardiovascular physiology, anatomy and pharmacology.
Demonstrate ability to diagnose and manage myocardial ischemia and/or infarction.
Demonstrate appropriate ability to order and interpret investigations common to cardiac
patients including, electrocardiograms, cardiac enzymes, echocardiogram and
angiogram findings.
Demonstrate an ability to recognize and manage cardiac arrhythmias, in particular those
with hemodynamic instability.
Communicator
The resident will be able to:
Communicate with Cardiology team (physicians, nurses) effectively in a written and
verbal manner.
Communicate effectively with patients and families.
Collaborator
The resident will be able to:
Demonstrates ability to work well as a member of a multidisciplinary health care team.
Manager
The resident will:
Demonstrates leadership skills in emergency situations. In particular with hypoxia,
shock and advanced cardiac life support (ACLS).
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Health Advocate
The resident will:
Understand lifestyle and socioeconomic issues that contribute to heart disease.
Advocate for patients to modify these factors if possible.
Professional
The resident will:
Be punctual and have an appropriate attendance record.
Attend and present at teaching rounds when required.
Be respectful to fellow health care members, patients and families.
Reviewed: September 2012, Dr. Granton
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GENERAL INTERNAL MEDICINE ROTATION (PGY-1)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
The following are the rotation specific goals and objectives for trainees during their General
Internal Medicine (GIM) experience. These have been formulated to guide the provision of an
educational experience which will encourage and allow the trainee to develop the knowledge,
skills and attitudes of a specialist in Internal Medicine.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
During the rotation, the resident will demonstrate proficiency in:
Assessment of patients presenting with undifferentiated medical complaints/problems
including eliciting a relevant history, performance of the appropriate physical
examination and evidence-based use of diagnostic testing.
Evidence-based management of common medical illnesses as well as less common but
remediable conditions.
Effective, integrated management of multiple medical problems in patients with complex
illnesses.
Performance of common procedures used in diagnosis and management of medical
patients including ECG interpretation.
Communicator
During the rotation, the resident will demonstrate proficiency in:
Obtaining a thorough and relevant medical history.
Bedside presentation of patient problems.
Discussion of diagnoses, investigations and management options with patients and their
families.
Obtaining informed consent for medical procedures and treatments.
Communication with members of the health care team.
Communication with referring and/or family physicians.
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Collaborator
During the rotation, the resident will:
Demonstrate proficiency in working effectively within the health care team.
Demonstrate appropriate use of consultative services.
Recognize and respect the roles of other physicians, nursing staff, physiotherapists,
occupational therapists, nutritionists, pharmacists, social workers, secretarial and
support staff, and community care agencies in provision of optimal patient care.
Manager
During the rotation, the resident will:
Oversee provision of care and implementation of decisions regarding patient care,
including effective delegation of care roles.
Understand the principles and practical application of health care economics and ethics
of resource allocation.
Utilize health care resources in a scientifically, ethically and economically defensible
manner.
Demonstrate effective time management to achieve balance between career and
personal responsibilities.
Health Advocate
On completion of the rotation, the trainee will:
Understand important determinants of health including psychosocial, economic and
biologic.
Recognize situations where advocacy for patients, the profession or society are
appropriate and be aware of strategies for effective advocacy at local, regional and
national levels.
Scholar
During the rotation, the resident will:
Develop and document an effective, long-term personal learning strategy.
Demonstrate the ability to generate clinical questions related to patient care and utilize
and analyze available resources to develop and implement evidence-based solutions to
such questions.
Professional
During the rotation, the resident will:
Demonstrate integrity, honesty and compassion in delivery of the highest quality of care.
Demonstrate appropriate personal and interpersonal professional behaviors.
Reviewed: 2012, Dr. Granton
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GENERAL SURGERY (PGY-1)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
Medical Expert/Clinical Decision-Maker
Residents are expected to:
Become familiar with common general surgical clinical problems both in the Emergency
Department and on the ward. Specifically, they are to become familiar with common
perioperative management issues, especially as they relate to preoperative and
postoperative surgical care.
Have the opportunity to follow patients assessed in the Emergency Department and
admitted to hospital through their urgent and emergent surgical care. This experience
dealing with continuity of care for patients will allow for a better appreciation of the
issues faced by General Surgeons and General Surgical residents as they apply to
Anesthesia.
Have the opportunity to increase expertise with technical skills such as suturing, Foley
catheter insertion, and minor surgical procedures such as incision and drainage of
abscesses and assisting at surgery.
Communicator
Residents are expected to:
Establish therapeutic relationships with patients and their families.
Obtain and synthesize a relevant history from patients, families, and referring physicians
and to be an effective listener.
Residents are expected to discuss appropriate information with patients and families
and other members of the health care team. They are also expected to communicate
effectively with referring services.
Collaborator
Residents are expected to:
Consult effectively with other physicians and health care professionals and to contribute
effectively to interdisciplinary team activities such as discharge planning and placement
of patients.
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Manager
Residents are expected to:
Utilize resources effectively to balance patient care, learning needs and outside
activities.
Allocate finite health care resources wisely.
Work effectively and efficiently in health care organization.
Utilize information technology to optimize patient care, life-long learning and other
activities.
Health Advocate
Residents are expected to:
Identify the important determinants of health effecting surgical patients.
To contribute effectively to improve health of patients and communities.
To recognize and respond to those issues where advocacy is appropriate.
Scholar
Residents are expected to:
Develop and implement personal and continued learning strategy.
To critically appraise medical information and to facilitate learning of patients, house
staff, students, and other health professionals.
To contribute to the development of new knowledge.
While on this rotation, residents will be excused to attend ½ academic day sessions
each week.
Residents are expected to read about cases in advance of surgery.
Residents are expected to teach medical students and other health care professionals.
Professional
Residents are expected to:
Deliver the highest quality of care with integrity, honesty and compassion.
Exhibit appropriate personal and professional behaviors.
Practice medicine ethically consistent with obligations of a physician.
Residents are expected to function in a way that creates a working environment for the
team that is positive and free of harassment and intimidation of any kind.
To adhere to the rules governing credentialing at the hospital.
To follow the code of conduct as set forth by the Schulich School of Medicine and
Dentistry.
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Professionalism will be assessed by interaction with colleagues, health care
professionals, patients, and in your day to day interaction as you practice medicine on
the surgical teams.
Reviewed: June 2012, Dr. Granton
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OBSTETRICS & GYNECOLOGY ROTATION (PGY-1)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
The goal of the Obstetrics & Gynecology rotation for PGY-1 trainees in anesthesia is the
development of an understanding of the needs and expectations of the anesthesiologist from
the obstetrician/gynecologist’s perspective, for the purpose of the trainee’s future career
development.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
Specific Knowledge Requirements
The resident will be able to:
Describe the anatomic and physiologic changes of pregnancy and the peripartum
period.
Describe fetal-placental anatomy and physiology.
Describe the various positions of the fetus in presentation for delivery.
List the indications for operative delivery including forceps and Cesarean section.
Describe the pathophysiology of common complications of pregnancy including
pregnancy induced hypertension, gestational diabetes, placental insufficiency, placenta
previa, and immune interactions between parturient and fetus (esp. Rh incompatibility).
Describe the appearance of normal and abnormal fetal heart rate tracings.
Describe the normal components of a fetal biophysical profile.
Specific Skill Requirements
The resident will be able to:
Complete a physical assessment of the pregnant patient.
Assess fetal well-being.
Provide suitable initial management for common complications of the postpartum period (i.e. postpartum hemorrhage, uterine atony, etc.).
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Communicator
The resident will be able to:
Obtain and document the relevant medical history thoroughly and efficiently.
Develop communication skills with other members of the health care team to benefit the
patient.
Explain obstetrical procedures (fetal heart rate tracings, fetal biophysical profiles, etc.) in
a clear and compassionate manner.
Describe patient information and outline obstetrical management plan to the attending
obstetrical resident or obstetrician in a professional and intelligent manner.
Discuss special needs (birthing plans, etc.) with nurses and other health care team
members in a respectful manner.
Collaborator
The resident will be able to:
Describe the importance of the role of each of the members of the birthing team and
support them in fulfilling their duties.
Describe maternal or fetal conditions warranting antepartum consultation with other
team members (i.e. anesthesiologist, internist, neonatologist, etc.).
Review management plans and courses of action with the obstetrical resident or
obstetrician at all times.
Health Advocate
The resident will be able to:
Understand the complex emotional atmosphere surrounding delivery of a newborn and
be able to act as an advocate for the family in the medical environment.
Encourage patients to optimize their health status throughout pregnancy.
Professional
The resident will be able to:
Demonstrate integrity and honesty when interacting with patients, families, and other
health care professionals.
Be punctual, efficient, and respectful at all times.
Evaluation
An end-of-rotation evaluation will be discussed with the trainee.
Reviewed: March 2012, Dr. Granton
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PEDIATRIC EMERGENCY MEDICINE (PGY-1)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
Specific Knowledge Requirements
Differentiation of the well child from the acutely ill child in order to build a base for the
pre-anesthetic assessment.
Initial ABC management of a sick child including basic airway management with oxygen
delivery, positioning, bag-valve-mask ventilation, and fluid resuscitation.
Approach to fever in neonates, infants, and children.
Airway ABC’s – asthma, bronchiolitis, croup, foreign bodies – their diagnosis and
management.
Fluid management and assessment of dehydration along with rehydration techniques.
Rapid sequence intubation – technique, indications and contraindications.
Procedural sedation – indications and contraindications.
Knowledge of pediatric pain management.
Management of otitis media, urinary tract infections, pneumonia, and gastroenteritis.
Approach to fracture management including Salter-Harris classification.
Diagnosis and management of common surgical emergencies – appendicitis, pyloric
stenosis, intussusception, volvulus, hernia.
Knowledge of drug dosing for common drugs – epinephrine, antibiotics, antiepileptics,
bronchodilators, antihistamines, steroids, and analgesics.
Knowledge of common overdoses and poisonings.
Methods to Achieve Competencies
o Formal and informal teaching sessions in the ED.
o Provision of both PALS and APLS courses to interested first-year residents.
o Provision of PEM library resources and selected landmark studies.
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Specific Skill Requirements
Bag-valve mask ventilation, orotracheal intubation, splinting, suturing, casting, lumbar
punctures, local anesthesia, intravenous placement, chest and abdominal radiograph
interpretation
Methods to Achieve Competencies
o Demonstration of technical procedures in the ED.
o Supervised procedures in the ED with immediate feedback.
Communicator
The resident will be able to:
Obtain a relevant history from patient, parents, and caregivers.
Communicate with the child’s family management plans to inform them and allay undue
anxieties.
Methods to Achieve Competencies
o Observed history-taking and physical examination skills.
o Observed management plans communicated to patient and family/caregiver.
Collaborator
The resident will be able to:
Consult with other physicians and members of the health care team effectively.
Understand the roles of the interdisciplinary team.
Methods to Achieve Competencies
o Observation of interaction with nurses, respiratory therapists, and x-ray
technicians.
Manager
The resident will be able to:
Utilize resources efficiently to manage patient care effectively.
Work effectively and efficiently in a health care organization.
Methods to Achieve Competencies
o Residents with appropriate staff supervision will decide which patients require
discharge, observation, or admission.
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Health Advocate
The resident will be able to:
Contribute effectively to improved health of patients and their communities.
Consider anticipatory guidance with each patient encounter.
Methods to Achieve Competencies
o Discussion of illness and injury prevention when appropriate.
Scholar
The resident will be able to:
Provide evidence-based medical practice via frequent critical appraisal of the literature.
Methods to Achieve Competencies
o Attendance at Pediatric Emergency Rounds.
o Presentation of Pediatric Emergency Rounds.
Professional
The resident will be able to:
Appreciate the complex emotional effects that an acute illness has upon a family.
Practice ethically according to professional standards with patients, families, and health-
care teams.
Methods to Achieve Competencies
o Close supervision of resident assessments with families and staff.
Reviewed: September 2012, Dr. Granton
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INTRODUCTION TO ANESTHESIA ROTATION (PGY-1 & 2)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
During the Introduction to Anesthesia Rotation, the resident will be expected to develop an
understanding of the fundamentals of anesthesia practice and the basic skills needed to
support this understanding.
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will be able to describe and implement clinical preoperative assessment,
including risk assessment and comprehensive anesthetic planning.
The resident will demonstrate an understanding of the physical principles relating to
anesthesia equipment and the safety aspects pertaining to this equipment, including
equipment checking.
The resident will be able to apply their knowledge of the physical principles of
monitoring systems to the clinical practice of anesthesia with particular reference to
common monitoring devices (EKG, pulse oximetry, non-invasive and invasive blood
pressure monitoring, gas analysis, temperature monitoring, and peripheral nerve
stimulation).
The resident will be proficient at airway management, demonstrating competence with
mask ventilation, airway insertion, direct laryngoscopy, and the use of Glidescope, and
laryngeal mask airway devices.
The resident will be able to describe the basic components of anesthesia (analgesia,
amnesia, areflexia, unconsciousness, and muscle relaxation/immobility) and the
appropriate clinical application of these modalities.
The resident will demonstrate ability to assess and manage, with appropriate
intervention, the respiratory and hemodynamic status of the patient during the
perioperative period.
The resident should be proficient at securing peripheral intravenous access, and be
familiar with techniques of arterial and central venous cannulation.
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The resident should be capable of performing spinal anesthesia, and be familiar with
epidural techniques, as well as having a good understanding of the equipment,
indications, limitations, and contraindications for regional anesthesia.
The resident will be familiar with the pharmacology of commonly used drugs in the
perioperative period, as well as drugs used during resuscitation, and in the
management of patients with common comorbidities. They will be aware of common
drug interactions.
The resident will be capable of providing anesthesia for ASA 1 and 2 patients
undergoing uncomplicated surgery with minimal supervision.
For those rotating at:
Victoria Hospital:
o Assessment for and provision of epidural insertion for labour and delivery should
become an acquired skill.
o Residents should gain basics of anatomy, physiology, pharmacology, and
psychology for pediatric patients.
University Hospital:
o Residents should begin to appreciate some anesthetic considerations for
neurosurgical cases and physiology and pharmacology as it applies to
intracranial pressure.
St. Joseph’s Health Care:
o Residents will be able to identify and predict issues that are specific to
ambulatory surgical cases including pain control, nausea and vomiting, and rapid
turnover discharge criteria.
Communicator
The resident will be able to effectively communicate with patients and/or their families
for the purpose of eliciting an appropriate history.
The resident will effectively communicate the risks and benefits of the anesthetic
options available for the patient’s surgery for the purpose of informing the patient and
including them in the decision making process.
The resident will be able to effectively communicate with all colleagues and members of
the team involved in caring for the patient. They will be able to protect the patient’s
interests, and be confident to address concerns in an assertive but non-confrontational
manner.
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Collaborator
The resident will be a team player and be able to appropriately consult other physicians
for advice and further management of the patient.
The resident will cooperate with colleagues to ensure patient care and safety.
The resident will recognize the key interactions between members of the operating
room team and strive to facilitate optimal patient care.
Manager
The resident will learn by observation and begin to be able to apply the principles of
effective operating list management through planning and preparation.
Health Advocate
The resident will continue to promote the health of their patient and will develop a
responsible attitude towards the utilization of finite healthcare resources.
Scholar
The resident will be self-directed and focused on their career learning objectives.
The resident will seek to apply the principles of evidence-based practice and continually
try to justify clinical decision making processes.
The resident should make a reasonable effort to prepare by prior reading or enquiry for
each day’s work.
The resident should attend and participate in the formal teaching opportunities offered
within the department and develop an awareness of research activities within their
environment.
Professional
The resident will demonstrate professional behavior towards senior and junior
colleagues, patients, and allied healthcare workers.
The resident will demonstrate a mature work ethic in keeping with the privilege of
practicing medicine.
The resident will accept advice and constructive feedback from their supervisors at
times of formal assessment.
Reviewed: June 2013, Dr. Granton
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SUBSPECIALTY OBJECTIVES
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ACUTE PAIN AND OUT OF OR ANESTHESIA
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
This rotation is a unique combination of the Pre-Admission Clinic at Victoria Hospital, the Acute
Pain Service, and provision of anesthesia services outside of the operating room. The
objectives for the Pre-Admission portion are the same as those for University Hospital and are
included below. The objectives for the Acute Pain Service and out of OR anesthesia follow.
The Pre-Admission Clinic is a rotation that will occur at either University Hospital or Victoria
Hospital over a four week period. The resident will spend the majority of time in the
preoperative clinic of either hospital. Residents will be expected to complete an appropriate
history and physical on each patient seen in the clinic. The resident will then present a plan for
further investigation, optimization, and perioperative management of the patients seen. Written
or dictated documentation of the consultations is expected.
ROTATION OBJECTIVES (PRE-ADMISSION CLINIC)
At the completion of the Pre-Admission portion of training, the resident will have acquired the
following competencies and will function effectively as:
Medical Expert/Clinical Decision-Maker
General Requirements
The resident will be able to:
Demonstrate appropriate and anesthesia specific history and physical skills, including
assessment of the airway.
Specific Knowledge Requirements
The resident will be able to:
Demonstrate internal medicine knowledge base as it applies to the etiology, natural
history, and management of the following disease states that are common reasons for
pre-admission clinic referral: coronary artery disease, chronic obstruction pulmonary
disease, advance kidney failure, advanced liver failure, cerebral vascular disease,
typical congenital disease states, obstructive sleep apnea, obesity, rheumatoid arthritis,
ankylosing spondylitis, and chronic pain.
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Demonstrate a working knowledge of indications and recommendations for ordering of
invasive and non-invasive investigations preoperatively, including: ECG, pulmonary
function testing, chest radiograph, investigations of underlying coronary artery disease,
and investigations for cerebral vascular disease.
Demonstrate the ability to synthesize a reasonable optimization/investigation anesthetic
management plan based on nature and urgency of surgery, history, physical, and
available investigations.
Communicator
The resident will be able to:
Communicate well with patients and families in the Pre-Admission Clinic, with a good
bedside manner.
Verbally explain findings of history and physical with anesthesia faculty supervisor and
provide a reasonable management plan.
Provide a concise dictated note regarding patient assessment and plan.
Collaborator
The resident will be able to:
Interact well with the multi-disciplinary team in the Pre-Admission Clinic.
Work well with other physicians in the Pre-Admission Clinic including internal medicine
and surgery.
Consult other specialties (internal medicine) when required for patient care.
Health Advocate
The resident will:
Understand the anesthesiologist’s role in optimization of the patient preoperatively.
Take steps to improve perioperative safety of patients (aspiration prophylaxis, post-
operative Critical Care admission, etc.).
If appropriate, demonstrate willingness to communicate to the surgeon the anesthesia
team’s concerns regarding timing, scope, and appropriateness of proposed surgery.
Understand the anesthesiologist’s role in patient education preoperatively, including
smoking cessation.
Be able to provide risks and benefits of possible postoperative pain control options.
Understand the anesthesiologist’s role in blood conservation and should be able to
describe the pros and cons of a variety of blood conservation strategies.
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Professional
The resident will:
Display professional behavior and attitude while dealing with patients, families, and staff.
READING LIST
Required Reading:
1. Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. Philadelphia: Lippincott;
1989. Chapter 26: 569-579.
2. Miller RD, editor. Anesthesia. 7th ed. New York: Churchill Livingstone; 1990. Chapter 33:
969-999. Risk of Anesthesia.
3. Miller RD, editor. Anesthesia. 7th ed. New York: Churchill Livingstone; 1990. Chapter 34:
1001-1066. Preoperative Evaluation.
4. Miller RD, editor. Anesthesia. 7th ed. New York: Churchill Livingstone; 1990. Chapter 35:
1067-1150. Anesthetic Implications of Concurrent
Suggested Readings:
5. Ann Thorac Surg. 2011 Mar; 91(3):944-82. 2011 update to the Society of Thoracic
Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical
practice guidelines.
6. Anesthesiology. 2002; 96:485-96. Practice advisory for preanesthesia evaluation. A report
by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.
7. BJA. 2011; 107 (1):83-96. Preoperative cardiac management of the patient for non-cardiac
surgery: an individual and evidence based approach.
8. The American Journal of Medicine. Feb. 2011; Vol. 124(2):144-154. Smoking Cessation
reduces postoperative complications: A systematic review and meta-analysis.
9. Circulation 2007; 116:1971-96. The ACC/AHA Guidelines on perioperative cardiovascular
evaluation and care for non-cardiac surgery.
10. NEJM December 2004; Vol. 351(27):2795-2804. Coronary artery revascularization before
major elective vascular surgery.
11. The Lancet May 2008; Vol. 371: 1839-47. Effects of extended release metoprolol succinate
in patients undergoing non-cardiac surgery (Poise trial): a randomized controlled trial.
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ROTATION OBJECTIVES (ACUTE PAIN SERVICE)
Upon completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will:
Demonstrate the ability to assess patient and surgery specific needs and options for
perioperative pain control.
Have working knowledge of indications, contra-indications, and complications of
narcotics, anti-inflammatory medications, antidepressants, sedatives, intrathecal
medications, and epidural analgesia as they pertain to perioperative pain control.
Understand the rational and is able to deliver multimodal perioperative analgesia.
Demonstrate the ability to assess and provide management for a patient with non-
surgical acute pain issues.
Demonstrate the ability to assess and modify acute analgesia management plan for
patients with chronic pain disorders.
Communicator
The resident will be able to:
Elicit appropriate input from patient or parents regarding effectiveness and concerns
about perioperative pain control.
Demonstrate effective and accurate written and verbal communication with nurses and
surgical team regarding pain control.
Collaborator
The resident will be able to:
Work well with the Acute Pain Service team and respects the roles of team members,
including consultants and nurses with advanced training.
Manager
The resident will be able to:
Efficiently participate or run acute pain service rounds on a high volume of patients.
Health Advocate
The resident will:
Demonstrate an understanding of the unique patient safety issues and complications
that can arise with perioperative pain control strategies including nausea, vomiting,
constipation, respiratory depression, delirium, hypotension, and neurological injury.
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Be able to counsel patients or parents on a variety of pain control options and describe
the risks and benefits of each.
Professional
The resident will:
Display professional behavior and attitude while dealing with patients, families, and staff.
READING LIST
Suggested Readings:
1. Miller’s Anesthesia 7th ed. Chapter 87. Acute postoperative pain.
2. Current Opinion in Anesthesiology. 2009; Vol. 22: Multimodal analgesia for controlling
acute postoperative pain.
3. Current opinion in anesthesiology. 2006; Vol. 19: 325-331. Perioperative management of
chronic pain patients with opioid dependency.
4. Excellent link to LHSC APS teaching site: http://www.lhsc.on.ca/priv/pain/ioa.htm
ROTATION OBJECTIVES (OUT OF OR ANESTHESIA)
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will be able to:
Demonstrate location, patient, and procedure specific knowledge of unique anesthesia
considerations when providing anesthesia services outside of the operating room
including:
o Available personnel with skills required to help anesthesiologist
o Timely availability of back-up in case of an emergency
o Location and acceptability of resuscitation equipment
o Transport of patients to Post Anesthetic Care Unit after procedure
o Pros and cons of sedation versus general anesthesia for procedures
Communicator
The resident will be able to:
Clearly communicate anesthesia specific requests and concerns to staff that may not be
familiar with the anesthesia teams’ needs.
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Health Advocate
The resident will:
Ensure proper equipment and personnel are available prior to starting the provision of
anesthesia services.
Understand the principles of and complies with radiation safety for the patient, staff, and
personally.
Professional
The resident will:
Display professional behaviors and attitudes while dealing with patients, families, and
staff.
READING LIST
Suggested Readings:
1. Miller’s Anesthesia 7th ed. Chapter 79. Anesthesia at remote locations
Reviewed: June 2013, Dr. Granton
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AIRWAY BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
General Requirements
The resident is expected to:
Demonstrate working knowledge of oral, pharyngeal, laryngeal, and tracheal anatomy.
Understand and have clinical suspicion of acute and chronic pathology that can
increase complexity of airway management.
Demonstrate knowledge of airway assessment and prediction of the difficult airway
(including elements of history, physical exam, and investigations).
Demonstrate working knowledge of the indications, contra-indications, advantages, and
disadvantages of a wide variety of airway management techniques.
Have an approach to the unexpected difficult airway (including a working knowledge of
the ASA Difficult Airway Algorithm).
Specific Knowledge Requirements
The resident will:
Demonstrate competence in the use of the following airway devices or management
techniques: bag mask ventilation, oral and/or nasal airways, direct laryngoscopy,
Glidescope, Laryngeal Mask Airway (LMA), lighted stylet, fiberoptic bronchoscope,
nasal intubation, airway topicalization, awake intubation, and in-line cervical spine
stabilization.
Communicator
The resident will be able to:
Communicate aspects of airway assessment to supervising anesthesiologist, patient,
and perioperative team.
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Effectively communicate plan of airway management to supervising anesthesiologist,
patient and perioperative team (particularly during the preoperative team debriefing—
often referred to as the surgical pause—when there are specific airway concerns).
Properly and accurately document airway assessment and management techniques
used on anesthetic record.
Collaborator
The resident will be able to:
Work effectively with members of multi-disciplinary team specific to airway management
(including registered respiratory therapists, nurses, surgeons, and anesthesiologists).
Manager
The resident will:
Efficiently and fairly manage resident duty/call schedules if assigned as senior resident
during airway rotation.
Use time of airway rotation to maximize exposure to challenging airway management
cases.
Health Advocate
The resident will:
Provide patients and other health care professionals with information regarding difficult
airway management in order to improve patient safety in the future.
Professional
The resident will:
Demonstrate ethical behavior in interactions with patients, families, supervisors, other
health care professionals, and peers.
Demonstrate knowledge of the need for and technique of disclosure of potential and
realized complications of airway management.
Demonstrate punctuality and adherence to proper operating room attire.
Adhere to hospital and departmental procedures and policies for the care of patients
and code of conduct for professional interactions.
READING LIST
Suggested Readings:
1. Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. 6th ed. Philadelphia:
Lippincott; 2009. Chapter 29: Airway Management.
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2. Miller RD, editor. Anesthesia. 7th ed. New York: Churchill Livingstone; 2010. Chapter 50:
Airway Management in the Adult.
3. Motoyama EK, Davis PJ, editors. Smith’s Anesthesia for Infants and Children. 7th ed.
Philadelphia: Mosby; 2006. Chapter 10: Induction of Anesthesia and Maintenance of the
Airway in Infants and Children.
Updated: June 2011, Dr. Granton & Dr. Turkstra
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CARDIAC ANESTHESIA BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
Residents completing the cardiac subspecialty rotations should achieve competence in the
management of routine anesthetic management of coronary bypass graft patients, valve
replacement and/or repair (aortic, mitral), and aortic valve procedures. In addition, they should
gain familiarity with complex cardiac cases involving patients with multiple comorbidities.
Clinical Faculty: Cardiac Anesthesiologists & Cardiac Surgeons.
Teaching Techniques: Teaching will be through direct clinical experience with consultant
guidance during clinical work load. Residents are also invited to attend morning TEE rounds.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will demonstrate knowledge of the basic sciences as applied to the preoperative, intraoperative, and postoperative periods of cardiac surgery.
A. Physiology and Anatomy
The resident is expected to:
o Describe the normal coronary anatomy and variants, normal cardiac physiology,
and the effects of disease states on the normal physiology.
o Describe the anatomy and physiology of cardiac valves, left ventricle, right
ventricle, atrial, major cardiac vessels, and circulatory system in both normal and
diseased states.
o Describe the normal conduction pathways of the heart and its clinical significance
in disease.
o Describe the embryologic circulation, development of the heart, and fetal
physiology as it applies to adult congenital heart disease.
o Describe the altered respiratory physiology of the immediately postoperative
ventilated patient with significant surgical incisions and pain (sternotomy, large
abdominal incision).
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o Describe common physiological changes occurring in the postoperative period
and the impact these have on end organ function (neurologic, renal, cardiac,
hepatic, gastro-intestinal).
B. Pharmacology
The resident should know:
o Commonly prescribed medications for cardiac surgical patients, the implications
for disease, and the impact on anesthetic management.
o Commonly used cardiac anesthetics and dosages.
o Heparin, antiplatelet agents, and anesthetic implications.
o Protamine for heparin reversal, along with side effects and complications.
o Antifibrinolytic agents, mechanisms of action, and indications.
o The use of blood products (PRBC, FFP, platelets, cryoprecipitate) and blood
alternatives (albumin, starch) as well as transfusion reactions and complications.
o Coagulation drugs currently available (DDAVP, activated factor 7a) their
indications, contraindications, dosages, and complications.
o Commonly used vasodilators, vasoconstrictors, inotropic agents, and their
indications, dosages, and side effects.
o The appropriate use of pain medications, non-steroidal anti-inflammatory drugs
and regional anesthetic techniques in cardiac surgical patients.
o Pharmacology of perioperative risk reduction strategies (lipid lowering agents, β-
blocker’s, aspirin).
C. Monitoring
The resident will:
o Be able to interpret ECG for ischemia, infarction, arrhythmias, and paced
rhythms. They will recognize the limitations and the sensitivity/specificity of ECG
as an ischemia monitor.
o Demonstrate principals of non-invasive and invasive BP monitoring and its
pitfalls.
o Acquire skills of arterial and central venous cannulation (with ultrasound),
peripheral venous cannulation, and pulmonary artery catheterization. Interpret
CVP and data from PA catheter (PAP, PCWP, Cardiac output) and know its
indications, complications, and management.
o Know basics of introductory TEE, including techniques of probe insertion and
several basic views, and its implication and application to the critical care patient.
o Understand laboratory monitoring of the coagulation system (PTT, INR,
fibrinogen), as applied to the cardiac patient.
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o Have the ability to assess the adequacy of mechanical ventilation using clinical
parameters (PT size & weight, peak & plateau ventilatory pressures, mode of
ventilation in conjunction with patient LOC, tidal volume, rate) and laboratory
arterial blood gas analysis.
o Recognize the parameters used to assess intraoperative blood loss and options
to treat blood loss including medical and surgical alternatives.
o Know the significance of temperature management in the intraoperative period,
including hypothermic techniques and the importance of normothermia during
beating heart procedures.
o Appreciate the indicators of volume status, especially when weaning from
bypass, and including the findings from invasive monitors, TEE, and clinical
indicators (urine volume).
o Utilize appropriate intraoperative blood work for the management of patient care.
o Have an awareness of new monitoring devices (non-invasive CO, BIS, NIRS)
and potential applications during cardiac surgery.
D. Clinical Assessment & Management
The resident will:
o Be able to complete a detailed history, physical exam, order appropriate
laboratory and ancillary investigations, and provide a management plan for a
cardiac surgical patient.
o Know current indications and recommendations for SBE prophylaxis.
o Be able to manage medical bleeding.
o Be able to correct common derangements in metabolic and electrolyte
disturbances in the intraoperative period.
o Know the basic principles of cardiac support devices including IABP and
extracorporeal membrane oxygenation.
o Know the common pathophysiology and management of patients with
complications of:
Coronary artery disease, acute myocardial ischemia and infarction,
complications of myocardial infarction and thrombolytic therapy
Valvular heart disease and valve replacement or repair
Aortic dissection, thoracic and thoracoabdominal aortic aneurysm
Shock and the use of volume resuscitation, venodilators/constrictors,
inotropes, and luisiotropes
Emergencies requiring ACLS
Cardiac tamponade, constrictive pericarditis
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Dilated, restrictive and obstructive cardiomyopathy (IHSS), CHF, and
diastolic dysfunction
Aberrant conduction, dysrhythmia, sudden acute and sub-acute ventricular
and supra-ventricular arrhythmia
Pacemakers and the indications for and applications of the various modes
of temporary pacing
Pneumohemothorax
Pulmonary edema, Pneumonia, CHF
COPD, asthma, sleep apnea in the ventilated patient
Heparin induced thrombocytopenia and heparin resistance
Neurologic risk stratification during CPB procedures
Renal failure and its management
Diabetes and endocrine control, and the implications of hyperglycemia
Communicator
The resident will:
Demonstrate effective communication with patients and families (description of
procedures, informed consent, anesthetic options and risks).
Demonstrate effective communication with OR team (cardiac surgeons, nurses and
perfusionists) and postoperative team (CSRU). Particularly during the initiation conduct
and removal of cardiopulmonary bypass.
Provide clear and concise written consultation and anesthetic records.
Collaborator
The resident will:
Recognize the need to utilize other specialists for the care and management of the
critical patient.
Foster healthy team relationships.
Manager
The resident will:
Manage OR time by efficiently conducting the anesthetic, continuing education, and
personal activities.
Make effective use of health care resources.
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Health Advocate
The resident will:
Demonstrate the use of risk reduction strategies, including use of ultrasound and sterile technique for invasive lines.
Scholar
The resident will:
Demonstrate commitment to continuing personal education including use of information
technology.
Be able to critically review cardiac anesthesia literature and describe the principles of
research relevant to this population.
Assist in education of other members of the OR team.
Professional
Residents must:
Always demonstrate respectful and compassionate behavior toward patients, their
families, and other health care providers.
Demonstrate an appropriate sense of responsibility to themselves and their patients.
Remain calm and organized in stressful or emergency situations.
Demonstrate appropriate interactions with colleagues and staff.
Evaluation
There will be an individual interview with the block coordinator at the end of the rotation.
Resident feedback is used to improve teaching techniques and rotation specific objectives.
READING LIST
Textbooks:
1. Miller’s Text Book of Anesthesia 7th edition. Chapter 60 Churchill Livingston Elsevier.
Philadelphia PA.
2. Barash’s, Clinical Anesthesia 6th edition. Chapter 41 Wolters Kluwer Philadelphia PA.
3. Kaplan, 5th edition. Saunders Elsevier. Philadelphia PA. Chapter 5, 11, 14,19, 20, 28,31.
Systematic Reviews:
4. Wang G, Bainbridge D, Martin J, Cheng D. The efficacy of an intraoperative cell saver
during cardiac surgery: a meta-analysis of randomized trials. Anesth Analg 2009;109:320-
30.
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5. Liakopoulos OJ, Choi YH, Kuhn EW, Wittwer T, Borys M, Madershahian N, Wassmer G,
Wahlers T. Statins for prevention of atrial fibrillation after cardiac surgery: a systematic
literature review. J Thorac Cardiovasc Surg 2009;138:678-86 e1.
6. Griesdale DE, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A, Dhaliwal R,
Henderson WR, Chittock DR, Finfer S, Talmor D. Intensive insulin therapy and mortality
among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ
2009;180:821-7.
7. Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill
adults: a meta-analysis. JAMA 2008;300:933-44.
8. Landoni G, Biondi-Zoccai GG, Zangrillo A, Bignami E, D'Avolio S, Marchetti C, Calabro
MG, Fochi O, Guarracino F, Tritapepe L, De Hert S, Torri G. Desflurane and sevoflurane in
cardiac surgery: a meta-analysis of randomized clinical trials. J Cardiothorac Vasc Anesth
2007;21:502-11.
9. Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. Bmj
2006;333:420.
10. Friedrich JO, Adhikari N, Herridge MS, Beyene J. Meta-analysis: low-dose dopamine
increases urine output but does not prevent renal dysfunction or death. Ann Intern Med
2005;142:510-24.
11. Fergusson D, Glass KC, Hutton B, Shapiro S. Randomized controlled trials of aprotinin in
cardiac surgery: could clinical equipoise have stopped the bleeding? Clin Trials
2005;2:218-29; discussion 29-32.
12. Cheng DC, Bainbridge D, Martin JE, Novick RJ. Does Off-pump Coronary Artery Bypass
Reduce Mortality, Morbidity, and Resource Utilization When Compared with Conventional
Coronary Artery Bypass? A Meta- analysis of Randomized Trials. Anesthesiology
2005;102:188-203.
Updated: June 2013, Dr. Granton
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CARDIAC SURGERY RECOVERY UNIT (CSRU)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
Residents completing the Cardiac surgery recovery Unit (CSRU) should achieve competence
in the management of routine postoperative care for Coronary Bypass Graft patients and valve
replacement and/or repair (aortic, mitral). In addition, they should gain familiarity with complex
cardiac cases involving patients with multiple comorbidities.
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
The resident will demonstrate knowledge of the basic sciences as applied to the critical postoperative period following cardiac surgery:
A. Physiology and Anatomy
The resident is expected to:
o Describe the normal coronary anatomy and variants, and normal cardiac
physiology and the effects of disease states on the normal physiology.
o Describe the anatomy and physiology of cardiac valves, left ventricle, right
ventricle, atria, major cardiac vessels, and circulatory system
o Describe the normal conduction pathways of the heart and its clinical significance
in disease
o Describe the altered respiratory physiology of the immediately postoperative
ventilated patient with significant surgical incisions and pain (sternotomy, large
abdominal incision)
o Describe common physiological changes occurring in the postoperative period
and the impact these have on end organ function. (neurologic, renal, cardiac,
hepatic, gastro-intestinal).
B. Pharmacology
The resident should know:
o Heparin, antiplatelet agents dosages and anesthetic implications
o Protamine for heparin reversal , along with side effects and complications
o Anti-fibrinolytic agents, mechanisms of action and indications
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o The use of blood products (PRBC, FFP, platelets, cryoprecipitate) and blood
alternatives (albumin, starch) as well as transfusion reactions and complications.
o Coagulation drugs currently available (DDAVP, activated factor 7a) their
indications, contraindications, dosages and complications
o Commonly used vasodilators, vasoconstrictors, and their indications, dosages,
and side effects.
o Anti-arrhythmic agents for prophylaxis and treatment of post-operative atrial
fibrillation, SVT and ventricular arrhythmias
o Pharmacology of perioperative risk reduction strategies (lipid lowering agents, B-
blocker’s, aspirin)
C. Monitoring
The resident will:
o Be able to interpret EKG for ischemia, infarction, arrhythmias and paced rhythms.
They will recognize the limitations, and the sensitivity/specificity of EKG as an
ischemia monitor.
o Be able to acquire skills of arterial and central venous cannulation, peripheral
venous cannulation, rewiring central venous access, PA catheterization; interpret
CVP and data from PA catheter (PAP, PCWP, Cardiac output) and know its
indications, complications and management.
o Make use of laboratory monitoring of the coagulation system (PTT, INR,
Fibrinogen) as applied to the postoperative cardiac patient.
o Have the ability to assess the adequacy of mechanical ventilation using clinical
parameters (pt size & weight, peak & plateau ventilatory pressures, mode of
ventilation in conjunction with patient LOC, tidal volume, rate) and laboratory
arterial blood gas analysis including the determination of patients ability to wean
from mechanical ventilation.
o Be able to recognize the parameters used to assess postoperative blood loss,
and options to treat blood loss including medical and surgical alternatives.
o Know the significance of temperature management in the postoperative period
o Appreciate the indicators of volume status in the special circumstances of post-
operative cardiac patients including the findings from invasive monitors, TEE and
clinical indicators (urine volume).
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D. Clinical Assessment & Management
The resident will:
o Be able to complete a detailed history, physical exam, order appropriate
laboratory and ancillary investigations and provide a management plan for a
patient admitted to the CSRU.
o Be able to manage the medical and the first stages of surgical postoperative
bleeding.
o Be able to identify criteria for intubation, extubation. Be able to wean patients
from the ventilator adjusting the modes of ventilatory support.
o Be able to correct common derangements in metabolic and electrolyte
disturbances in the postoperative cardiac patient
o Know the basic principles of cardiac support devices including IABP and
extracorporeal membrane oxygenation.
o Know the common pathophysiology and management of patients admitted to a
cardiac critical care setting with complications of:
Coronary artery disease, acute myocardial ischemia and infarction,
complications of myocardial infarction and thrombolytic therapy
Valvular heart disease and valve replacement or repair
Shock and the use of volume resuscitation, vasodilators/constrictors,
ionotropes
Emergencies requiring ACLS
Cardiac tamponade
Aberrant conduction, dysrhythmia, sudden acute and sub-acute ventricular
and supra-ventricular arrhythmia
Pacemakers & the indications for and applications of the various modes of
temporary pacing
Pneumo/hemothorax
Pulmonary edema, Pneumonia, CHF
COPD, asthma, sleep apnea in the ventilated patient
Heparin induced thrombocytopenia and heparin resistance
Neurologic sequelae post CPB procedures
Gastrointestinal complications
Renal failure and its management
Diabetes and endocrine control
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Communicator
The resident will be able to:
Obtain accurate and relevant history and perform a detailed physical examination using
effective listening skills.
Explain the status of the patient and expected progress to his/her family.
Communicate patient information and outline a management plan to the attending in a
professional manner.
Communicate management plan effectively in both routine and emergency situations to
critical care team (ICU nurse, RT).
Discuss management issues of patients and planned treatment course during morning
hand over rounds with other residents and fellows.
Collaborator
The resident will:
Recognize the need to utilize other specialists for the care and management of the
critical patient.
Collaborate with surgical team in the shared management of patients.
Respect roles and input of allied health care members.
Work effectively as member of CSRU team.
Manager
The resident will be able to:
Manage the CSRU to improve patient flow and safety.
Health Advocate
The resident will:
Provide care that minimizes risk of perioperative complications to patients (DVT
prophylaxis, ASA, sterile procedure, etc.).
Professional
Residents must:
Always demonstrate respectful and compassionate behavior toward patients and their
families.
Remain calm and organized in stressful or emergency situations.
Demonstrate professional interactions with colleges, consultants, allied health care and
surgical teams.
Be punctual and prepared each day.
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Evaluation
There will be an individual interview with the block coordinator at the end of the rotation.
Resident feedback is used to improve teaching techniques and rotation specific objectives.
Reviewed: June 2012, Dr. Granton
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CHRONIC PAIN BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
The Chronic Pain Management rotation provides the anesthesia resident with an opportunity to
further develop diagnostic and therapeutic expertise in a variety of analgesic modalities to
improve patients’ quality of life, including but not limited to regional anesthesia techniques.
The basic goals of this one-month rotation are:
1. To develop knowledge of the types of chronic pain syndromes that present to a tertiary
pain clinic.
2. To gain familiarity with the variety of pharmacologic, non-pharmacologic and surgical
modalities available.
3. To gain an understanding of the impact of chronic pain on patients’ lives and work and
that of their families.
Further expertise will require additional elective rotations.
There is an Interdisciplinary Pain Program at Western University directed by an endowed chair
in Pain Management (the Earl Russell Chair). The vision of the Program is that the treatment
and study of pain is a priority that bridges academic disciplines. Integrating the fields of acute
and chronic pain in the training of the anesthesiologist will especially encourage the
development of new paradigms for the prevention and treatment of chronic pain.
There is one tertiary Pain Clinic in London. St. Joseph’s Health Care is establishing a
multidisciplinary model with an affiliated psychologist, a dedicated RN as well as three
physiatrists, one neurologist, and four anesthesiologists (Dr. Geoff Bellingham, Dr. Kate Ower,
Dr. Jim Watson, and Dr. Pat Morley-Forster). Dr. Rob Banner provides complementary and
alternative medicine treatments at his private clinic. A schedule of these clinics is attached. By
the end of the rotation the resident will be expected to have attended the five anesthesia-run
clinics at least once. There is some scheduling flexibility depending on an individual’s interest
and needs. Residents from Family Medicine, Internal Medicine, Neurology, as well as an
Anesthesia Fellow, may also be doing rotations in that particular month.
Your schedule and objectives will be emailed to you one week prior to the start of your rotation.
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CLINIC SCHEDULE FOR ST. JOSEPH’S PAIN CLINIC
Hours: (generally) 0800 - 1600
Monday: Dr. Bellingham Dr. Morley-Forster
Tuesday: Dr. Bellingham Every other Tuesday in fluoroscopy, please call clinic (519-646-6100 Ext. 66019) for schedule
Wednesday: Dr. Watson
Thursday: Dr. Ower Dr. Morley-Forster
Friday: Dr. Morley-Forster
CLINIC SCHEDULE FOR DR. BANNER
Location: 620 Richmond, Unit I next to the Running Room
Hours: Tuesday, Wednesday, and Friday 0900 - 1700
Phone number: 519-850-6575. Please call in advance if you wish to attend.
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ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
General Requirements
Residents will:
Demonstrate knowledge of anatomy and physiology of pain pathways in the peripheral
and central nervous system.
Understand the role of psychological factors, particularly anxiety and depression, on
pain perception and disability.
Obtain a complete pain history and perform a relevant physical examination.
Formulate a differential diagnosis and treatment plan which incorporates pharmacologic
and non-pharmacologic modalities of treatment.
Demonstrate knowledge of specific diagnostic/treatment modalities (indications, contra-
indications, complications and technique).
Demonstrate knowledge of chronic pain medication (opioids, anti-inflammatories,
anticonvulsants, anti-depressants).
Be aware of national practice guidelines for chronic pain management.
Demonstrate knowledge of basic interventional techniques commonly employed in
chronic pain medicine including: peripheral nerve blocks, sympathetic blockade for
upper & lower extremity, trigger point injections, epidural steroid injections, blocks for
diagnosis and treatment of the facet joint syndrome, and sacroiliac joint injections.
Be aware of effective use of consultation services in chronic pain management.
Demonstrate knowledge of basic legal, social, and bioethical issues encountered in
chronic pain management, including informed consent.
Specific Knowledge Requirements
At the completion of the chronic pain clinic rotation, the resident will be able to apply
knowledge gained in the treatment of the following specific pain disorders: complex
regional pain syndrome, neuropathic pain syndromes (i.e. peripheral diabetic
neuropathy, post-herpetic neuralgia), central pain syndromes, intractable anginal pain,
visceral pain, pelvic pain, headaches, pain related to peripheral vascular insufficiency,
role of personality disorders, anxiety states, and depression, and compensation and
disability.
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Communicator
Residents will:
Establish a professional relationship with patients and families.
Obtain and collate relevant history from patients and families.
Listen effectively.
Demonstrate appropriate oral and written communication skills in inpatient, outpatient,
and operating room environments.
Collaborator
Residents will:
Consult effectively with other physicians and health care professionals.
Demonstrate an understanding of the respective abilities of all team members.
Manager
Residents will:
Demonstrate basic knowledge of the management of an ambulatory care pain clinic.
Utilize information technology to optimize patient care and life-long learning.
Demonstrate knowledge of quality assurance to outcomes in a chronic pain clinic.
Demonstrate effective time management skills.
Health Advocate
Residents will:
Identify the important determinants of health affecting chronic pain patients.
Recognize opportunities for anesthesiologists to advocate for resources for chronic pain
management.
Educate both patients and families about their pain conditions, as well as other
members of the health care team.
Scholar
Residents will:
Critically appraise sources of information in the pain management literature.
Be able to judge whether a research project is properly designed using critical appraisal
methods.
Professional
Residents will:
Deliver the highest quality of care with integrity, honesty, and compassion.
Exhibit appropriate personal and interpersonal professional behaviors.
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Practice medicine ethically, consistent with the obligations of a physician.
Include the patient in discussions concerning appropriate diagnostic and management
procedures.
Respect the opinions of fellow consultants and referring physicians in the management
of patient problems and be willing to provide means whereby differences of opinion can
be discussed and resolved.
Establish a pattern of continuing development of personal clinical skills and knowledge
through medical education.
Recognize and have an approach to ethical issues in pain medicine.
READING LIST
Standard Texts:
1. Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. Philadelphia: Lippincott;
1989. p. 1427-50.
2. Miller RD, editor. Anesthesia. 3rd ed. New York: Churchill Livingstone; 1990. p. 1927-50.
Specialty Texts*:
3. Abram SE, Haddox JD, editors. The Pain Clinic Manual. 2nd ed. Philadelphia: Lippincott;
1999.
4. Warfield CA, Fausatt HJ, editors. Manual of Pain Management. Boston: Lippincott; 1990.
5. Grady KM, Severn AM, Eldridge P, Eldridge PR, editors. Key Topics in Chronic Pain. 2nd
ed. Oxford: Bios Scientific; 2002.
Other References:
6. Raj P. The Management of Chronic Pain by the Anesthesiologist, Lectures in
Anesthesiology. 1988;2:39-51.
7. A folder of Pain Management articles is available in the LHSC-UH library.
*Residents should read through at least one of these texts to understand the subspecialty of
Chronic Pain Management.
Updated: August 2011, Dr. Granton & Dr. Ower
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GENERAL ANESTHESIA BLOCK (PGY-3 & 4)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
During a general anesthesia rotation, the resident will be expected to display an understanding
of advanced anesthesia practice and apply this knowledge for the management of patients.
The overall goal of this rotation is to allow the resident to gain further experience in a variety of
anesthesia management situations, elective, emergent and consultative.
ROTATION OBJECTIVES
At the completion of the General Anesthesia rotation, the resident should exhibit the following
knowledge, skills and attitudes:
Medical Expert/Clinical Decision-Maker
The resident will be able to describe and implement clinical preoperative assessment,
including risk assessment, and comprehensive anesthetic planning.
The resident will demonstrate an understanding of the physical principles relating to
anesthesia equipment, as well as the safety aspects pertaining to this equipment,
including equipment checking.
The resident will be able to apply their knowledge of the physical principles of
monitoring systems to the clinical practice of anesthesia, with particular reference to
common monitoring devices – EKG, Pulse Oximetry, Non Invasive and Invasive Blood
Pressure Monitoring, Gas Analysis, Temperature Monitoring, Peripheral Nerve
Stimulation.
The resident will be proficient at airway management, demonstrating competence with
mask ventilation, airway insertion, direct laryngoscopy, and the use of Glydescope,
Laryngeal Mask Airway devices and bronchoscope.
The resident should be proficient at securing peripheral intravenous access, and be
skilled with techniques of arterial and central venous cannulation.
The resident should be capable of performing spinal anesthesia, and be skilled with
epidural techniques, as well as having good comprehension of the equipment,
indications, limitations and contraindications for regional anesthesia.
The resident will be familiar with the pharmacology of commonly used drugs in the
perioperative period, as well as drugs used during resuscitation, and in the
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management of patients with common co morbidities. They will be aware of common
drug interactions.
The resident will be capable of providing anesthesia for ASA 3 and 4 patients
undergoing complicated surgery with some supervision
For those rotating at:
Victoria Hospital:
o Supervised provision of advanced obstetrical anesthesia
o Resident should understand the anatomy, physiology, pharmacology and
psychology for pediatric patients
University Hospital:
o Resident should provide care for advanced neurosurgical cases and manipulate
physiology and pharmacology as it applies to intracranial pressure.
o Resident should provide anesthetic management for transplantation cases.
St. Joseph’s Health Care:
o Residents will be able to identify and predict issues that are specific to
ambulatory surgical cases, including, pain control, nausea and vomiting, rapid
turnover discharge criteria.
Communicator
The resident will be able to effectively communicate with patients and/or their families
for the purpose of eliciting an appropriate history.
The resident will effectively communicate the risks and benefits of the anesthetic
options available for the patient’s surgery for the purpose of informing the patient and
including them in the decision making process.
The resident will be able to effectively communicate with all colleagues and members of
the team involved in caring for the patient.
The resident will communicate anesthetic concerns to supervising anesthesiologist
during care of patients.
Collaborator
The resident will cooperate with colleagues to ensure patient care and safety.
The resident will recognize the key interactions between members of the operating
room team, and strive to facilitate optimal patient care.
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Manager
The resident will be able to describe or apply the principles of effective operating list
management, through planning and preparation.
Health Advocate
The resident will continue to promote the health of their patient, and will develop a
responsible attitude towards the utilization of finite healthcare resources.
Scholar
The resident will be self-directed, and focused on their career learning objectives.
The resident will seek to apply the principles of evidence-based practice, and
continually try to justify clinical decision making processes.
The resident should make a reasonable effort to prepare by prior reading or enquiry for
each day’s work.
The resident should attend and participate in the formal teaching opportunities offered
within the department, and develop an awareness of research activities within their
environment.
Professional
The resident will demonstrate professional behavior towards senior and junior
colleagues, patients and allied healthcare workers.
The resident will demonstrate a mature work ethic, in keeping with the privilege of
practicing medicine.
The resident will accept advice and constructive feedback from their supervisors at
times of formal assessment.
Reviewed: June 2012, Dr. Granton
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NEUROANESTHESIA BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
Two separate one-month rotations in neuroanesthesia will provide the resident with a
theoretical basis and clinical experience in the anesthetic management of adults undergoing
surgical treatment of diseases of the CNS and spine. This clinical experience is supplemented
by a formal series of seminars in neuroanesthesia in the core curriculum and informal lectures
within the OR setting.
Guided independent study is also encouraged with the provision of a Manual of
Neuroanesthesia and compilation of SNACC-recommended peer-reviewed articles located in
the Anesthesia Library at LHSC-UH, B3-222.
Upon completion of the neuroanesthesia rotation, residents should have demonstrated
proficiency in caring for patients with neurologic disease in a compassionate manner. This
includes the preoperative evaluation, intraoperative management, and postoperative care
utilizing the most current medical/anesthetic knowledge pertinent to each case. Residents are
expected to become proficient at using online medical information, communicating with
patients and working effectively with patient care team, demonstrating ethical practices, and
practicing cost-effective yet quality health care. The clinical experience will provide exposure to
a variety of basic and complex procedures in patients with neurologic disease with graded
independence and responsibility.
ROTATION OBJECTIVES
At the completion of the neuroanesthesia rotation, the resident should exhibit the following
knowledge, skills and attitudes:
Medical Expert/Clinical Decision-Maker
The resident will be able to:
Demonstrate knowledge of basic sciences as applicable to neuroanesthesia, including:
neuroanatomy, neurophysiology, and neuropharmacology.
Demonstrate basic understanding of the impact of commonly performed neurosurgical
procedures on anesthetic management.
Demonstrate clinical knowledge and skills necessary for the practice of
neuroanesthesia including:
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o Preoperative neurological assessment (using Glasgow Coma Scale, Hunt-Hess
Classification for SAH and basic neurological exam).
o Intraoperative support including:
Special Positioning (sitting, prone, park-bench, lateral and knee-chest).
Understanding basic principles of neurophysiologic monitoring – EEG,
Evoked potential (SSEP, BAEP), Transcranial Doppler, cerebral
oximetry, and intracranial pressure monitoring methods available.
Specific interventions – systemic arterial hypotension/hypertension,
CSF drainage, ICP management, hypothermia and precordial Doppler
monitoring for air embolus.
Management of specific perioperative complications such as seizures,
cerebral ischemia, intracranial hypertension, intraoperative aneurysm
rupture, air embolism, cranial nerve dysfunction and neuroendocrine
disturbance (DI, SIADH).
Postoperative management of neurological patients in PACU, ICU and
the Neuro-Observation Unit.
Demonstrate competence in all technical procedures commonly employed in
neuroanesthesia practice – including airway management (basic and difficult),
cardiovascular and neuro-resuscitation, invasive monitoring (arterial line, central line
and LP Drain placement).
Develop and implement a rational anesthetic plan of management for each of the
following neurosurgical procedures:
o Craniotomy for mass lesions (tumor, abscess, hematoma)
o Cerebrovascular procedures (aneurysm, AVM, carotid vascular disease)
o CSF shunting procedures
o Transsphenoidal surgery
o Stereotactic procedures
o Awake craniotomy
o Neuroradiological procedures (embolization, thrombolytic and MRI)
o Spine surgery
Communicator
The resident will be able to:
Establish a therapeutic relationship with patients and their families in the limited time
available.
Obtain and collate relevant history from patients and families.
Listen effectively.
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Demonstrate empathy, consideration and compassion in communicating with patients
and families.
Communicate effectively with medical/surgical colleagues, nurses, and paramedical
personnel regarding the anesthetic management of the patient.
Demonstrate appropriate written communication skills through accurate, legible, and
complete documentation of the anesthetic record, patient chart and in consultation.
Collaborator
The resident will be able to:
Demonstrate the ability to function in the clinical environment using the full abilities of all
team members (surgical, nursing, ICU, etc.).
Develop their anesthetic plan for their patients in consultation and in concert with
surgery, nursing and ICU (if necessary) for more complicated neurosurgical patients.
When time permits, residents are encouraged to attend multidisciplinary Neurosciences
and Epilepsy Rounds. These experiences should permit the resident to:
o Understand and value the skills of other specialists and health care
professionals.
o Understand the limits of their knowledge and skills.
o Be able to understand, accept and respect the opinions of others on the neuro
team.
Function in the OR as a member of the neuro team and work in a positive, constructive
manner, respecting the importance of the roles of all team members.
Manager
The resident will:
Demonstrate the ability to manage their operating room:
o Ensuring necessary equipment, monitoring, and medications are available for
each case.
o Making preparations to deal with anticipated complications.
o All these activities should be conducted in an effective and efficient timely
manner in order to avoid OR delays.
Utilize personal resources effectively in order to balance patient care, continuing
education and personal activities.
Utilize information technology to optimize patient care and lifelong learning.
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Health Advocate
The resident will:
Begin to recognize the opportunities for anesthesiologist to advocate for neurosurgical
patients. In particular with regards to patient safety.
Begin to adopt a leadership role in the postoperative care of their patients by
anticipating and arranging for either PACU, ICU, or Neuro-Observation Unit care.
Scholar
The resident will:
Be responsible for developing, implementing and regularly re-evaluating a personal
continuing education strategy.
Contribute to the development of new knowledge through facilitation/participation in
ongoing departmental research activities.
Be required to prepare in advance for the O.R. cases scheduled through additional
reading, patient chart review/assessment.
Professional
The resident will:
Demonstrate a commitment to executing, professional responsibilities with integrity,
honesty and compassion.
Demonstrate appropriate personal and interpersonal professional behaviors and
boundaries.
Recognize limits of personal skill and knowledge by appropriately consulting other
physicians when caring for the patient.
Revised: April 2011, Dr. Granton
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PEDIATRIC ANESTHESIA
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
Given a pediatric patient presenting for any type of surgery, the resident will outline a plan of
management and institute a safe anesthetic for that patient. The plan should encompass the
unique physiology of the pediatric patient and also awareness of the psychological impact of
the experience for the child and its family.
ROTATION OBJECTIVES
Medical Expert/Clinical Decision-Maker
The resident will be required to outline the important differences between adult,
pediatric, neonate, and premature infant anatomy and physiology, concentrating on
those that affect the conduct of anesthesia.
The resident will be able to perform an appropriate pre-operative evaluation of a
pediatric patient using relevant historical, physical and laboratory information.
The resident will know currently acceptable criteria for accepting a child for anesthesia
as well as guidelines for outpatient anesthesia and pre-operative fasting.
The resident will be able to describe the differences in the adult and pediatric airway.
The resident’s goal is to become proficient in the assessment of the pediatric airway
and in the management of the difficult airway, including the selection of appropriate
equipment.
Residents will be able to institute appropriate fluid and electrolytes and temperature
management in the perioperative period for surgical pediatric patients.
The resident will demonstrate an appropriate approach to and management of common
postoperative issues, including postoperative pain, agitation, nausea, and vomiting,
PACU discharge criteria and criteria for unplanned admission.
The resident will describe the special considerations of the premature infant coming for
surgery and also will understand the longer term problems of providing anesthetic care
to patients who were born prematurely but present for surgery at a later date.
The resident will describe the anesthetic management and potential complications of
patients presenting for common procedures in the following areas: ophthalmology,
dental surgery, elective ENT procedures, and kyphoscoliosis.
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The resident will describe the anesthetic implications of the following disorders:
hematologic disorders including anemia, sickle cell states, thalassemia, ITP,
hemophilia; atypical plasma cholinesterases; diabetes mellitus; non-cardiac surgery in
children with congenital heart diseases; Down’s syndrome; malignant hyperpyrexia;
cystic fibrosis; renal insufficiency or failure.
The resident will describe the anesthetic management of patients presenting for
common neurosurgical procedures, including: hydrocephalus; increased intra-cranial
pressure; intracranial hematoma; craniosynostosis; myelomeningocele;
encephalocele; spinal cord tumour; intracranial tumour; common neuron-radiologic
techniques.
The resident will be familiar with the perioperative management of children with
common pediatric cardiovascular anomalies including: Tetralogy of Fallot; patent
ductus arteriosus; aortic coarctation; atrial septal defects; ventricular septal defects.
The resident will describe the anesthetic management of common congenital defects
that may require surgery during the neonatal period. As a minimum the resident will
describe the management of the following: congenital lobar emphysema; congenital
diaphragmatic hernia; tracheoesophageal fistula and esophageal atresia; congenital
hypertrophic pyloric stenosis; omphalocele and gastroschisis; biliary atresia.
The resident will discuss , diagnose, and treat the more common forms of pediatric lung
disease. In the newborn, the resident will discuss the importance of pulmonary
surfactant; respiratory distress syndrome of the newborn and abnormal breathing
patterns. In the older child, the resident will diagnose and treat croup, bronchitis, cystic
fibrosis, and epiglottitis. The resident will describe in detail the anesthetic management
of upper airway obstruction in a child.
The resident will utilize the appropriate regional anesthetic techniques in pediatric
anesthesia and pediatric analgesia.
The resident will be familiar with the practical aspects of providing anesthesia for
children outside of the operating room including anesthesia for MRI, CT scan, and other
investigative procedures.
Communicator
The resident will be able to use a variety of approaches in dealing with children of all
ages in their preparation for anesthesia and surgery.
The resident will recognize the psychological impact of hospitalization, anesthesia and
surgery on both the patient and their family.
The resident will provide accurate, appropriate information in a timely fashion to the
family.
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The resident will ensure that informed consent is obtained prior to undertaking invasive
procedures.
The resident will effectively communicate with all members of the treatment team using
effective verbal communication skills.
The resident’s written communication, including charting of the perioperative events, will
consist of concise and clear documentation.
Collaborator
The resident will demonstrate the capacity to consult effectively with the neo and
perinatologist, the pediatricians and the surgeons to assure optimal management of
patients.
The resident will work effectively as an integral member of the perioperative team. This
will include the ability to resolve conflicts, provide feedback and assume a leadership
role where appropriate.
Manager
The resident will utilize resources effectively to provide anesthesia services to the
pediatric patient.
The resident will practice according to national standards and provincial guidelines for
the management of pediatric patients.
Health Advocate
The resident will demonstrate increasing expertise and leadership in maintaining and
improving the standards of pediatric anesthesia practice and patient care.
Scholar
The resident should have the ability to critically review the literature and understand and
evaluate new information and research.
The resident should contribute to the learning of others.
The resident should contribute to the development of new knowledge when possible.
Professional
The resident should demonstrate an increasing sense of responsibility and “case
ownership”
The resident should deliver the highest quality of care with integrity, honesty and
compassion.
The resident should demonstrate appropriate respect of the opinion of patients and
team members in the provision of quality pediatric care.
Reviewed: April 2012, Dr. Granton
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PRE-ADMISSION CLINIC BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
Pre-admission clinic is a rotation that will occur at either University Hospital or Victoria Hospital
over four weeks. The resident will spend the majority of time in the preoperative clinic of either
hospital. Residents will be expected to complete an appropriate history and physical on each
patient seen in the clinic. The resident will then present a plan for further investigation,
optimization and perioperative management of the patients seen. Written or dictated
documentation of the consultations is expected.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will:
Demonstrate appropriate and anesthesia specific history and physical skills, including
assessment of the airway.
Demonstrate internal medicine knowledge base as it applies to etiology, natural history
and management of the following disease states that are common reasons for pre-admit
clinic referral: coronary artery disease, Chronic Obstruction Pulmonary Disease,
advance kidney failure, advanced liver failure, cerebral vascular disease, typical
congenital disease states, obstructive sleep apnea, obesity, rheumatoid arthritis,
ankylosing spondylitis, chronic pain.
Demonstrate working knowledge of indications and recommendations for ordering of
invasive and non-invasive investigations preoperatively, including: ECG, pulmonary
function testing, chest radiograph, investigations of underlying coronary artery disease,
investigations for cerebral vascular disease.
Demonstrate ability to synthesize a reasonable optimization, investigation anesthetic
management plan based on nature and urgency of surgery, history, physical and
available investigations.
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Communicator
The resident will be able to:
Communicate well with patient and families in the Pre-admission Clinic, with a good
bedside manner.
Verbally explain findings of history and physical with anesthesia faculty supervisor and
provide a reasonable management plan.
Provide a concise dictated note regarding patient assessment and plan.
Collaborator
The resident will be able to:
Interact well with multi-disciplinary team in the Pre-admission Clinic.
Work well with other physicians in the Pre-admission Clinic, including internal medicine
and surgery.
Health Advocate
The resident will be able to:
Understand the anesthesiologist’s role in optimization of the patient preoperatively.
Takes steps to improve perioperative safety of patients (aspiration prophylaxis, Critical
Care admission post-operatively, etc.).
If appropriate, demonstrates willingness to communicate with surgeon the anesthesia
team’s concerns regarding timing, scope and appropriateness of proposed surgery
Understand the anesthesiologist’s role in patient education preoperatively, including
smoking cessation.
Provide options and risks and benefits of possible postoperative pain control options.
Understand the anesthesiologist’s role in blood conservation and should be able to
describe the pros and cons of a variety of blood conservation strategies.
Professional
The resident will:
Display professional behavior and attitude while dealing with patients, families and staff.
READING LIST
Required Reading:
1. Barash, Clinical Anesthesia, Chapter 26: 569-579 Preoperative Patient Assessment and
Management
2. Miller’s Anesthesia, Chapter 33: 969-999 Risk of Anesthesia
3. Miller’s Anesthesia, Chapter 34: 1001-1066 Preoperative Evaluation
4. Miller’s Anesthesia, Chapter 35: 1067-1150 Anesthetic Implications of Concurrent Diseases
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Suggested Reading:
5. Ann Thorac Surg. 2011 Mar; 91(3):944-82. 2011 update to the Society of Thoracic
Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical
practice guidelines.
6. Anesthesiology. 2002; 96: 485-96 Practice Advisory for Preanesthesia Evaluation, A report
by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation
7. BJA. 2011; 107 (1): 83-96 Preoperative Cardiac Management of the Patient for Non-
Cardiac Surgery: An Individual and Evidence Based Approach
8. The American Journal of Medicine. Feb. 2011; Vol. 124 (2): 144 – 154 Smoking Cessation
Reduces Postoperative Complications: A Systemic Review and Meta-Analysis
9. Circulation 2007; 116: 1971-96. The ACC/AHA Guidelines on Perioperative Cardiovascular
Evaluation and Care for Non-Cardiac Surgery
10. NEJM December 2004; Vol. 351 (27): 2795 – 2804 Coronary Artery Revascularization
Before Major Elective Vascular Surgery
11. The Lancet May 2008; Vol. 371: 1839 – 47 Effects of Extended Release Metoprolol
Succinate in Patients Undergoing Non-Cardiac Surgery (POISE trial): A randomized
controlled trial.
Reviewed: April 2012, Dr. Granton
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REGIONAL ANESTHESIA BLOCK (ST. JOSEPH’S)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will demonstrate knowledge acquisition in the following areas:
Anatomy related to specific regional anesthesia (RA) technique including: surface
landmarks, perineural structure, ultra sound anatomy, sensory inervation, motor
inervation, and components and details of brachial plexus, lumbar plexus, and sacral
plexus.
Physiology related to specific RA techniques and disease processes, including: nerve
transmission/blockade, physiologic response to acute pain, and the patient with chronic
pain at the site of surgery.
Pharmacology of local anesthetics, adjuvants (epinephrine, opioids, HCO3, etc.),
chronic opioid use in the patient presenting for surgery.
Regional anesthesia equipment including: needles, peripheral nerve stimulator,
ultrasound, catheters, and stimulating catheters
Complications/side effects, including: IV toxicity and management of local anesthetic
overdose, neural injury, needle trauma to surrounding tissue (i.e. hematoma,
pneumothorax, dural puncture), unintended neural blockade (i.e phrenic nerve,
epidural).
Contraindications related to specific RA techniques including infection, anticoagulation,
pre-existing neural injury, increased ICP, and pulmonary disease.
Various RA techniques including IV regional anesthesia, peripheral nerve blockade
(single shot, continuous technique, rescue), and neuraxial blockade.
Communicator
The resident will:
Demonstrate abilities in effective communication with patients and family, other
physicians and ancillary personnel via:
o Written (charting complete & legible, consultation).
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o Verbal (anesthesia and analgesia options for various procedures, case
presentations, personal discussion).
o Listening (effectively listen and assimilate information important for patient care
and for personal growth).
Collaborator
The resident will demonstrate abilities in the following areas:
A good relationship with the perioperative team, essential to provide exemplary care to
the patient, including the anesthesiology team, the surgical team, and the nursing staff
of the Block Room, OR and PACU.
Manager
As Manager of the block room the resident will demonstrate an understanding of the Block
Room/OR patient flow dynamics. This will include:
Coordination of patient flow perioperatively.
Appropriate patient selection.
Appropriate timing/calling for the patient (i.e. which patient to attend to first given limited
resources).
Scholar
The resident will demonstrate the ability to:
Implement continuing education strategies.
Apply the principles of critical appraisal.
Teach other residents, medical students or other personnel.
Health Advocate
The resident will demonstrate an ability to:
Provide appropriate information to the patient and/or their family so they can make an
informed decision (and obtain consent) regarding regional anesthesia as:
o A primary anesthetic technique.
o A component of their intra & post-op analgesia.
o Dealing with adverse outcomes.
Professional
The resident will:
Demonstrate appropriate behaviors and attitude towards patients, his/her family and all
personnel involved in the care of that patient, the anesthesiology team, surgical team,
and nursing staff.
Reviewed: July 2012, Dr. Granton
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REGIONAL ANESTHESIA BLOCK (UH)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
It should be noted that the University Hospital Regional Anesthesia Block will typically be a
supplemental rotation after completion of the St. Joseph’s Health Care Regional Rotation.
Given the reduced regional volume at University Hospital versus St. Joseph’s Health Care, the
resident may be required to participate on the Acute Pain Service or within the general
operating room assignments to maintain optimal clinical exposure and education.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will demonstrate knowledge acquisition in the following areas:
Anatomy related to specific regional anesthesia (RA) technique including: surface
landmarks, perineural structure, ultra sound anatomy, sensory inervation, motor
inervation, and components and details of brachial plexus, lumbar plexus, and sacral
plexus.
Physiology related to specific RA techniques and disease processes, including: nerve
transmission/blockade, physiologic response to acute pain, and the patient with chronic
pain at the site of surgery.
Pharmacology of local anesthetics, adjuvants (epinephrine, opioids, HCO3, etc.),
chronic opioid use in the patient presenting for surgery.
Regional anesthesia equipment including: needles, peripheral nerve stimulator,
ultrasound, catheters, and stimulating catheters
Complications/side effects, including: IV toxicity and management of local anesthetic
overdose, neural injury, needle trauma to surrounding tissue (i.e. hematoma,
pneumothorax, dural puncture), unintended neural blockade (i.e phrenic nerve,
epidural).
Contraindications related to specific RA techniques including infection, anticoagulation,
pre-existing neural injury, increased ICP, and pulmonary disease.
Various RA techniques including IV regional anesthesia, peripheral nerve blockade
(single shot, continuous technique, rescue), and neuraxial blockade.
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Communicator
The resident will:
Demonstrate abilities in effective communication to patients and family, other physicians
and ancillary personnel via:
o Written (charting complete & legible, consultation).
o Verbal (anesthesia and analgesia options for various procedures, case
presentations, personal discussion).
o Listening (effectively listen and assimilate information important for patient care
and for personal growth).
Collaborator
The resident will demonstrate abilities in the following areas:
A good relationship with the perioperative team, essential to provide exemplary care to
the patient, including the anesthesiology team, the surgical team, and the nursing staff
of the Block Room, OR and PACU.
Manager
As Manager of the block room the resident will demonstrate an understanding of the Block
Room/OR patient flow dynamics. This will include:
Coordination of patient flow perioperatively.
Appropriate patient selection.
Appropriate timing/calling for the patient (i.e. which patient to attend to first given limited
resources).
Health Advocate
The resident will demonstrate an ability to:
Provide appropriate information to the patient and/or their family so they can make an
informed decision (and obtain consent) regarding regional anesthesia as:
o A primary anesthetic technique.
o A component of their intra & post-op analgesia.
o Dealing with adverse outcomes.
Professional
The resident will:
Demonstrate appropriate behaviors and attitude towards patients, his/her family and all
personnel involved in the care of that patient, the anesthesiology team, surgical team,
and nursing staff.
Updated: July 2012, Dr. Granton
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RURAL REGIONAL COMMUNITY ANESTHESIA ROTATION Southwestern Ontario Medicine Education Network (SWOMEN) and the
Department of Anesthesia & Perioperative Medicine
Specific Objectives in CanMEDS Format
OVERALL GOALS
In response to a growing demand from the community for specialist physicians in many
different disciplines, and a recognition by the RCPSC of the importance of integrating electives
in community based medicine into training programs, Western University has established a
Southwestern Ontario rural medicine unit and a multi-specialty community training network.
Electives in Community Anesthesia are offered at various sites throughout Southwestern
Ontario. The elective is one month in duration, and the main participating sites are St. Thomas,
Stratford, and Owen Sound. Other sites can also be arranged.
There are currently eight staff members providing professional services to the following sites:
St. Thomas Elgin General Hospital, Tillsonburg Memorial Hospital, Interface (2 sites), Pediatric
Dentistry (Dr. Jeff Richmond), the Pain Clinic at the St. Thomas Elgin General Hospital.
This rotation allows residents to experience anesthesia as it is practiced outside of a major
teaching hospital. Anesthesia services are provided to the community in a number of
settings. A small but efficient suite of operating theatres offers the resident an opportunity to
participate in the anesthetic management of patients undergoing a variety of common surgical
procedures. Orthopedics, ENT, General Surgery, Opthalmology, OB-Gyn and Urology form the
basis of a typical community case mix comprising patients from a complete spectrum of ages
and ASA status.
Opportunities to develop special areas of expertise are presented by a large volume of oral
and maxillofacial hypotensive cases and less so with a limited volume of thoracic anesthesia.
Pre-operative consultations are done as part of an outpatient clinic. The obstetrical experience
will include OB analgesia for labor and delivery, including combined spinal epidural and
continuous epidural infusions. Involvement in an informal acute pain service for post-surgical
and trauma patients rounds out the continuum of anesthetic care provided and includes the
supervision of perioperative neuraxial and peripheral regional anesthesia as well as PCA.
The Department of Anesthesia is actively involved in all ventilated patients in the critical care
unit.
Opportunity exists to participate in a chronic pain clinic under the direction of a board certified
pain specialist including the assessment and treatment of various somatic and neuropathic
pain states. Techniques employed include: analgesic infusions, acupuncture, trigger point
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injections, nerve blocks, stellate ganglion blocks, epidural steroid injections, facet injections,
andiv regional bretylium blocks. Ultrasound is utilized when image guidance is required.
Residents self-assign to work with any of the consultant staff representing varied interests,
backgrounds and experience, including a mixture of FRCPC, board eligible and CCFP
Anesthesia.
The rotation follows the local practice pattern:
Call is 1 in 5 in house with the next day off, or
1 in 5 from home with the expectation of working the following day.
In the past, residents have mainly been PGY-5, but requests for this experience at an
earlier stage of training could likely be accommodated.
This is a highly rated elective experience which enables residents at all levels of training to
explore an exciting alternative to academic anesthesia practice. Please feel free to contact the
SWOMEN Academic Director (Dr. Mark Soderman) or the SWOMEN office for more
information about Rotations in Anesthesia.
Dr. Mark Soderman
SWOMEN Academic Director, Anesthesia
www.stegh.on.ca
Email: [email protected]
South Western Ontario Medical Education Network (SWOMEN)
100 Collip Circle, Suite 225
Schulich School of Medicine & Dentistry
Western University
London, Ontario, Canada, N6G 4X8
Tel: (519) 661-2111 ext.87487
www.swomen.ca
Please refer to the following links for further information regarding this opportunity:
SWOMEN Core Electives & Accommodation Policy
http://www.schulich.uwo.ca/swomen/coreelectivestravelpolicy
Core and Electives PGE Expense Form
https://web.schulich.uwo.ca/swomen/forms/index.php?page=coreElectivesExpenses
SWOMEN Conference Funding for Trainees
http://www.schulich.uwo.ca/swomen/conffunding4trainees/
SWOMEN Windsor Anesthesia Rotation
http://www.schulich.uwo.ca/swomen/windsoranesthesia
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RURAL REGIONAL COMMUNITY ANESTHESIA ROTATION Southwestern Ontario Medicine Education Network (SWOMEN) and the
Department of Anesthesia & Perioperative Medicine
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
The resident will be able to:
Demonstrate ability to carry out a directed history and physical as it pertains to
anesthesia care.
Demonstrate knowledge of anatomy, pharmacology and physiology appropriate for
training level.
Demonstrate knowledge of diseases and chronic conditions that may impact anesthesia
care.
Demonstrate skill in airway management and other procedural skills as they may arrive
in a given community (such as i.v. access, central lines, arterial lines, spinals and
epidurals).
Communicator
The resident will be able to:
Establish therapeutic relationship with patients and their family.
Complete timely, accurate and legible documentation.
Communicate patient summaries concisely to the consultant physician.
Collaborator
The resident will be able to:
Contribute to the multidisciplinary team t in perioperative medicine.
Manager
The resident will be able to:
Recognize the position of the Anesthesiologist as a resource to a community hospital
and anesthesia department.
Recognize the limits of clinical care which can be provided in the community setting.
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Health Advocate
The resident will be able to:
Understand the differences between academic and community anesthesia practice.
Appreciate how these impact the patient and the anesthesiologist.
Identify areas of challenges in the clinical setting, compare and contrast these between academic and community based practice.
Professional
The resident will be able to:
Demonstrate honesty and integrity.
Demonstrate respect for diversity.
Demonstrate respect for the dignity of patients and fellow health-care workers.
Demonstrate punctuality and consistent attendance.
Reviewed: July 2012, Dr. Granton
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THORACIC ANESTHESIA BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
General Requirements
The resident will:
Demonstrate knowledge of general internal medicine with particular reference to the
cardiovascular, respiratory, renal and coagulation systems, blood transfusion, fluid,
electrolyte and acid - base balance.
Demonstrate knowledge of the principles and practice of anesthesia as they apply to
patient support during thoracic surgery.
Demonstrate competence in BCLS, ACLS and ATLS.
Specific Knowledge Requirements
The resident will demonstrate knowledge and competence in the following:
Anatomy/Physiology (Thoracic cavity, Airway, Mediastinum, Pulmonary vasculature,
Bronchial vessels, Lymphatic system, Work of breathing, Physiology of lung collapse,
Cough reflex)
Preoperative evaluation of the patient undergoing thoracic surgery, including:
o History (Dyspnea, Cough, Cigarette smoking, Exercise tolerance, Risks factors
for acute lung injury: Preoperative alcohol abuse, Pneumonectomy,
Intraoperative high ventilatory pressures and excessive amounts of fluid
administration).
o Physical examination (Respiratory pattern, Respiratory rate and pattern, Breath
sounds).
o Diagnostic studies (EKG, CXR, ABG).
o Assessment of respiratory function (Respiratory mechanics and volumes:
Spirometry, Flow-volume loops; Lung parenchymal function: Diffusing capacity
for carbon monoxide; Cardiopulmonary interaction: Maximal oxygen
consumption; Ventilation-Perfusion scintigraphy, Split-lung function studies).
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Concomitant medical conditions, including:
o Cardiovascular disease – cardiac complications represent the second most
common cause of perioperative M&M in the thoracic surgical population
(Ischemia, Arrhythmia).
o Age – rate of respiratory complications are double and cardiac complications are
triple in elderly patients undergoing thoracotomy, when compared to younger
patients.
o Renal dysfunction after pulmonary resection is associated with a perioperative
mortality rate of 19%.
o COPD (Respiratory drive – elevated PaCO2 at rest, Nocturnal hypoxemia, Right
ventricular dysfunction, Bullae, Flow limitation, Auto-peep).
o Restrictive pulmonary disease.
o Primary thoracic tumors (Tobacco smoke is responsible for 90% of all lung
cancers).
Non- small cell lung cancer (Squamous cell carcinoma, Adenocarcinoma,
Large cell undifferentiated carcinoma)
Small cell lung cancer
Carcinoid tumors
Pleural tumors
o Anesthetic considerations in lung cancer patients (Mass effects, Metabolic
effects, Metastases, Medications, Intrathoracic metastatic manifestations,
Extrathoracic metastatic manifestations, Extrathoracic nonmetastatic
manifestations).
Preoperative preparation of the patient undergoing thoracic surgery, including:
o Premedication
o Treat bronchospasm, atelectasis, infection and pulmonary edema preoperatively
o Hydration and removal of bronchial secretions, physiotherapy, smoking cessation
Monitoring during thoracic anesthesia.
o Oxygenation (pulse oximetry, ABGs), Capnometry, invasive hemodynamic
monitoring (Arterial line, CVP, PAC, TEE, Continuous spirometry).
Positioning (Lateral position).
o Neurovascular injuries, physiologic changes in ventilation and perfusion.
Physiology of One - Lung Ventilation.
o Lateral position, awake, breathing spontaneously, chest closed.
o Lateral position, awake, breathing spontaneously, chest open.
o Lateral position, anesthetized, breathing spontaneously, chest closed.
o Lateral position, anesthetized, breathing spontaneously, chest open.
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o Lateral position, anesthetized, paralyzed, chest open.
o Lateral position, OLV, anesthetized, paralyzed, chest open.
One Lung Ventilation.
o Indications, methods of lung separation.
Double-lumen tubes (Design, Size selection, Insertion methods,
Positioning, Complications, Contraindications), Univent tube, Bronchial
blockers.
Management and Strategies to Improve Oxygenation during One-Lung Ventilation.
o FiO2 of 1.0, Ventilate with a TV of 6-8ml/kg, Plateau airway pressure < 25cm
H2O, verification of tube position, optimize hemodymanics, maintenance of
normocapnia, recruitment maneuver of ventilated lung to eliminate atelectasis,
dependent-lung PEEP, selective nondependent-lung CPAP, differential
PEEP/CPAP, intermittent two lung ventilation, TIVA, selective nondependent-
lung high-frequency ventilation, clamping the PA of non-ventilated lung.
Anesthetic Management and Techniques.
o General anesthesia, Regional anesthesia, combined epidural blockade and
general anesthesia, fluid management, nitrous oxide, temperature, prevention of
bronchospasm, CAD.
Hypoxic Pulmonary Vasoconstriction.
o Mechanisms, effects of anesthetics, nitric oxide.
Anesthetic Management for Common Surgical Procedures
o Flexible fiberoptic bronchoscopy, rigid bronchoscopy (Apneic oxygenation,
Apnea and intermittent ventilation, Sanders injection system, Mechanical
ventilator, HFPPV), Mediastinoscopy, VATS, Thoracotomy, complications,
postoperative concerns.
Anesthesia for Patients undergoing Bronchoalveolar Lavage
o Treatment for symptomatic pulmonary alveolar proteinosis, intraoperative
management.
Anesthesia for Patients with Bronchopleural Fistula and Empyema (etiology, surgical
management, ventilation, anesthetic management).
Anesthetic Implications of Spontaneous Pneumothorax Anesthesia for Patients
undergoing Bullectomy and Volume Reduction Pneumoplasty.
o Surgery, anesthetic considerations, postoperative ventilation.
Anesthesia for Patients undergoing Decortication and Pleurodesis Procedures.
o Clinical features, anesthesia management.
Anesthesia for Patients Undergoing Esophageal Surgery.
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o Esophagoscopy, Zenker's Diverticulum, Achalasia, Hiatus Hernia,
Esophagectomy.
Anesthesia for Patients Undergoing Laser Surgery of the Airway.
o Physics of lasers, laser surgery of the airway, intraoperative considerations,
complications.
Anesthesia for Patients Undergoing Lung Transplantation.
o Pathophysiology of the transplanted lung, preoperative assessment and patient
selection, donor selection and procurement, preoperative preparation,
postoperative analgesia, operation for single-lung transplantation, bilateral
sequential single-lung versus double-lung transplantation, postoperative
management.
Anesthesia for Patients with Mediastinal Masses.
o Signs and symptoms, diagnostic evaluation, anesthetic implications and
management (airway obstruction, vascular/cardiac compression, superior vena
cava syndrome).
Anesthesia for Patients with Thoracic Outlet Syndrome.
Anesthesia for Patients undergoing Thymectomy: Myasthenia Gravis
o Clinical features, medical therapy, anesthetic considerations, postoperative
concerns and respiratory failure.
Myasthenic Syndrome.
Anesthesia for Patients undergoing Tracheal Resection and Trancheobronchial
Reconstruction.
o Surgical considerations, perioperative management issues, modes of ventilation.
Anesthesia for Patients undergoing Urgent Surgery.
o Anesthesia for patients with massive hemoptysis, anesthesia for patients
undergoing removal of foreign body from the airways, anesthesia for patients
undergoing endoscopy for ingested foreign bodies.
Complications of Thoracic Surgery and their Management Strategies.
o Respiratory failure and management of postoperative mechanical ventilation,
atelectasis, pneumothorax, cardiac herniation, cardiac ischemia and arrhythmias,
low cardiac output syndrome, hemorrhage, nerve injuries (Brachial plexus,
Sciatic nerve, Peroneal nerve).
Postoperative Pain Management.
o Systemic analgesia (PCA – Opioids, NSAIDS, Ketamine, Dexmedetomidine,
Pregabalin/gabapentin), local anesthetics/nerve blocks (Intercostal nerve blocks,
Intrapleural analgesia, Thoracic paravertebral block, Epidural analgesia),
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shoulder pain, post-thoracotomy neuralgia and chronic incisional pain,
management of opioid tolerant patients (Multimodal analgesia).
Technical Skills.
o Be proficient in the provision of thoracic epidural analgesia for upper abdominal
and thoracic surgical procedures
o Be skilled in airway management for bronchoscopy, mediastinal masses and
one-lung ventilation
o Be skilled in starting large bore intravenous infusions, arterial lines, CVP and PA
lines in thoracic surgical patients.
Communicator
The resident will:
demonstrate effective communication with patients and families of description of
procedures, informed consent and anesthetic options and risks.
demonstrate effective communication with OR team (thoracic surgeons, nurses and
other members of the health care team) and postoperative team (ICU, PACU).
provide clear and concise written consultation and anesthetic records.
Collaborator
The resident will:
seek perioperative consultation with colleagues when required.
contribute effectively to other interdisciplinary team activities.
demonstrate ability to function in the clinical environment using the full abilities of all
team members.
Manager
The resident will be able to:
manage OR time by efficiently conducting the anesthetic, continuing education and
personal activities.
utilize information technology to optimize patient care and lifelong learning.
Health Advocate
The resident will be able to:
provide patient advocacy for various perioperative issues (i.e., patient safety, analgesia,
postoperative monitoring).
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Scholar
The resident will:
demonstrate commitment to continuing personal education.
be able to critically review thoracic anesthesia literature and describe the principles of
research relevant to this population.
assist in education of other members of the OR team.
Professional
The resident will:
demonstrate a sense of responsibility, integrity, honesty and compassion when caring
for patients.
demonstrate respect for patients and colleagues.
deliver highest quality care to patients.
practice medicine ethically consistent with the obligations of a physician.
respect the opinions of fellow consultants and referring physicians in the management
of patient problems and be willing to provide means whereby differences of opinion can
be discussed and resolved.
show recognition of limits of personal skill and knowledge by appropriate consulting
other physicians and paramedical personnel when caring for the patient.
READING LIST
Recommended Material:
1. Thoracic Anesthesia (3rd Edition); Kaplan, J.A.; Slinger, P. D.; 2003.
2. Respiratory Function; Chapter11; p. 233-255; Clinical Anesthesia (6th Edition); Edited by
Barash P.G.; Cullen B.F.; Stoetling R.K.; Cahalan M.K.; Stock M.C.; 2009.
3. Anesthesia for Thoracic Surgery; Chapter 40; p.1032-1072; Clinical Anesthesia (6th
Edition); Edited by Barash P.G.; Cullen B.F.; Stoetling R.K.; Cahalan M.K.; Stock M.C.;
2009.
4. Respiratory Physiology; Chapter 15; p.361-392; Miller’s Anesthesia (7th Edition); 2010.
5. Pulmonary Pharmacology; Chapter 22; p.561-594; Miller’s Anesthesia (7th Edition); 2010.
6. Nitric Oxide and Inhaled Pulmonary Vasodilators; Chapter31; p. 941-956; Miller’s
Anesthesia (7th Edition); 2010.
7. Anesthesia for Thoracic Surgery; Chapter 59; p.1819-1887; Miller’s Anesthesia (7th
Edition); 2010.
8. Respiratory Care; Chapter 93; p. 2879-2898. Miller’s Anesthesia (7th Edition); 2010.
9. Journal of Cardiothoracic and Vascular Anesthesia.
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10. Seminars in Cardiothoracic and Vascular Anesthesia.
11. Anesthesiology Clinics; Volume 26, Issue 2, Pages 241-398 (June 2008); Thoracic
Anesthesia; Edited by Peter Slinger.
Updated: August 2011, Dr. Granton & Dr. Nicolaou
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TRANSESOPHAGEAL ECHOCARDIOGRAPHY ROTATION
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
Residents completing a one block elective in Transesophageal Echocardiaography (TEE) will
gain a basic understanding of the role of echocardiography in perioperative patient
assessment and its integration as a monitor during cardiac surgery. In addition, the core focus
will be on performing a complete perioperative examination.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert
A. Physiology and Anatomy
The resident is expected to:
o Describe detailed cardiac anatomy, physiology and its relationship to images
obtained during a TEE exam.
o Know important aspects of the anatomy and physiology of cardiac valves, left
ventricle, right ventricle, left and right atria, coronary sinus, SVC, IVC and aorta.
B. Monitoring
The resident will be able to:
o Describe the advantages and limitations of TEE as a cardiac monitor.
o Understand the concepts of wall motion analysis and wall motion scores and the
effect of ischemia and other disease processes on this score.
o Describe ways of monitoring the cardiac ejection fraction.
o Performance of a complete examination to obtain standard views.
o Demonstrate the role of TEE in the perioperative setting including advantages for
its use as well as limitations and contraindications
C. Clinical Management
Clinical management will be limited as the scope of the rotation will not allow complex
echocardiographic interpretation. Any management issues will be coordinated with the
consultant anesthesiologist. However, some basic concepts will be reviewed:
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o Identify potential causes of hypotension on TEE and suggest treatment options
(hypovolemia, LV failure)
o Identify potential high risk stroke patients (poor aorta’s) and be aware of alternate
treatment strategies for management of these patients.
o Identify the use of TEE during weaning from bypass and suggest treatment
options for hypotension (volume, inotropes).
Communicator
Effective communication skills will be taught and encouraged at several levels:
Between Resident and the Cardiac Anesthesiology Attending
o Communicate TEE findings and the implications for the current procedure or for
treatment during unstable events.
Between Resident and the Surgeon
o To provide a brief TEE report to the surgeon to identify potential problems or
abnormalities discovered during the examination and to come to an agreement
on the presumed best course of action.
Collaborator
Residents are expected to learn this role in several areas and become increasingly
comfortable with it in their senior years:
Recognize their limitations and seek consultation from medical experts in other
disciplines
Learn how to advise other physicians in an oral format on cardiac issues in which the
resident has developed expertise.
Foster healthy team relationships
Professional
Residents must:
Always demonstrate respectful, and compassionate behavior toward patients, their
families and other health care providers
Remain calm and organized in stressful, or emergency situations
Participate through attendance, interaction and presentation at rounds including
departmental, echocardiographic and cardiac didactic teaching.
READING LIST
Written material (books, lecture notes) as well as material on the web site (videotaped lectures,
electronic journals) is made available to residents. There is also an extensive library of
digitally archived images to review.
Reviewed: June 2012, Dr. Granton
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VASCULAR ANESTHESIA BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
The resident will be able to:
Demonstrate knowledge of general internal medicine, anatomy, physiology and
pharmacology with particular reference to the cardiovascular, respiratory, hepatic, renal
and coagulation systems, blood transfusion, acid – base, fluid and electrolyte balance.
Demonstrate knowledge of the principles and practice of anesthesia as they apply to
patient support during vascular surgery.
Demonstrate competence in BCLS, ACLS and ATLS.
Demonstrate knowledge and competence in the following:
o Anatomy, physiology, and pathophysiology of the peripheral circulation.
o Vascular disease: epidemiologic, medical, and surgical aspects (pathophysiology
of atherosclerosis, natural history of patients with peripheral vascular disease,
medical therapy of atherosclerosis, the role of statins in perioperative outcomes).
o Preoperative evaluation and preparation of the vascular patient: clinical
predictors of increased perioperative CVS risk, type of surgery, ACC/AHA
Guidelines on perioperative cardiovascular evaluation care of patients
undergoing noncardiac surgery, assess and optimize coexisting disease
(hypertension, coronary artery disease, heart failure, cardiac valvular disease,
diabetes mellitus, COPD and tobacco abuse, renal failure, cerebrovascular
disease), coronary revascularization before noncardiac surgery risks vs.
benefits, PTCA and stenting before noncardiac surgery Implications and
optimal timing of noncardiac surgery after PTCA and stenting
o Pharmacological agents used in vascular patients (nitrates, -adrenergic receptor
antagonists, ACE inhibitors, angiotensin II receptor antagonists, digoxin, loop and
thiaziade diuretics, spironolactone, calcium channel blockers, clonidine,
hydralazine, insulin and oral hypoglycemic, cholesterol lowering agents,
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epinephrine and norepinephrine, dopamine and dobutamine, milrinone,
vasopressin, heparin, low molecular weight heparin, anticoagulants)
o Perioperative Myocardial Ischemia:
Etiology and prevention
Perioperative stress response and risk of myocardial ischemia
Perioperative medical management of coronary artery disease: nitrates,
-adrenergic blockade (2-agonists, calcium channel blockers, statins,
ACE Inhibitors).
o Perioperative Renal Protection (cardiac performance and perfusion pressure,
fluid management, mannitol, N-acetylcysteine, fenoldopam)
o Hematologic Considerations in Vascular Surgery (normal hemostasis,laboratory
evaluation, congenital bleeding disorders, acquired bleeding disorders, platelet
defects, hypercoagulable states and venous thrombosis), antithrombin III
deficiency, protein C deficiency, protein S deficiency, defects in fibrinolysis,
venous thrombosis, anticoagulant therapy, heparin, LMWH and heparinoids,
Coumadin, platelet inhibitors, herbal therapy, thrombolytic therapy, pentoxifylline
(procoagulant therapy), tranexamic acid, desmopressin (intraoperative blood loss
and replacement, postoperative bleeding and reoperation)
o Monitoring During VascularAnesthesia
o Electrocardiography: arrhythmias, conduction defects, myocardial ischemia
(three electrode system, modified three electrode system, five electrode system)
o Pulse Oximetry
o Capnometry
o Noninvasive Blood Pressure Monitoring
o Body Temperature
o Invasive Hemodynamic Monitoring
o Advantages, indications, contraindications and complications of the following:
arterial pressure monitoring, CVP monitoring, pulmonary artery catheterization,
ardiac output, TEE.
o Abdominal Aortic Reconstruction
Etiology, Epidemiology and Pathophysiology of AAA and Aortoiliac
Occlusive Disease
Natural History and Surgical Mortality
Pathophysiology of Aortic Occlusion and Reperfusion (cardiovascular
changes, renal hemodynamics and renal protection, humoral and
coagulation profile, visceral and mesenteric ischemia, central nervous
system and spinal cord ischemia and protection).
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Clamp Level: infrarenal, suprarenal, supraceliac
Anesthetic Management: autologous blood procurement, anesthetic drugs
and techniques, thoracic epidural.
o Thoracoabdominal Aortic Aneurysm Surgery
Etiology
Preoperative Preparation and Monitoring
Crawford Classification of TAAA’s
Morbidity and Mortality
Neurologic Complications: anatomy and blood supply of spinal cord, artery
of Adamkiewicz, cerebrovascular accidents, spinal cord infarction –
paraplegia, Crawford’s classification of TAAA’s and incidence of
paraplegia.
Spinal Cord Protection: limitation of cross-clamp duration, reattachment of
critical intercostal arteries, maintenance of proximal blood pressure, avoid
hyperglycemia, CSF drainage, hypothermia, evoked potentials, naloxone
infusion, left atrial-to-distal aortic bypass with retrograde perfusion, avoid
postoperative hypotension.
Renal ischemia and protection
Coagulation and metabolic management
One lung ventilation
Anesthetic management
o Endovascular Aortic Repair
Stent – Graft Devices and Approval
Patient Selection
Preoperative Diagnostic Imaging of Aneurysm, Surrounding Anatomy and
Device Sizing
Endovascular Technique for EVAR and TEVAR
Adjunctive Debranching Surgical Procedures when coverage of LSCA or
LCA is
necessary to provide an adequate proximal fixation site for the stent
Anesthetic Management – Regional vs. General
Indications for CSF Drainage in TEVAR
Complications (damage to access vessels, endoleaks, graft migration,
renal ischemia, paraplegia, stroke, aorto - esophageal fistula, conversion
to open)
Lifelong Radiological Surveillance and Costs
Patient Outcomes – OPEN vs. ENDOVASCULAR
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o Lower Extremity Revascularization
Epidemiology and Natural History of Peripheral Vascular Disease
Pathophysiology of Atherosclerosis
Medical Therapy for Atherosclerosis and Complications of Medical
Therapy
Chronic Medical Problems and Risk Prediction in Peripheral Vascular
disease Patients
Acute Arterial Occlusion
Chronic Arterial Occlusion
Surgical Management
Preoperative Preparation and Monitoring
Regional versus General Anesthesia
Neuraxial Anesthesia and Agents Affecting Hemostasis
Risk of Spinal or Epidural Hematoma
Anesthetic Management
Postoperative Considerations
o Carotid Endarterectomy
Surgical indications
Perioperative Cardiovascular Morbidity and Mortality
Preoperative Evaluation
Anesthetic Management
o General vs. Regional vs. Local
o Advantages and disadvantages of each
o Superficial and Deep cervical plexus block
o Carbon dioxide and glucose management
Neurologic Monitoring and Cerebral Perfusion
o Neurologic assessment of awake patient
o Assessment of cerebral blood flow
o Stump pressures
o 133Xe washout
o Transcranial Doppler (middle cerebral artery flow)
o Cerebral electrical activity
o electroencephalography ± computer processing
o SSEPs
o Cerebral oxygenation
o Jugular venous oxygen saturation
o Cerebral oximetry
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Postoperative Considerations
o Neurologic injury
o Postoperative hyperperfusion syndrome
o Blood pressure liability
o Cranial nerve and carotid body dysfunction
o Airway and ventilation problems
o Cardiac ischemia/MI
Endovascular Treatment of Carotid Disease: Carotid Angioplasty and
Stenting
o Postoperative Management of Vascular Patients
Postoperative Pain Management (Preemptive analgesia, PCA, Epidural,
Nerve blocks)
Mechanical ventilation and invasive monitoring in ICU for some patients
Complications, including: complications of invasive monitoring,
complications of surgical procedure (stroke following CEA, Hemodynamic
instability following CEA, Cranial nerve injury following CEA, Spinal cord
injury, Acute renal failure, Sexual dysfunction, Bleeding, Low cardiac
output syndrome, Sepsis), respiratory complications (Risk factors, Pulmonary
disease, Cardiac disease, Emergency surgery)
o Technical Skills
Be proficient in the provision of thoracic epidural analgesia for upper
abdominal and thoracic surgical procedures
Be skilled in airway management for bronchoscopy, one-lung ventilation
and insertion of spinal drains and CSF monitoring for thoracic aneurysm
repair
Be skilled in starting large bore intravenous infusions, arterial lines, CVP
and PA lines in vascular surgical patients
Communicator
The resident will be able to:
demonstrate effective communication with patients and families of description of
procedures, informed consent and anesthetic options and risks
demonstrate effective communication with OR team (vascular surgeons, nurses and
other members of the health care team) and postoperative team (ICU, PACU)
provide clear and concise written consultation and anesthetic records
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Collaborator
The resident will be able to:
seek perioperative consultation with colleagues when required
contribute effectively to other interdisciplinary team activities
demonstrate ability to function in the clinical environment using the full abilities of all
team members
Manager
The resident will be able to:
manage OR time by efficiently conducting the anesthetic, continuing education and
personal activities
utilize information technology to optimize patient care and lifelong learning
Health Advocate
The resident will be able to:
provide patient advocacy for various perioperative issues (i.e., patient safety, analgesia,
postoperative monitoring)
Scholar
The resident will be able to:
demonstrate commitment to continuing personal education
be able to critically review vascular anesthesia literature and describe the principles of
research relevant to this population
assist in education of other members of the OR team
Professional
The resident will be able to:
demonstrate a sense of responsibility, integrity, honesty and compassion when caring
for patients
demonstrate respect for patients and colleagues
deliver highest quality care to patients
practice medicine ethically consistent with the obligations of a physician
respect the opinions of fellow consultants and referring physicians in the management
of patient problems and be willing to provide means whereby differences of opinion can
be discussed and resolved
show recognition of limits of personal skill and knowledge by appropriate consulting
other physicians and paramedical personnel when caring for the patient
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READING LIST
Recommended Material:
1. Cardiac Physiology; p.393 – 410; Miller’s Anesthesia (7th Edition).
2. Cardiovascular Pharmacology; p.595 – 632; Miller’s Anesthesia (7th Edition).
3. Cardiovascular Monitoring; p.1267-1328; Miller’s Anesthesia (7th Edition).
4. Anesthesia for Vascular Surgery; p.1985 - 2044; Miller’s Anesthesia (7th Edition).
5. Cardiovascular Anatomy and Physiology; p. 209 – 232; Clinical Anesthesia (6th Edition);
Edited by Barash, Cullen, Stoelting, Cahalan, Stock; 2009.
6. Anesthesia for Vascular Surgery; p. 1108-1136; Clinical Anesthesia (6th Edition); Edited by
Barash, Cullen, Stoelting, Cahalan, Stock; 2009.
7. Journal of Cardiothoracic and Vascular Anesthesia.
8. Seminars in Cardiothoracic and Vascular Anesthesia.
9. Vascular Anesthesia; Second Edition; Edited by Kaplan, Lake and Murray; 2004.
Updated: July 2011, Dr. Granton & Dr. Nicolaou
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CONSOLIDATION ANESTHESIA BLOCK
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
During the Consolidation Anesthesia Rotation, the resident will be expected to display an
understanding of the advanced anesthesia practice and apply this knowledge for the relatively
independent management of patients.
ROTATION OBJECTIVES
Medical Expert
The resident will be able to describe and implement clinical preoperative assessment,
including risk assessment, and comprehensive anesthetic planning.
The resident will demonstrate an understanding of the physical principles relating to
anesthesia equipment, as well as the safety aspects pertaining to this equipment,
including equipment checking.
The resident will be able to apply their knowledge of the physical principles of
monitoring systems to the clinical practice of anesthesia, with particular reference to
common monitoring devices – EKG, Pulse Oximetry, Non Invasive and Invasive Blood
Pressure Monitoring, Gas Analysis, Temperature Monitoring, Peripheral Nerve
Stimulation.
The resident will be proficient at airway management, demonstrating competence with
mask ventilation, airway insertion, direct laryngoscopy, and the use of Glydescope,
Laryngeal Mask Airway devices and bronchoscope.
The resident should be proficient at securing peripheral intravenous access, and be
skilled with techniques of arterial and central venous cannulation.
The resident should be capable of performing spinal anesthesia, and be skilled with
epidural techniques, as well as having good comprehension of the equipment,
indications, limitations and contraindications for regional anesthesia.
The resident will be familiar with the pharmacology of commonly used drugs in the
perioperative period, as well as drugs used during resuscitation, and in the
management of patients with common co morbidities. They will be aware of common
drug interactions.
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The resident will be capable of providing anesthesia for ASA 3 and 4 patients
undergoing complicated surgery with minimal supervision.
For those rotating at:
Victoria Hospital:
o Independent provision of advanced obstetrical anesthesia.
o Resident should understand the anatomy, physiology, pharmacology and
psychology for pediatric patients.
University Hospital:
o Resident should provide care for advanced neurosurgical cases and manipulate
physiology and pharmacology as it applies to intracranial pressure.
o Resident should be able to provide anesthesia care for emergent cardiac surgical
patients.
o Resident should provide anesthetic management for transplantation cases.
St Joseph’s Health Centre:
o Residents will be able to identify and predict issues that are specific to
ambulatory surgical cases, including, pain control, nausea and vomiting, rapid
turnover discharge criteria.
Communicator
The resident will be able to effectively communicate with patients and/or their families
for the purpose of eliciting an appropriate history.
The resident will effectively communicate the risks and benefits of the anesthetic
options available for the patient’s surgery for the purpose of informing the patient and
including them in the decision making process.
The resident will be able to effectively communicate with all colleagues and members of
the team involved in caring for the patient.
Resident will communicate anesthetic concerns to supervising anesthesiologist during
care of patients.
Collaborator
The resident will cooperate with colleagues to ensure patient care and safety.
The resident will recognize the key interactions between members of the operating
room team, and strive to facilitate optimal patient care.
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Manager
The resident will be able to describe or apply the principles of effective operating list
management, through planning and preparation.
Health Advocate
The Resident will continue to promote the health of their patient, and will develop a
responsible attitude towards the utilization of finite healthcare resources.
Scholar
The resident will be self-directed, and focused on their career learning objectives.
The resident will seek to apply the principles of evidence-based practice, and
continually try to justify clinical decision making processes.
The resident should make a reasonable effort to prepare by prior reading or enquiry for
each day’s work.
The resident should attend and participate in the formal teaching opportunities offered
within the department, and develop an awareness of research activities within their
environment.
Professional
The resident will demonstrate professional behavior towards senior and junior
colleagues, patients and allied healthcare workers.
The resident will demonstrate a mature work ethic, in keeping with the privilege of
practicing medicine.
The resident will accept advice and constructive feedback from their supervisors at
times of formal assessment.
Reviewed: June 2012, Dr. Granton
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OFF-SERVICE ROTATION
OBJECTIVES
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CARDIAC CARE UNIT (PGY-2 TO 5)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
All anesthesia residents will undertake at least a one block rotation in the Cardiac Care Unit
(CCU) either at Victoria Hospital or University Hospital.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
The resident will be able to:
Demonstrate knowledge of cardiovascular physiology, anatomy and pharmacology.
Demonstrate ability to diagnose and manage myocardial ischemia and/or infarction.
Demonstrate ability to diagnose and manage acutely decompensated heart failure and
cardiogenic shock.
Demonstrate appropriate ability to order and interpret investigations common to cardiac
patients including, electrocardiograms, cardiac enzymes, echocardiogram and
angiogram findings.
Demonstrate an ability to recognize and manage cardiac arrhythmias, in particular those
with hemodynamic instability.
Communicator
The resident will be able to:
Communicate with CCU team (physicians, nurses) effectively in a written and verbal
manner.
Communicate effectively with patients and families.
Collaborator
The resident will be able to:
Demonstrate the ability to work well as a member of a multidisciplinary health care
team.
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Manager
The resident will:
Demonstrate leadership skills in emergency situations. In particular with hypoxia, shock
and advanced cardiac life support (ACLS).
Health Advocate
The resident will:
Understand lifestyle and socioeconomic issues that contribute to heart disease.
Advocate for patients to modify these factors if possible.
Professional
The resident will:
Be punctual and have an appropriate attendance record.
Attend and present at teaching rounds when required.
Be respectful to fellow health care members, patients, and families.
Reviewed: August 2012, Dr. Granton
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CARDIAC ELECTROPHYSIOLOGY (PGY-2 TO 4)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
Specific Knowledge Requirements
The resident will be able to:
Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
Access and apply relevant information to clinical practice.
Demonstrate effective consultation services with respect to patient care, and education.
Specific Skill Requirements
A. Clinical Skills
The resident must be able to:
Obtain an accurate patient history and perform an appropriate physical examination.
Develop a weighted differential diagnosis.
Develop an appropriate plan of care and interpret electrocardiographic, laboratory and
radiological investigations.
Recommend an appropriate therapeutic plan taking into account such matters as age,
general health, risk/benefit ratio, and prognosis.
EP Specific
o Develop a logical and systematic approach to interpretation of ECGs with regard
to bradycardia, tachycardia, and pacing.
o Gain a detailed understanding of the pathophysiology of common cardiac
arrhythmias (AF, A flutter, SVT, VT, bradycardia), their investigation and
treatment.
o Understand of the pharmacology and clinical use of antiarrhythmic medications.
o Be proficient at assessment of the patient with bradycardia, tachycardia,
palpitations, syncope, cardiac arrest, and high risk of arrhythmia.
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o Gain a detailed understanding of the pathophysiology of the common cardiac
arrhythmias, their investigation and treatment (medication, ablation, pacing
therapy or surgery).
o Develop an understanding of the role in synchronization pacing in patients with
heart failure.
B. Technical Skills
The resident will:
EP Specific
o Gain knowledge of indications for implantation of temporary and permanent
pacemakers, and an understanding of the role of biventricular pacing for heart
failure management.
o Gain knowledge of indications, both primary and secondary, for implantation of
ICDs.
o Gain knowledge of indications for EP study and ablation.
o Gain knowledge of indications for laser lead extraction.
o Gain experience interpreting ECGs, holter monitors and event recorder tracings.
o Become familiar with preparation, risks and perioperative issues regarding device
implant, EP study, and lead extraction.
o Develop an awareness of the technical approaches to pacemaker and ICD
implantation. This includes implantation of single and dual lead devices, as well
as programming and troubleshooting.
o Gain exposure to lead extraction in terms of indications, techniques, preoperative
and postoperative management of extraction patients.
Communicator
General Requirements
The resident will be able to:
Establish therapeutic relationships with patients / families.
Obtain and synthesize relevant information from patients/families/communities.
Listen effectively.
Discuss appropriate information with patients/families and the health care team.
Specific Knowledge Requirements
The resident must be able to:
Communicate with the patients and be sensitive to the patients' emotional status
surrounding illness.
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Describe the dynamics of the traumatized family.
Discuss the concerns patients have of loss of control, self-worth, and personal dignity.
Describe the need for effective use of language.
Discuss the need to explain medical matters in simple terms.
Describe the role of interpreters in dealing with some patient groups (cultural, deaf).
Appreciate how differences in race, gender and ethnicity affect patient/families
responses to therapeutic suggestions and diagnosis.
Specific Skill Requirements
The resident must able to:
Address patients concerns with empathy and respect in every encounter.
Explain details of medical conditions and therapy in understandable terms.
Include all members of the health care team in discussions of therapeutic plan when
appropriate.
Communicate with medical colleagues, health team personnel, patients, and families in
a professional, timely, accurate, informative and, compassionate manner, at all times.
EP Specific
o Independently perform full history and directed physical exam on patients
referred for arrhythmia assessment
o Present a clear, concise history and physical exam pertaining to arrhythmia
inpatients and outpatients, with a logical plan for investigation and therapy
o Actively participate in patient education discussions regarding risks and benefits
of implant, extraction, and ablation procedures
Collaborator
General Requirements
The resident will be able to:
Consult effectively with other physicians and health care professionals.
Contribute effectively to interdisciplinary team activities.
Specific Knowledge Requirements
The resident must be able to:
Describe the roles of the health care professionals in a team.
Describe the unique aspects of care provided by nursing, physiotherapy, and health
care technologists.
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Specific Skill Requirements
The resident must able to:
Seek the advice of other members of the health care team.
Effectively participate in team meetings to discuss problems in investigation and
therapy.
Consult with other physicians.
EP Specific
o Actively participate in a multidisciplinary approach to the arrhythmia patient.
Manager
General Requirements
The resident will be able to:
Utilize resources effectively to balance patient care, learning needs, and outside
activities.
Allocate finite health care resources wisely.
Work effectively and efficiently in a health care organization.
Utilize information technology to optimize patient care, life-long learning and other
activities.
Specific Knowledge Requirements
The resident must be able to:
Describe the essential aspects of health care funding and the different models of health
care delivery.
Specific Skill Requirements
The resident must able to:
Undertake quality assurance and quality delivery analyses.
Develop plans more effective use of resources for health care programs.
Apply technology effectively to patient care.
Contribute effectively in strategic planning.
EP Specific
o Gain understanding of resource utilization in arrhythmia management, in terms of
cost-effective investigation and therapy for the arrhythmia patient.
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Health Advocate
General Requirements
The resident will be able to:
Identify the important determinants of health affecting patients.
Contribute effectively to improved health of patients and communities.
Recognize and respond to those issues where advocacy is appropriate.
Specific Knowledge Requirements
The resident must be able to:
Describe the epidemiology of cardiac arrhythmias.
Discuss the importance of preventive medicine for cardiac diseases.
Describe methods of patient education and preventive medicine intervention for cardiac
diseases.
Specific Skill Requirements
The resident must able to:
Participate in patient education.
Assist patients in the acquisition and interpretation of health care information.
EP Specific
o Advise families of the role of genetics in the genesis of arrhythmia.
o Understand arrhythmia therapy options and alternatives, including the risks and
benefits of interventional procedures.
Scholar
General Requirements
The resident will be able to:
Develop, implement and monitor a personal continuing education strategy.
Critically appraise and apply sources of medical information.
Facilitate the learning of patients, house staff, students and other health professionals.
Contribute to development of new medical knowledge.
Specific Knowledge Requirements
The resident must be able to:
Describe the important role of clinical and basic research in arrhythmia practice.
Describe the scientific method and of outcome based research.
Discuss the application of statistical methods to critical appraisal.
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Discuss the importance of continuing medical education (CME) for arrhythmia
specialists.
Describe where information on medical matters is reliably obtained.
Specific Skill Requirements
The resident must able to:
Question current practice.
Apply outcome-based methodology to interpretation of clinical information.
Critically appraise the current literature.
Develop a plan for continuing personal professional development that includes but is not
limited to CME meetings.
Appraise the relevant medical literature on a regular basis.
EP Specific
o Teach other health care professionals about arrhythmia related topics.
o Gain knowledge of important clinical trials and other manuscripts which have
guided modern arrhythmia management.
o Actively search peer-reviewed literature to answer management questions
pertaining to patients seen in clinic and on the ward.
Professional
General Requirements
The resident will be able to:
Deliver highest quality care with integrity, honesty and compassion.
Exhibit appropriate personal and interpersonal professional behaviour.
Practice medicine ethically consistent with the obligations of a physician.
Specific Knowledge Requirements
The resident must be able to:
Discuss the professional and ethical responsibilities of a specialist.
Describe the requirements of patient confidentiality.
Specific Skill Requirements
The resident must able to:
Demonstrate personal and professional attitudes consistent with a specialist.
Display sensitivity to patient needs even when they conflict with best medical care.
Maintain patient confidentiality.
Practice in an ethical, honest, and forthright manner.
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Respond to conflict and abuse constructively.
EP Specific
o Actively participate in ongoing management of arrhythmia inpatients and consults
o Attend outpatient clinic at least 1 day per week, seeing patients independently
and presenting the case and proposed management to attending physician
o Attend and participate in arrhythmia service rounds on Wednesday and Friday 8-
9am
o Inform the service of expected absences or leave prior to beginning rotation, to
allow for appropriate patient and physician scheduling
Revised: April 2011, Dr. Granton
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CONSULT MEDICINE ROTATION
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
Anesthesia resident can complete a one or two block rotation in Consult Medicine. This
rotation may be done in any of the teaching hospitals and will be a mix of inpatient and
outpatient internal medicine. The anesthesia resident should use this rotation to improve their
understanding and ability to optimize a patient preoperatively and care for patients in the
perioperative setting.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
During the rotation, the resident will demonstrate proficiency in:
The assessment of patients presenting with undifferentiated medical
complaints/problems including eliciting a relevant history, performance of the
appropriate physical examination and evidence-based use of diagnostic testing.
Evidence-based management of common medical illnesses as well as less common but
remediable conditions.
Effective, integrated management of multiple medical problems in patients with complex
illnesses.
Performance of common procedures used in diagnosis and management of medical
patients including ECG interpretation.
Communicator
The resident will be able to:
Obtain a thorough and relevant medical history.
Complete a bedside presentation of patient problems.
Discuss diagnoses, investigations and management options with patients and their
families.
Obtain informed consent for medical procedures and treatments.
Communicate with members of the health care team.
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Communicate with referring and/or family physicians.
Collaborator
The resident will:
Demonstrate proficiency in working effectively within the health care team.
Demonstrate appropriate use of consultative services.
Recognize and respect the roles of other physicians, nursing staff, physiotherapists,
occupational therapists, nutritionists, pharmacists, social workers, secretarial and
support staff, and community care agencies in provision of optimal patient care.
Manager
During the rotation, the resident will:
Oversee provision of care and implementation of decisions regarding patient care,
including effective delegation of care roles.
Understand the principles and practical application of health care economics and ethics
of resource allocation.
Utilize health care resources in a scientifically, ethically and economically defensible
manner.
Demonstrate effective time management to achieve balance between career and
personal responsibilities.
Health Advocate
On completion of the rotation, the trainee will:
Understand important determinants of health including psychosocial, economic and
biologic.
Demonstrate the ability to adapt patient assessment and management based on health
determinants.
Recognize situations where advocacy for patients, the profession or society are
appropriate and be aware of strategies for effective advocacy at local, regional and
national levels.
Scholar
During the rotation, the resident will:
Demonstrate ability to use library and electronic resources to obtain information
required for patient care and further their own education.
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Professional
During the rotation, the resident will:
Demonstrate integrity, honesty and compassion in delivery of the highest quality of care.
Demonstrate appropriate personal and interpersonal professional behaviors.
Demonstrate awareness of the role and responsibilities of the profession within society.
Develop and demonstrate use of a framework for recognizing and dealing with ethical
issues in clinical and/or research practice including truth-telling, consent, conflict of
interest, resource allocation and end-of-life care.
Reviewed: July 2012, Dr. Granton
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CRITICAL CARE MEDICINE
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
Critical Care Medicine is a multidisciplinary field concerned with patients who have sustained,
or are at risk of sustaining life threatening, single or multiple organ system failure due to
disease or injury. Critical Care Medicine seeks to provide for the needs of these patients
through immediate and continuous observation and intervention so as to restore health and
prevent complications.
Training will be primarily based on encounters with patients presenting with a variety of
medical and surgical illnesses to the two multidisciplinary intensive care units of the London
Health Sciences Centre (LHSC), under the supervision of faculty and senior residents/fellows.
Faculty and senior residents/fellows will provide teaching by role modeling, bedside teaching
and provision of constructive feedback. Patient care rounds, teaching rounds and clinical
conferences will supplement patient encounters.
EXPECTATIONS
The Critical Care rotation is offered to residents of many different home programs and level of
residency. In all cases, the goal of this limited experience is to provide an overview of the
assessment and management of critically ill patients, and to promote the acquisition of the
basic knowledge, skills and attitude related to Critical Care.
Over the 1 to 3 block training period, it is expected that residents will demonstrate ongoing
development in each of the CanMEDS roles (as outlined below). The objectives are generic
and will apply to all junior residents, from any home program (surgery, medicine, anesthesia,
etc.) rotating in one of the two multidisciplinary intensive care units of the LHSC.
The acquisition of competencies will be documented using a Critical Care specific in-training
evaluation report (ITER) at the end of rotation. Feedback from faculty, senior residents/fellows,
nursing and allied health (multisource feedback) will be considered in the final rotation
evaluation.
OVERALL GOALS
By the end of the rotation the resident will have acquired some basic knowledge, skills and
attitudes necessary to initiate the assessment and management of a patient presenting with a
critical illness, and understood the importance of multidisciplinary contribution in the optimal
management of the critically ill.
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ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
By the end of the rotation, the resident will have:
Demonstrated the ability to perform a complete and thorough history and physical
examination of the critically ill patient, allowing for a proper differential diagnosis and
management.
Demonstrated an appropriate level of knowledge allowing for the clinical assessment,
diagnosis and initial management of a critically ill patient with the following conditions:
Hemodynamic instability, Respiratory failure, Hemorrhage (including massive
transfusion), Altered level of consciousness, Delirium, Nutritional support needs, End-of-
life issues
Demonstrated proper skills in initiating promptly a plan for the appropriate management
of the above conditions.
Developed skills for a timely response and organized approach to emergencies
situations in Critical Care: Remaining calm, Prioritizing appropriately, Displaying
leadership
Understood the basics of continuous monitoring (invasive BP monitoring, CVP, ICP,
outputs, etc.) and its importance in the close follow-up and management of the critically
ill patient.
Specific Procedural / Technical Skills
By the end of the rotation, the resident will have:
Demonstrated an understanding of the indications, risks and different steps involved in
the performance of the procedures mentioned below.
Demonstrated appropriate skills in the preparation (gathering equipment, assistance,
etc.) and performance of the named procedures, particularly relating to infection control
and use of protective equipment.
Demonstrated the technical skills necessary to perform the following procedure(s):
Central access - internal jugular central catheter insertion (or femoral-subclavian access
when appropriate), Arterial catheter insertion, Intubation
Acquired consistency in properly documenting the procedures performed (successful or
not).
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Communicator
By the end of the rotation, the resident will have demonstrated:
The ability to provide a concise prioritized patient presentation during rounds.
The ability to provide patients and their families with information that is clear and
encourages discussion / participation in decision-making.
The ability to listen and communicate clearly with the ICU team (nurses, allied health,
senior residents and consultants) and other services, regarding patient status and
management plan.
The ability to write or dictate clear, concise and up-to-date daily progress notes,
discharge summaries and consultation notes.
Collaborator
During the rotation, the resident will have demonstrated:
Recognition and respect of the roles of the ICU team members (residents, nurses,
respiratory therapists, allied health, etc.) AND of the other consulting services in the
ICU.
The ability to deal effectively and constructively with differences in opinion and conflict
situations arising in the interdisciplinary ICU environment.
Manager
During the rotation, the resident will have demonstrated:
Effective organizational and time management skills.
Leadership skills within the team.
Health Advocate
On completion of the rotation, the resident will have:
Identified opportunities for advocacy and disease prevention, and prevention of
complications in individual patients.
Practiced preventative care including, for example, use of protective equipment when
indicated and sterile technique for catheter insertion.
Scholar
By the end of the rotation, the resident will have:
Attended and participated in scheduled seminars and journal clubs.
Demonstrated initiative in learning about their assigned patient’s illnesses, even if not
directly relevant to their specialty.
Show initiative in teaching members of the ICU team (nurses, other residents, etc.)
through discussions or presentation.
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Professional
During the rotation, the resident will have:
Demonstrated integrity, honesty and compassion.
Demonstrated respect for privacy and confidentiality.
Displayed reliability and conscientiousness in monitoring and follow-up of patients
issues.
Demonstrated good insight into own performance (aware of own limitations), seek
advice appropriately, and take feedback graciously.
The ability to be prompt and on time for scheduled rounds and seminar.
Approved: June 2013
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CRITICAL CARE ULTRASOUND
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
This elective is one block in duration. It is open to one critical care resident on a first come- first
served basis that is negotiated with Dr. Arntfield. Learning objectives will focus on the skills of
acquisition and interpretation of point of care ultrasound images in critically ill patients.
Supervisor: Dr. Robert Arntfield ([email protected] )
Site: Critical Care Trauma Centre, Medical Surgical ICU, Victoria Hospital ED
Responsibilities
The resident(s) carrying out their critical care ultrasound elective are responsible for providing
point of care ultrasound services in the CCTC and, when possible, to other critically ill patients
at Victoria Hospital during weekday hours. There are no nighttime or weekend call
responsibilities. Given there is no known harm from ultrasound technology, ultrasound exams
may be carried out liberally for both educational and diagnostic/therapeutic and procedural
(when indicated) purposes. Patient selection for ultrasound may be driven by either a CCTC
team member request or be self-initiated by the resident on service. If ultrasound exams are
elective and educational in nature, they are not to delay or interfere with any aspects of care
(nursing, medical, family) for the patient.
Ultrasound images obtained must all be archived appropriately using methods well described
in tutorials made available to the resident. Further, meticulous organization of these studies
within Qpath is expected in order to facilitate Dr. Arntfield’s oversight as well as to track the
number of studies being acquired by the resident across each indication. Benchmarks for each
indication will be determined at the beginning of each rotation for each resident.
Upon completion of a non-educational ultrasound examination, the resident must communicate
the findings to the medical team directly. Review of images with Dr. Arntfield may occur first if
required. Direct image review is encouraged between the resident and the CCTC team
member. A hand written or type written report must also be inserted in to the patient chart.
The resident will be responsible for completing a 5 hour critical care echocardiography
curriculum prior to starting their rotation. An additional 9 hours of content must be reviewed by
the resident in the first 2 weeks of the rotation.
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At regular intervals, in person image review and hands on training with the rotation supervisor
(Dr. Arntfield) will occur. This will supplement the wireless oversight of images being acquired
via the hospital-based point of care ultrasound management software (Qpath).
At the conclusion of the rotation, the resident will be expected to contribute two small projects.
Firstly, a case write up and accompanying images for the “case of the month” on the point of
care ultrasound webpage “uwosono.ca”. The second will be to lead a lunchtime image review
session for CCTC residents and staff, highlighting interesting cases and learning points from
the past month.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
General Requirements
Residents will:
Learn and apply basic ultrasound physics, machine controls and transducers in
acquiring ultrasound images in critically ill patients.
Appreciate the clinical syndromes where general critical care ultrasound and critical
care echocardiography may play a pivotal role in guiding diagnosis and management.
Achieve comfort in generating quality ultrasound images across different organ systems
in a critically ill patient.
Understand the limitations of ultrasound technology, its user-dependence as well as
common imaging artifacts and imaging pitfalls.
Learn how to integrate point of care ultrasound findings in to the care trajectory of the
critically ill patient.
Achieve comfort in a teaching role with junior residents in demonstrating some
fundamental ultrasound teaching, especially as it relates to procedural guidance for
vascular access.
Learn to identify the role of cleaning and proper storage of point of care ultrasound
machines as part of their upkeep and preservation in a busy ICU environment.
Appreciate the importance of a quality assurance program as part of patient safety and
proper training for point of care ultrasound and other user-dependent methods of patient
care.
Identify the role for diagnostic studies from other consultant imaging specialists for more
complex clinical questions or when point of care imaging is unable to answer the clinical
questions at hand.
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Specific Knowledge Requirements
The resident is expected to describe:
Factors influencing image acquisition quality when imaging critically ill patients
Causes and ultrasound findings in circulatory failure due to various causes including:
o Left ventricular failure
o Hypovolemia
o Acute right sided heart failure (cor pulmonale)
o Cardiac tamponade
o Acute massive left sided valvular regurgitation
o Circulatory arrest
Causes and ultrasound findings in respiratory failure due to various causes including:
o Pleural effusion
o Pneumothorax
o Alveolar-interstitial syndrome (CHF, ARDS)
o Normal aeration pattern (PE, obstructive lung disease)
o Lobar collapse
Requirements for acceptable cardiac ultrasound images and anatomic structures seen
when images are obtained from the parasternal, apical and subcostal positions
Knowledge of ultrasound artifacts, including mirror image, enhancement, edge, side
lobe, ring down and reverberation artifacts
Understanding of potential mimics, artifactual or anatomic, of common pathology (false
positives) in both cardiac and general critical care ultrasound applications
Understanding the difference between volume status and volume responsiveness
Knowledge of the requirements for positive, negative and indeterminate ultrasound
studies when assessing for binary clinical questions such as pleural fluid, pericardial
fluid, pneumothorax
Knowledge of qualitative and quantitative approaches to evaluating volume
responsiveness, cardiac output, left ventricular function, pericardial fluid, pleural
effusion, pneumothorax
Understanding of the physics of Doppler, the distinction between continuous wave (CW)
and pulse wave (PW) Doppler, aliasing, pulse repetition frequency and the Nyquist limit.
Knowledge on how to use Qpath to generate reports and review feedback.
Identify suitable critical care patients for point of care transesophageal
echocardiography
Identify patients where clinical questions require escalation to diagnostic imaging
specialists
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Specific Skill Requirements
The resident is able to:
Generate interpretable general critical care ultrasound images in the assessment for
pneumothorax, pleural effusion, ascites.
Generate interpretable basic critical care echocardiography images from multiple
transthoracic windows, including the parasternal, apical and subcostal points of view.
Accurately recognize (interpret) the ultrasound findings consistent with pneumothorax,
pleural effusion and ascites
Accurately recognize (interpret) the echocardiographic findings consistent with
pericardial effusion, various states of LV function, cor pulmonale, massive valvular
pathology and a volume responsive IVC.
Defer making interpretations on ultrasound images that are either of suboptimal quality
or fall outside of the capabilities or scope of the resident’s training and experience.
Propose and discuss (with the patient’s care team) appropriate clinical management
plans in response to findings on point of care ultrasound.
Landmark safe and high yield locations for chest drainage or abdominal drainage
procedures using ultrasound.
Demonstrate competence in cannulating various vessels (central veins, peripheral
veins, peripheral arteries) with ultrasound guidance and sterile technique.
Use echocardiography to assist in the resuscitation and prognosis of patients in cardiac
arrest.
Communicator
The resident will be able to:
Verbal communication of ultrasound findings to care team, including nurse and resident.
Document all ultrasound findings in patient chart either by hand-written note or through
a Qpath generated report (preferred).
Provide point of care ultrasound support to ward patients on the CCOT service who may
benefit from point of care assessment of circulatory or respiratory failure.
Collaborator
The resident will:
Establishes trusting relationships with the nursing staff, residents and the patients.
Liaise professionally and respectfully with all consultant services.
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Health Advocate
On completion of the rotation, the trainee will:
Recognizes that ultrasound is one of many tools to guide diagnostics and therapeutics
in an ICU setting.
Appreciates that patient positioning and patient exposure for ultrasound exams may be
stressful or disruptive for patients.
Patient safety: Thoroughly clean the machine and transducers after each use, using
cavi-wipes.
Evaluation
The trainee will be evaluated with a number of tools.
Qualitatively:
A majority of individual ultrasound scans will be evaluated either in person or by using the
electronic quality assurance software (Qpath) whereby reports on quality are emailed to the
rotator. At the end of each week, an in person review session will occur, reviewing the week’s
work and focusing on bridging gaps in ultrasound image generation, interpretation or clinical
integration.
Quantitatively:
At the beginning of each block, the resident and Dr. Arntfield will decide on an appropriate
number of studies within each indication to be completed. In general, these will correspond to
40 cardiac studies and 25 each of thoracic and pleural studies. Studies will be tracked
automatically by the image archiving software (Qpath). Some variation may occur if holidays
or conference time is taken by the rotator. Failure to achieve these targets will result in a non-
satisfactory evaluation.
Summary feedback will be provided at the end of the block along with an exit interview and
practical hands-on evaluation. The In-Training Evaluation Report (ITER) will be reviewed with
the trainee, signed, and forwarded to the office of the Critical Care Program Director.
Reviewed: August 2012, Dr. Granton
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NEONATAL INTENSIVE CARE UNIT
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
The goal of the NICU rotation for trainees in anesthesia is development of an understanding of
the common neonatal illnesses, their treatment, and their implications for anesthetic
management or perioperative care. In addition, there will be a focus on newborn assessment
and resuscitation.
It will be helpful is residents have completed the Neonatal Resuscitation Program (NRP) prior
to the rotation.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
Specific Knowledge Requirements
The resident will be able to:
Identify neonates requiring resuscitation.
Recognize common neonatal surgical emergencies.
Identify common neonatal critical care problems (eg. temperature control, respiratory
compromise, fluid and electrolyte disturbances, glucose management and circulatory
problems).
Propose appropriate management plans in both the NICU and the OR for these
common neonatal critical care problems.
Have working knowledge of Neonatal Resuscitation (Neonatal Resuscitation Program,
NRP).
Specific Skills Requirements
The resident will be able to:
Complete a history and physical assessment pertinent to the neonate requiring critical
care intervention.
Present a stratified differential diagnosis of the neonate’s illness.
Prescribe initial management of the neonate’s critical condition.
Provide neonatal resuscitation as member of resuscitation team.
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Interpret common laboratory evaluations in neonatal critical care medicine including
umbilical cord blood gases, complete blood count and differential, chest x-ray, etc.
Communicator
The resident will be able to:
Obtain and document the relevant medical history and physical exam thoroughly and
efficiently.
Develop communication skills with other members of the health care team to benefit the
patient.
Collaborator
The resident will be able to:
Be aware of the role of the neonatology consultant in peripartum management of the
neonate.
Be aware of the role of the neonatology consultant in perioperative management of the
neonate.
Participate in team neonatal resuscitation.
Describe the importance of the role of each of the members of the neonatal
resuscitation team and support them in fulfilling their duties.
Health Advocate
The resident will be able to:
Understand the complex emotional atmosphere surrounding delivery of a newborn and
impact of a critically ill child on parents/caregivers.
Scholar
The resident will:
Attend and participate teaching rounds.
Professional
The resident will be able to:
Demonstrate integrity and honesty when interacting with neonates, families, and other
health care professionals.
Be punctual, efficient, and respectful at all times.
READING LIST
Suggested Readings:
1. ACoRN, Acute Care of at-Risk Newborns - First Edition, 2005 (ISBN 0-9736755-0-0), Rev 02/06 (ISBN 0-9736755-1-9), Updated '2010 Version' Oct 2009 (ISBN 978-0-9736755-2-8)
Reviewed Granton 2012
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PALLIATIVE MEDICINE
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
Anesthesia residents may complete a rotation(s) in palliative medicine during their residency
which will allow for a broad exposure to the care of terminally ill patients along with the
numerous and often-times challenging problems. Residents will be exposed to numerous
ethical issues that will require careful attention and skill in order to manage these issues
effectively. They will recognize, as with all areas of medicine, the delivery of compassionate
care is tantamount however during the terminal phase of illness these skills are of particular
importance. Anesthesiologists are often identified as pain and symptom control physicians.
Their expertise may be requested to assist with patients dying in their community with
controlled symptoms, even if they do not practice palliative medicine. Many patients admitted
to ICU do not survive, requiring delivery of palliative care principles in the ICU setting. Due to
the nature palliative care work, the resident will find many of the skills required to perform
effectively during this rotation are very well represented in the goals and objectives associated
with the CanMeds roles as established by the Royal College of Physicians and Surgeons of
Canada.
ROTATION OBJECTIVES
Medical Expert/Clinical Decision Maker
The specialist trainee must be able to:
Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
Access and apply relevant information to clinical practice.
Demonstrate effective consultation services with respect to patient care, education and
legal opinions.
Understand ethics, law, and policy governing palliative care delivery in Canada.
Understand symptom management (Education will be based on clinical situations that
present during the rotation).
A. Pain
The resident will:
o Be able to assess and treat different types of pain and pain syndromes.
o Know the pharmacology of NSAIDs, opioids, and adjuvant drugs.
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o Know about opioid tolerance, physical dependence, and addiction.
o Know routes of administration of opioids, i.e. morphine, hydromorphone and
fentanyl.
o Have knowledge of non-pharmacologic approaches to pain management.
B. Dyspnea, delirium, nausea and vomiting, constipation, bowel obstruction,
decubitus ulcers, anxiety, depression, etc.
The resident will be able to:
o Discuss the pathophysiology and treatment of these different symptoms as they
arise in the patients being treated during their rotation.
C. Emergencies
o Residents will be involved in the assessment and management of palliative
emergencies as they arise in the patients during the rotation which may include:
hypercalcemia, severe dyspnea, severe pain, spinal cord compression, SVC
syndrome, pathologic fractures, seizures and hemorrhage in the palliative setting.
Communicator
The resident will be able to:
Establish therapeutic relationships with patients/families.
Obtain and synthesize relevant history from patients/families/communities.
Listen effectively.
Discuss appropriate information with patients/families and the health care team.
Use different techniques and approaches for communicating distressing information to
patients/families.
Work with patients and families to determine appropriate goals of treatment for stage of
disease.
Recognize personal limitations and ask for assistance when exposed to new situations
or information, whether it be ethical, clinical, investigational, or management strategies.
Collaborator
The resident will be able to:
Consult effectively with other physicians and health care professionals.
Demonstrate timely and appropriate consultation skills directed towards various medical
specialties contributing to the patients care.
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Manager
The resident will:
Allocate finite health care resources wisely.
Work effectively in health care organization.
Use information technology to optimize patient care, and life-long learning.
Health Advocate
The resident will be able to:
Identify the important determinants of health affecting patients.
Recognize and respond to those issues where advocacy is appropriate.
Understand through observation the important role of health advocacy for patients that
the physician plays at various levels of hospital administration and government.
Scholar
The resident will be able to:
Critically appraise sources of medical information.
Facilitate learning of patients, house staff/students, and other health care professionals.
Demonstrate effective skills and techniques necessary to acquire information for patient
care from various sources: i.e. the library and internet based searches.
The resident may have the opportunity to present in an informal setting a topic of
interest that is relevant to the delivery of palliative care.
Professional
The resident will:
Deliver the highest quality of care with integrity, honesty and compassion.
Exhibit appropriate personal and interpersonal professional behaviours.
Practice medicine ethically, consistent with the obligations of a physician.
Evaluation
Residents/fellows will be evaluated on their assessment and care of the patients, relationships
with patients, families and interdisciplinary team members. The trainee often is invited to
present in an informal setting a topic of interest that is relevant to delivery of palliative care.
Reviewed: April 2012, Dr. Granton
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PEDIATRIC CRITICAL CARE
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
ROTATION OBJECTIVES
Medical Expert/Clinical Decision Maker
Specific Knowledge Requirements
The anesthesia resident will be able to:
The anesthesia resident will be able to identify children requiring resuscitation and
describe standards for pediatric and neonatal resuscitation
The resident will be able to recognize common pediatric surgical emergencies, their
epidemiology and presentation and will be able to propose appropriate management
The resident will be able to identify common pediatric critical care problems (respiratory,
fluid and electrolyte, circulatory, trauma and metabolic problems). The resident will be
able to propose management plans in both the PCCU and the OR. Recognition of
possible complications associated with management and= underlying patient conditions
should also occur.
The resident will be able to describe the pathophysiology of common causes of critical
illness in children
The resident should be able to understand different modes of ventilation in critically ill
pediatric patients
Specific Skill Requirements
The resident will be able to:
The resident will acquire technical skills in the following procedures:
o Peripheral intravenous access
o Pediatric airway management
o Resuscitation of critically ill child
The resident will be able to provide pediatric resuscitation
Communicator
The resident will be able to:
Establish a therapeutic relationship with the patient and families
Effectively obtain relevant information from all sources and communicates to the team
Be aware of the unique stressful environment of the Pediatric Critical Care Unit
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Establish good relationships with peers and other health care professionals
Collaborator
The resident will be able to:
Communicate effectively with all health care professionals including allied health
professionals
Recognizes and acknowledges the roles of different health care providers
Should be able to manage conflict well
Contributes productively to interdisciplinary activities
Manager
The resident will be able to:
Understands and makes effective use of information technology such as methods for
searching medical databases
Makes cost-effective use of health care resources based on sound judgment
Health Advocate
The resident will be able to recognize and respond to situations where patient advocacy is
needed, such as:
Be able to recognize preventive measures in status asthmaticus patients
Advocate for organ donation, etc.
Scholar
The resident will be able to:
Partake in the assigned academic activities in the PCCU
May be expected to teach airway management skills to the junior house-staff
Professional
The resident will be able to:
Demonstrate integrity, compassion and respect for diversity
Fulfills medical, legal and professional obligations of the specialist
Demonstrate reliability and conscientiousness
Reviewed: 2012, Dr. Granton
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RESPIROLOGY ROTATION (PGY-2 TO 5)
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
The goal of the Respirology rotation for trainees in anesthesia is the development of an
understanding of the common respiratory diseases, their treatment, and their implications for
anesthetic management.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
Specific Knowledge Requirements
The resident will be able to:
Describe the pathophysiology of respiratory diseases including reactive airways
disease, restrictive lung disease, pulmonary malignancy, tuberculosis, cystic fibrosis
and other infectious and occupational lung diseases.
Describe the natural history and complications of these respiratory diseases.
Describe the symptoms and physical findings associated with the diseases.
Describe the usual acute and long term management and therapeutic measures used to
treat these diseases.
Describe the laboratory tests used in evaluating pulmonary disease, along with their
indications, interpretations and limitations.
Describe the perioperative risk factors for patients with respiratory diseases undergoing
surgery.
Describe the necessary preparation and premedications for patients with respiratory
diseases undergoing surgery.
Specific Skill Requirements
The resident will be able to:
Complete a history and physical assessment pertinent to the respiratory system.
Present a stratified differential diagnosis of the patient’s illness.
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Prescribe initial management of the patient’s condition.
Interpret common laboratory evaluations in respiratory medicine, including chest x-ray,
arterial blood gases, pulmonary function tests and nuclear medicine imaging of the
pulmonary system.
Communicator
The resident will be able to:
Obtain and document the relevant medical history thoroughly and efficiently.
Develop communication skills with other members of the health care team to benefit the
patient.
Collaborator
The resident will:
Be aware of the role of the respirology consultant in perioperative management of the
surgical patient.
Health Advocate
The resident will:
Understand the complex emotional effects of the illness on the patient and their family.
Encourage patients to optimize their health status.
Professional
The resident will:
Demonstrate integrity and honesty when interacting with patients, families, and other
health care professionals.
Be punctual, efficient, and respectful at all times.
Reviewed: June 2012, Dr. Granton
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TRANSFUSION MEDICINE ROTATION
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements in Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
The goal of the Transfusion Medicine rotation for trainees in anesthesia is development of an
understanding of the common anemias and coagulopathies, their treatment, and their
implications for anesthetic management. In addition, experience in hematologic laboratory
testing methods and interpretation will be stressed.
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision Maker
Specific Knowledge Requirements
The resident will be able to:
Describe the physiology of oxygen carrying by the blood.
Describe the physiology of inadequate oxygen delivery by the blood and the treatment
of this.
List the various types of anemia, along with their etiology, and describe their
pathophysiology.
Describe the usual acute and long term management and therapeutic measures
(including blood transfusion) used to treat these anemias.
Describe the coagulation pathway.
List the disorders of hemostasis and describe their pathophysiology and treatment.
Describe the laboratory tests used in evaluating anemia and coagulopathy, along with
their indications, interpretations and limitations.
List the indications for transfusions of the various available blood products, and in
conjunction with this, describe the physiologic effects of transfusions of the various
blood products, including their side effects and the management of these.
Describe the perioperative risk factors for patients with hematologic diseases
undergoing surgery.
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Describe the necessary preparation and premedications for patients with hematologic
diseases undergoing surgery.
Specific Skill Requirements
The resident will:
Have sufficient working knowledge of the following laboratory tests in order to be able to
describe how they are performed and interpret the results. The resident will be expected
to perform some tests in those categories marked with an asterisk (*).
o Tests of hemostasis* and thrombosis (including coagulation screening, DIC
fibrinolysis tests and platelet disorders).
o Automated hematology tests (CBC/differential) and basic blood morphology.
o Special hematology tests* (eg. hemoglobin, electrophoresis/sickledex, tests for
hemolysis).
o Immunohematology tests* (eg. blood typing, antibody investigation).
Have a working knowledge and have participated in the collection of blood for
transfusion purposes, the separation of the various blood products from the collected
whole blood sample, and the preparation and storage of the individual blood products.
Communicator
The resident will be able to:
Develop communication skills with other members of the health care team to benefit the
patient.
Describe the social concerns regarding blood transfusion including:
o Autologous donation
o Directed donation by family members
o Review of Jehovah’s Witnesses
Discuss the changing views in society regarding the safety of blood products.
Collaborator
The resident will be able to:
Describe the roles of the people participating in the donation and collection of blood for
transfusion and its storage and delivery to recipients.
Be aware of the role of the hematology consultant in perioperative management of the
surgical patient.
Manager
The resident will be able to:
Consider health care resources when determining the transfusion management plan.
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Acknowledge the difficulties and decision-making involved in utilization and allocation of
finite health care resources.
Health Advocate
The resident will be able to:
Provide appropriate education to ensure patients are well informed and well prepared.
Encourage patients to optimize their health status.
Scholar
The resident will be able to:
Teach medical students, under supervision of staff, about clinical problems.
Demonstrate critical enquiry of a clinical question that they have raised or that has
appeared during teaching discussions.
Professional
The resident will be able to:
Demonstrate integrity and honesty when interacting with patients, families, and other
health care professionals.
Be punctual, efficient, and respectful at all times.
Evaluation
The resident will receive daily feedback from clinical preceptors. The resident will be expected
to complete a rounds presentation once per rotation. An end-of-rotation written evaluation will
be completed by both the resident and clinical preceptor. The resident evaluation will be
discussed with the resident and signed by both the resident and the preceptor.
Reviewed: July 2012, Dr. Granton
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RESEARCH ROTATION
THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA
Objectives of Training and Specialty Training Requirements i n Anesthesia
Specific Objectives in CanMEDS Format
OVERALL GOALS
1. Residents will meaningfully participate in the design & execution of a research or
Quality Improvement project or education project. Ideally, such participation should be
from beginning to end of the project (skills & knowledge).
2. Residents will be advocates for the importance of research in clinical practice
(attitudes).
3. Residents will continue to engage in research or QI initiatives as clinicians
(sustainability).
ROTATION OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as:
Medical Expert/Clinical Decision-Maker
Residents will:
Be able to execute an effective search strategy, retrieve references, manage
information in reference management software, and cite sources.
Prepare a research proposal, quality improvement plan or education project.
Communicator
General Requirements
Dissemination of research plan & results.
Ability to discuss research, quality improvement or education project in a sophisticated
manner.
Specific Requirements
Residents will:
To the extent possible, prepare a manuscript or abstract to report the results of their
research project that conforms to the publication guidelines of an appropriate academic
journal.
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Present the results of their ongoing or completed project at the Mac/Western Research
Day or another appropriate scientific meeting.
Additional points:
In lieu of a manuscript submitted to an academic journal, the resident may disseminate the
results of the research or quality improvement project in another suitable fashion, such as a
professional meeting or academic conference.
Collaborator
General Requirements
To demonstrate inter- and intra-professional collaboration during the conduct of the
research, quality improvement project or education project.
Specific Requirements
Residents will:
Work with other health professionals as necessary to ensure each step of the research,
quality improvement project or education project is executed effectively, and with
efficient use of resources.
Cooperate with the Research/Project Supervisor in the timely submission of the project
idea, literature review, protocol, and applications for ethics approval.
Ensure open communication during the Informed Consent process, respecting the
patient and their family as valuable partners in the research endeavor.
Manager
General Requirements
Data collection and analysis.
Timely completion of research tasks.
Specific Requirements
Residents will:
Organize research rotation time appropriately and meet submission deadlines in a
timely fashion.
Maintain clear records of research data.
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Health Advocate
General Requirements
To influence patient-centered outcomes through asking critical research questions and
addressing quality improvement or education issues that will have a direct benefit to
patients, communities, and health systems.
Specific Requirements
Residents will:
Demonstrate a clear understanding of the benefits their research, quality improvement
project or education project may have on patients, communities, and health systems.
Be able to identify whether ethical approval is necessary for their research project and
make application to the appropriate Research Ethics Board, if necessary.
Scholar
General Requirements
To understand the process and steps of scientific research, quality improvement or
education.
To demonstrate critical thinking.
Specific Requirements
Residents will:
Formulate a viable research question or project.
With assistance, residents will identify the components required to design a research,
quality improvement or education project to answer their question or clinical problem.
With assistance, residents will prepare a proposal that addresses rationale for the
project, the research hypothesis, methods, data analysis, expected outcomes, and a
plan for dissemination of the results.
Professional
General Requirements
Demonstrate commitment to the health and well-being of individual patients and
populations.
Respect the obligations of the research rotation.
Specific Requirements
Residents will:
Respect patient confidentiality and autonomy.
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Ensure secure research data if appropriate Respect deadlines for project completion set forth by supervisor and department.
Reviewed: 2012, Dr. Granton
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ANESTHESIA/FAMILY MEDICINE
ENHANCED SKILLS PROGRAM
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ANESTHESIA/FAMILY MEDICINE ENHANCED SKILLS
ANESTHESIA PROGRAM The Department of Anesthesia & Perioperative Medicine
The Enhanced Skills Anesthesia Program is a one year program designed to provide family
physicians with the knowledge and skills to be able to provide anesthesia care for low risk
patients undergoing relatively uncomplicated procedures particularly in smaller rural
communities. It is of interest to recent graduates from family medicine training programs who
wish to acquire the skills necessary for independent anesthetic practice.
Participants in the program rotate through the three teaching sites, community and/or rural
hospitals so that they will acquire the knowledge, skills and experience required to provide
anesthesia to a wide variety of patients in a number of settings.
The terminal objective for the program is to train practitioners to the level where they will be
effective and safe practitioners of anesthesia in the small hospital setting. The program has
been successfully achieving this end for more than 25 years.
While striving to optimize the breadth and depth of clinical experience for the trainee, the
program is also designed to be a flexible educational experience. Thus, the program is
custom-tailored to each individual trainee, based on the trainee's past experience and
educational objectives.
Learning Environment
The majority of the anesthesia training will be provided at St. Joseph's Health Care and the
Victoria and University sites of London Health Sciences Centre, as well as a two block
community experience at our sister site in St. Thomas (St. Thomas Elgin General Hospital) - a
20 minute drive from the centre of London. A one block rotation at Strathroy Middlesex
General Hospital rounds out the community and FP-A experience.
St. Joseph's Health Care provides the resident with exposure to operative cases similar to
those likely to be found in a community hospital setting. There is a focus on ambulatory
anesthesia and regional anesthesia.
The Victoria Hospital site of London Health Sciences Centre rotation emphasizes heavily the
trauma, obstetrics and emergency aspects of the anesthetic practice. The family medicine
resident will be expected to provide airway management under anesthesia consultant
supervision in both emergent and non-emergent situations. The operating room experience at
Victoria Hospital is also designed to expose the resident to a variety of cases that the family
medicine anesthetist would expect to encounter for both adult and pediatric patients.
Obstetrical anesthesia experience is also coordinated at Victoria Hospital. This will allow
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development of proficiency in the various techniques of analgesia for labour and delivery,
including epidural analgesia, patient-controlled analgesia, and inhalational analgesia.
University Hospital allows for the exposure to more complicated medical patients, an
introduction to Neuro-resuscitation and anesthesia, and also has general and sports medicine
cases.
The St. Thomas Elgin General and Strathroy Middlesex General sites allow for community
based exposure and gives an opportunity to work with Family Medicine Anesthesia
practitioners.
Elective time in other disciplines appropriate to the trainee's educational objectives can be
arranged on an elective basis. The main elective to be considered in the enhanced skills
anesthesia training program is one to two blocks of intensive care medicine. This rotation
would allow the family medicine resident exposure to the types of cases that a community
hospital ICU may be called on to handle.
The opportunity to participate in research appropriate to the family practice anesthetist is
continuously available.
The family medicine resident is expected share an on-call schedule (in compliance with PARO
guidelines), along with other anesthesia residents.
Hierarchal Structure
1) Directors – Dr. Jeff Granton & Dr. Jeremy Keller
2) Site coordinators (to ensure goals & objectives are achieved and evaluations are
completed):
a. Victoria Hospital – Dr. Kevin Teaque
b. University Hospital – Dr. Rosemary Craen
c. St. Thomas-Elgin Hospital – Dr. Nicole Campbell
d. St. Joseph’s Hospital – Dr. Paidrig Armstrong
3) Administrative support – Linda Szabo
Organization
1. Ambulatory and OB – 4 blocks
2. General anesthesia – 4 blocks
3. Specialized anesthesia – 1 block
4. Critical care – 1 block
5. Community – 3 blocks
Ambulatory: Occurs at St Joseph’s Hospital (SJH) and the focus is on outpatient surgery.
Specialty areas include plastic surgery, orthopaedic surgery, general surgery, ophthalmology,
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urology (including lithotripsy). Trainees get a great deal of experience with regional anesthesia
and conscious sedation techniques.
General/OB: Occurs at Victoria Hospital (VH), which has a vast array of services. Specialty
areas include, OB/GYN, high-risk obstetrics, vascular surgery, thoracic surgery, general
surgery, trauma, paediatric surgery, orthopaedic surgery, ENT and plastic surgery. Patients at
this centre have a very high burden of illness and trainees get experience managing
challenging cases. So much so, that the level of difficulty can often cause some anxiety for the
trainee at the initiation of the rotation.
Specialty: Occurs at University Hospital (UH), which has several highly specialized services.
The family medicine/anesthesia trainees rotate at UH primarily to gain experience with neuro-
anesthesia. This allows them to round out their training. However they do gain exposure to
other specialty areas including arthroplasty, plastic surgery, ENT (ear/sinus), general surgery,
cardiac surgery and transplant.
Critical Care: During this rotation the resident is expected to gain a working knowledge of
critical care medicine and an understanding of the common pathophysiology of critically ill
patients. Residents will also become familiar with the principles of hemodynamic monitoring,
airway management and ventilator care. This can be an unfamiliar environment for the family
medicine/anesthesia trainee and does take some adjustment.
Electives: Elective time in other disciplines appropriate to the trainee’s educational objectives
can be arranged on an elective basis. General community anesthesia electives are usually
arranged at St. Thomas-Elgin General Hospital.
Scholarly Activities
1. All residents in the Enhanced Skills program are required to complete a scholarly project.
A written report is not required but welcome. A formal presentation at resident research
day in June is required. Topics should be discussed with Dr. Grushka (Enhanced Skills
Program Director) and Dr. Granton. Please refer to the Enhanced Skills Orientation
Manual for more direction regarding project requirements and departmental assistance with
funds, ethics approval, literature reviews, etc.
2. An introductory course in anesthesia is operated for the new anesthesia trainees each
year. These include the Enhanced Skills-Anesthesia residents and the new Royal College
anesthesia trainees. Enhanced Skills-Anesthesia trainees are also expected to be involved
with the afternoon academic half day sessions which are run for the Royal College
anesthesia trainees. Special effort is made to highlight areas of focus for the family
practice trainee in these sessions. Individual hospital-based seminar series are run at the
various hospital sites. Each Wednesday morning the individual hospital sites have their
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weekly rounds that cover everything from morbidity and mortality reviews to individual case
discussions. The Department of Anesthesia enjoys the presence of visiting professors on a
regular basis. The visiting professors present a topic of their focus at a city-wide round and
often conduct a resident lecture as well. There is an active evidence-based Journal Club.
The foregoing academic activities provide a full range of educational opportunities for the
Enhanced Skills-Anesthesia trainee. As well, the anesthesia trainee is assigned to an
individual staff anesthetist on a daily basis for the practical clinical teaching aspect. This
allows time on a daily basis for supervised clinical activity, as well as on-going discussion of
practical and academic aspects of anesthesia.
3. All anesthesia residents attend the annual Anesthesia Resident Research Day held in June
in partnership with McMaster University.
4. The resident is encouraged to teach at PGY-1/PGY-2 academic half day on a topic related
to their field of specialization. This can be discussed with the Academic Program Director
(Dr. Wickett) and the Enhanced Skills Program Director (Dr. Grushka).
5. The Enhanced Skills resident may attend both PGME and Family Medicine Grand rounds.
6. The Enhanced Skills-Anesthesia will participate in C-STAR simulations with fellow Royal
College Anesthesia residents.
Duties
1. On-call
Residents will rotate through at least four sites. Call will vary by site and will not exceed 1:4.
Call duties will be shared by residents in the Royal College Anesthesia program when both
types of trainees are present.
2. Research
See above.
3. Teaching
See above.
Evaluation
1. The resident will be supervised on a daily basis and will obtain 1 evaluation per rotation
from a site director on the one45 system.
2. The resident can meet informally with the site director at the mid-way point of each block to
discuss cases and review any concerns.
3. A midterm review with the program director will take place to ascertain the resident’s
progression either in person, by phone or by video-link (skype).
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ANESTHESIA/FAMILY MEDICINE ENHANCED SKILLS
ANESTHESIA PROGRAM The Department of Anesthesia & Perioperative Medicine
Specific Objectives in CanMEDS-FM Format
OVERALL GOALS
The goals and educational objectives are to provide pre-anesthetic assessment of the patient,
to determine the levels of anesthetic risk and to provide competent, safe anesthesia for
patients requiring "non-radical" surgery in the community setting, to provide management of
emergency situations requiring anesthesia skills (cardiac arrest, trauma, obstetric problems,
stabilization for transport), to coordinate transfer as necessary, and to fully recognize the
limitations of self and facility.
Finally, the onus is placed on the Family Physician-anesthetist to update professional skills
when required and to know one's own limitations.
PROGRAM OBJECTIVES
Family Medicine Expert
1. The Family Medicine Resident will become knowledgeable in the following as it
pertains to the discipline of anesthesia:
1.1. The Family Medicine Resident will understand the age-related differences in
anatomy, physiology, and pharmacology among children , adults, pregnant
women, and the elderly:
1.1.1. Knowledge of the practice guidelines of the Canadian Anesthesiologists’ Society.
1.1.2. Knowledge of anatomy and physiology of the airway and the following systems:
cardiovascular, respiratory, renal, hepatic, endocrine, neurologic and
hematologic.
1.1.3. Knowledge of pharmacology pertaining to inhalation drugs, induction agents,
opioids, and other common analgesics, muscle relaxants and reversal agents,
local anesthetics and cardiac resuscitation drugs.
1.1.4. Knowledge of commonly used therapeutic drugs and other health related
products and their interactions with anesthetic agents.
1.2. The Family Medicine Resident will be able to identify the pathophysiologic
variables that have an impact on the use of anesthetic drugs and techniques:
1.2.1. Knowledge of effects on pharmacology of diminished cardiovascular, respiratory,
renal, hematologic, hepatic, and neurologic function.
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1.3. The Family Medicine Resident can apply knowledge in creating anesthetic plans
with respect to anesthetic drugs and techniques:
1.3.1. Knowledge of indications and contraindications, risks and benefits of general
anesthetic techniques.
1.3.2. Knowledge of indications and contraindications, risks and benefits of regional
anesthetic techniques to include central neuraxial blocks.
1.3.3. Knowledge of basic bioethical issues encountered in anesthesia practice
including informed consent.
1.3.4. Demonstrates skill in establishing and maintaining cardiovascular and respiratory
support.
1.4. The Family Medicine Resident will become knowledgeable with respect to the
following general requirements that pertain to the practice of anesthesia:
1.4.1. Administering anesthesia requires knowledge and skills for maintaining and
controlling the cardio respiratory function of patients who are relatively well or for
patients with single or multi-system dysfunction or failure. The person who
administers the anesthetic must know the effects of various pharmacologic
agents on these patients. These skills are necessary during surgical procedures
but are also required in other clinical situations. These skills are particularly
important in non-urban areas, to maximize the care of patients with limited staff.
(a) Pre-Anesthetic Assessment:
It is especially important for the Family-Physician anesthetist to carefully screen
patients pre-operatively to determine their physical status (ASA category) and
suitability for surgery. This allows the practitioner to identify cases that may be
beyond the capabilities of either the anesthetist or the facility. The Family-
Physician anesthetist must be able to recognize which patients require
immediate stabilization and transport to a tertiary care facility. In addition, the
circumstances in which a delay in surgery is advised must also be understood.
The Family-Physician anesthetist must understand the pathophysiology of the
patient's disease process and its relation to anesthesia and surgery and be able
to make use of appropriate examination and laboratory tests, and to
recommend measures to achieve preoperative optimization of the patient's
medical condition.
(b) Airway Control:
The Family-Physician anesthetist should be skilled at the assessment of the
airway, for patency, protection and ease of intubation. Management skills
include bag mask ventilation, laryngeal mask insertion and intubation. Use of
advanced techniques for intubation is also expected.
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(c) Ventilation:
The management of patients requiring a ventilator is necessary for general
anesthesia, short-term care in the rural setting and for care during transport. In
the intensive care setting, the Family-Physician anesthetist must be skilled in
the management of mechanical ventilation, non-invasive and invasive
monitoring and appropriate pharmacotherapy for chronic, acute or emergency
respiratory problems.
(d) Cardiovascular Status:
The cardiac status of the anesthetized patient must be assessed, continually
monitored, and managed with appropriate drug therapy. The Family-Physician
anesthetist must be skilled in acute resuscitation during cardiac arrest.
1.4.2. Administering anesthesia requires general knowledge of the following specific
applications:
(a) Surgical:
To provide anesthesia during surgery the Family Physician-anesthetist must be
able to:
Select a safe and effective anesthetic technique.
Select appropriate invasive or noninvasive monitoring methods and use
additional equipment as required.
Safely conduct intraoperative management.
Effectively manage complications of anesthesia within prescribed limits.
Select and supervise appropriate postoperative management of the
patient
Know when it is appropriate to transfer the care of the patient to another
practitioner.
Use anesthesia equipment and demonstrate an understanding of its
principles and basic maintenance.
Respond to the special needs of specific groups of patients such as
children, pregnant women, geriatric patients, ambulatory patients.
Plan and enact a plan for postoperative pain control.
The GP anesthetist must be able to respond to:
Emergency anesthesia (situations in which the risk of further illness or
death would increase during transportation).
Urgent anesthesia (when the safety of the patient might be compromised
during transportation).
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Elective anesthesia (to maintain surgical/anesthetic support skills for the
convenience of the patient and the community).
(b) Trauma Management:
In the area of trauma management the Family Physician-anesthetist must be
skilled in airway management, cardio respiratory stabilization, insertion of
vascular lines, assessing the status of the patient, evaluating the urgency of
surgery, and ventilation management, as well as in the identification and
management of life-threatening emergency situations.
(c) Obstetrical Anesthesia:
The Family Physician-anesthetist must demonstrate skill in epidural anesthesia
for the management of pain during labour and delivery. In addition provide
regional and if required general anesthesia for Cesarean sections, manage the
complications of pregnancy requiring an anesthetic (spontaneous abortion,
antepartum hemorrhage, premature labour, fetal distress, prolonged second
stage) and be able to provide neonatal resuscitation.
(d) Medical Management:
The Family Physician-anesthetist must be able to demonstrate appropriate
management of acute or chronic cardiac arrhythmias or myocardial infarction;
management of acute or chronic respiratory diseases; short-term ventilation
and the preoperative screening of patients requiring referral to another centre.
(e) Social and Ethical Considerations in the Rural Setting:
The availability of anesthetic and surgical services improves the convenience of
health care in rural communities. In addition, surgery in community hospitals
maintains a base of expertise and skills in rural areas and reduces patient load
in urban centres. The physician's personal responsibility for continuing medical
education and skill development must be instilled during training. All physicians
should be aware of the problems of impairment by fatigue or by chemical
dependence and of the need for quality assurance and peer review.
2. The Family Medicine Resident will become knowledgeable in the following as it
pertains to perioperative anesthesia:
2.1. Performs preoperative risk assessment to identify medical conditions,
institutional limitations or personal limitations requiring appropriate referral of
the patient:
2.1.1. Demonstrates clinical skills in pre-anesthetic assessment with respect to the
airway and bodily systems.
2.1.2. Advises patients re optimization of medical conditions.
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2.1.3. Advises patients of the risks and benefits of the anesthetic plan including plans
for referring the patient.
2.2. Intra-Operative Care:
2.2.1. Creates appropriate anesthetic plans with appropriate monitoring.
2.2.2. Anticipates problems and is capable of managing them.
2.3. Post-Operative Care:
2.3.1. Demonstrates appropriate choices for post-operative management including
management of acute pain to include use of local anesthetic techniques and
intravenous patient controlled analgesia
3. The Family Medicine Resident will become knowledgeable in the following as it
pertains to resuscitation and life support:
3.1. Demonstrates skill in the initial resuscitation (exemplified by resuscitation courses such
as PALS, NALS, ACLS and ATLS).
4. The Family Medicine Resident will become knowledgeable in the following as it
pertains to technical competence in the field of anesthesia:
4.1. Knows the design and function of anesthetic equipment:
4.1.1. Provides expertise to the community related to the acquisition and maintenance
of anesthetic equipment.
4.1.2. Uses components of the gas machine appropriately (anesthesia delivery circuits,
vaporizers, ventilators, scavenging systems).
4.1.3. Uses monitors, airway equipment and vascular access devices appropriately.
4.1.4. Can detect when equipment malfunctions or provides incorrect data.
4.1.5. Demonstrates appropriate use of anesthesia equipment including performance of
pre-anesthetic check of the gas machine according to CAS standards.
4.2. Demonstrates a level of competence acceptable for level of training with respect
to the procedures commonly employed in anesthesia practice:
4.2.1. Demonstrates clinical skills necessary for competent airway management with a
suitable variety of alternate management skills including invasive airway skills.
4.2.2. Demonstrates clinical skills in initiating vascular access and patient monitoring
(non-invasive and invasive), including arterial and central venous line insertion.
4.2.3. Demonstrates clinical skills in performing regional anesthesia/analgesia
techniques to include neuraxial and peripheral nerve blocks.
4.2.4. Demonstrates clinical skills necessary for management of labour analgesia and
anesthesia.
4.2.5. Demonstrates clinical skills necessary for the provision of anesthesia for children,
excluding neonates and infants.
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4.2.6. Demonstrates knowledge and basic clinical skills for outpatient management of
chronic and palliative care pain.
Manager
GP-Anesthesia residents will:
Order appropriate and economical selection of diagnostic and screening tests.
Make referrals effectively.
Demonstrate understanding of roles of all health care providers in the team.
Understand how to mobilize a health care team in an emergency situation.
Demonstrate the ability to make effective diagnostic decisions.
Understand the need and abitlity to assess for risk management, quality assurance and
improvement.
Understand the role of information management in the care of hospitalized patients.
Communicator
GP-Anesthesia Residents will be able to communicate effectively with patients, family members and
members of the health care team:
Demonstrates listening skills.
Demonstrates language skills (verbal, writing, charting).
Demonstrates non-verbal skills (expressive and receptive).
Demonstrates skills in adapting communication appropriately to a patient’s or
colleague’s culture and age.
Demonstrates attitudinal skills (ability to respectfully hear, understand and discuss an
opinion, idea or value that may be different from their own).
Apply these communication skills to facilitate shared and informed decision-making.
Function within a team composed of members from various health care disciplines.
Recognizing situations where a specialist consultation is appropriate, and effectiveness
in communicating the purpose of the referral, the patient’s clinical condition and
pertinent previous medical history.
Collaborator
GP-Anesthesia Residents will be able to collaborate:
Work collaboratively in different models of health care.
Engage patients and families as active participants in their care.
Understand the role of the anesthetist as a teacher and consultant.
Health Advocate
GP-Anesthesia Residents will be able to advocate for the health of patients:
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Acting as an effective patient advocate.
Provides care with patient safety as primary concern.
Employs risk reduction strategies (such as sterile technique when appropriate).
Professional
GP-Anesthesia Residents will have demonstrated professionalism:
Demonstrates (i.e. day to day behaviour) that reassures that the resident is responsible,
reliable and trustworthy.
Identify patients at risk because of social, family or other health situations.
Demonstrate leadership, professional and ethical qualities.
Able to appropriately deal with issues surrounding confidentiality and consent.
Able to identify ethical problems and have an approach to their solution.
Able to demonstrate an understanding of medicolegal issues relevant to professional
activities.
Demonstrates compassion and empathy.
Demonstrates appropriate time management skills.
The resident will demonstrate effective performance in stressful and emergency
situations.
The resident will demonstrate awareness of stress management, fatigue, substance
abuse and quality assurance.
Scholar
GP-Anesthesia Resident will have demonstrated their scholarly proficiencies:
Strategies for lifelong learning and continuing maintenance of professional competence.
Demonstrates self-directed learning based on reflective practice.
Access, critically evaluate and use medical information in health care decisions.
Developed by: Dr. Daniel Grushka, Dr. Jeff Granton & Anesthesia Program Subcommittee
Reviewed: July 2011
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ROYAL COLLEGE OF PHYSICIANS
AND SURGEONS OF CANADA
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Objectives of Training in
Anesthesiology
© 2000 The Royal College of Physicians and Surgeons of Canada. All rights reserved. This document may be reproduced for educational purposes only
provided that the following phrase is included in all related materials: Copyright © 2000 The Royal College of Physicians and Surgeons of Canada. Referenced
and produced with permission. Please forward a copy of the final product to the Office of Education, attn: Associate Director. Written permission from the Royal
College is required for all other uses. For further information regarding intellectual property, please contact: [email protected] . For questions
regarding the use of this document, please contact: [email protected] .
2000
(Please also see the “Policies and Procedures” booklet.)
DEFINITION
Anesthesiology is a medical specialty which includes patient assessment and provision of life
support, amnesia, and analgesia for both surgical procedures and childbirth; assessment and
management of critically ill patients; and the assessment and management of patients with acute
and chronic pain.
GENERAL OBJECTIVES
Upon completion of training, a resident is expected to be a competent specialist anesthesiologist,
capable of assuming a consultant’s role in the specialty. The resident must acquire a working
knowledge of the theoretical basis of the specialty, including its foundations in the basic medical
sciences and research. Training must also encompass the provision of anesthesia services for all
age groups in varied clinical situations. Performance must, therefore, reflect the anesthesiologist’s
knowledge of surgery, intensive care and resuscitation, the management of acute and chronic pain
and includes assessment and provision of appropriate care of the mother and neonate in obstetrics.
The resident must demonstrate a thorough knowledge of how perioperative management should be
modified in the presence of concurrent medical problems.
The resident must also demonstrate the knowledge, skills and attitudes relating to gender, culture
and ethnicity pertinent to Anesthesiology. In addition, all residents must demonstrate an ability to
incorporate gender, cultural and ethnic perspectives in research methodology, data presentation
and analysis.
SPECIFIC OBJECTIVES
At the completion of training, the resident will have acquired the following competencies and will
function effectively as a:
Medical Expert/Clinical Decision-maker
General Requirements:
• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal
opinions.
Objectives of Training in
Anesthesiology
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Objectives of Training in
Anesthesiology
Specific Requirements:
• Demonstrate knowledge of the basic sciences as applicable to anesthesiology, including
anatomy, physiology, pharmacology, biochemistry and physics.
• Demonstrate knowledge of general internal medicine with particular reference to the
cardiovascular, respiratory, renal, hepatic, endocrine, hematologic and neurologic systems.
• Demonstrate knowledge of age related variables in medicine as they apply to neonatal,
pediatric, adult and geriatric patient care.
• Demonstrate knowledge of the principles and practice of anesthesiology as they apply to patient
support during surgery or obstetrics.
• Demonstrate clinical skills necessary for basic resuscitation and life support as practiced in
critical care facilities.
• Demonstrate knowledge of the principles of management of patients with acute and chronic
pain.
• Demonstrate knowledge of the role of the consultant anesthesiologist in the provision of safe
anesthetic services within both community and teaching facilities.
• Demonstrate clinical skills necessary for the independent practice of anesthesiology, including
preoperative assessment, intraoperative support and postoperative management of patients of
any physical status, all ages and for all commonly performed surgical and obstetrical
procedures.
• Demonstrate clinical skills necessary to general internal medicine and intensive care including
the ability to investigate, diagnose, and manage appropriately factors that influence a patient’s
medical and surgical care.
• Recognize that prior to provision of anesthetic care specific medical intervention and
modification of risk factors may be required.
• Demonstrate competence in all technical procedures commonly employed in anesthetic
practice, including airway management, cardiovascular resuscitation, patient monitoring and life
support, general, and regional anesthetic and analgesic techniques and postoperative care.
• Demonstrate knowledge of basic legal and bioethical issues encountered in anesthetic practice
including informed consent.
Communicator
General Requirements:
• Establish a professional relationship with patients and families.
• Obtain and collate relevant history from patients, and families.
• Listen effectively.
• Discuss appropriate information with patients and families and other members of the health
care team.
Specific Requirements:
• Demonstrate consideration and compassion in communicating with patients and families.
• Provide accurate information appropriate to the clinical situation.
• Communicate effectively with medical colleagues, nurses, and paramedical personnel in
inpatient, outpatient, and operating room environments.
• Demonstrate appropriate oral and written communication skills.
© 2000 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
• Ensure adequate information has been provided to the patient prior to undertaking
invasive procedures.
Collaborator
General Requirements:
• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.
Specific Requirements:
• Demonstrate ability to function in the clinical environment using the full abilities of all team
members.
Manager
General Requirements:
• Utilize personal resources effectively in order to balance patient care, continuing education, and
personal activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care, and lifelong learning.
Specific Requirements:
• Demonstrate knowledge of the management of operating rooms.
• Demonstrate knowledge of the contributors to anesthetic expenditures.
• Demonstrate knowledge of the guidelines concerning anesthetic practice and equipment in
Canada.
• Record appropriate information for anesthetics and consultations provided.
• Demonstrate principles of quality assurance, and be able to conduct morbidity and mortality
reviews.
Health Advocate
General Requirements:
• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognize and respond to those issues where advocacy is appropriate.
Specific Requirements:
• Provide direction to hospital administrators regarding compliance with national practice
guidelines and equipment standards for anesthesiology.
• Recognize the opportunities for anesthesiologists to advocate for resources for chronic pain
management, emerging medical technologies and new health care practices in general.
© 2000 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
Scholar
General Requirements:
• Develop, implement, and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Facilitate learning of patients, students, and other health professionals.
• Contribute to the development of new knowledge.
Specific Requirements:
• Develop criteria for evaluating the anesthetic literature.
• Critically assess the literature using these criteria.
• Describe the principles of good research.
• Using these principles, judge whether a research project is properly designed.
Professional
General Requirements:
• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practice medicine ethically consistent with the obligations of a physician.
Specific Requirements:
• Periodically review his/her own personal and professional performance against national
standards.
• Include the patient in discussions concerning appropriate diagnostic and management
procedures.
• Respect the opinions of fellow consultants and referring physicians in the management of
patient problems and be willing to provide means whereby differences of opinion can be
discussed and resolved.
• Show recognition of limits of personal skill and knowledge by appropriately consulting other
physicians and paramedical personnel when caring for the patient.
• Establish a pattern of continuing development of personal clinical skills and knowledge through
medical education.
Revised into CanMEDS format - May 2000
© 2000 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
2006
These training requirements apply to those who begin training on or after July 1st, 2006.
The purpose of the training required under Section 1 of the training requirements is to introduce
and expose the resident to independent responsibility for decisions involving clinical judgment
skills; the further development of an effective and mature physician-patient relationship; and the
achievement of competence in primary technical skills across a broad range of medical practice,
and an understanding of the nature of the relationships between a referring physician and
consultant clinical Anesthesiologist.
MINIMUM TRAINING REQUIREMENTS 1. Five years of approved residency in Anesthesiology. This period must include:
1.1. One year of basic clinical training, which must be completed before approved training begins. Training done during this year can be credited only under Section 1
1.2. Four years of approved training. This period must include:
1.2.1. Two and a half years (30 months) of approved resident training in Anesthesiology.
This period is designated as the primary training for the science and clinical practice of
anesthesiology; required elements of the training must therefore reflect the need to
diversify the experience to enable the resident to fulfill the consultant role. The
following minimum required elements of training may be undertaken as separate
rotations, or interspersed with one another, provided that it can be demonstrated that
experience fulfilling the minimum requirements has been obtained:
1.2.1.1. Adult Anesthesiology (12 months minimum) - including experience in
out-patient surgical management, recognized general and subspecialty
surgical procedures, and associated emergency conditions; an appropriate
combination of general and regional anesthetic experience must be
demonstrable
1.2.1.2. Pediatric Anesthesiology (3 months minimum)
1.2.1.3. Obstetrical Anesthesiology (2 months minimum)
1.2.1.4. Chronic pain management (1 month minimum) incorporating experience in long-term care
1.3. One year of approved resident training in Internal Medicine, to be undertaken preferably
after a year of clinical training in Anesthesiology. This year, in conjunction with the basic
clinical training, is designed to allow the resident to achieve primary skills across a broad
range of medical practice; to develop a mature and effective physician-patient relationship;
to acquire the general medical knowledge necessary to function as a competent consultant in Anesthesiology. Therefore, this year must include:
Specialty Training Requirements in
Anesthesiology
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2010 The Royal
College of Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Education, attn:
Associate Director. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact:
[email protected] . For questions regarding the use of this document, please contact: [email protected] .
Page 184
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Objectives of Training in
Anesthesiology
1.3.1. At least six months of approved resident training in adult Internal Medicine.
Rotations eligible for credit include general internal medicine and/or any combination
of experience in at least two of the following subspecialties: Cardiology, coronary
care, Respirology, Neurology, Hematology, Nephrology, Endocrinology, and Infectious Diseases
1.3.2. At least three months of approved resident training in adult intensive care. In
addition, it is strongly recommended that the acute care experience include broader
elements, such as neonatal/pediatric ICU, coronary care and emergency medicine. A maximum of six months ICU experience is allowed under this section
1.3.3. Up to six months of research done in an approved centre may also be
acceptable for credit in this section, where special arrangements have been made to
include intensive care training under 1.2.1. [Please see Notes on Research or Clinical Pharmacology]
1.3.4. Up to six months of training in an accredited clinical pharmacology program
during the final residency year may be credited under this section, when special
arrangements have been made to include intensive care training under Section 1.2.1 [Please see Notes]
1.4. Six months of training that may include:
1.4.1. Further training in an approved Anesthesiology program
1.4.2. Research experience in a clinical or basic science department approved by the Royal College
1.4.3. Six months training in clinical pharmacology undertaken in an accredited program during the final residency year
1.4.4. Any other course of study and training relevant to the objectives of
Anesthesiology and acceptable to the director of the training program and the Royal
College
NOTES:
Research or Clinical Pharmacology
In appropriate circumstances and upon the recommendation of the program director, to facilitate a
one-year commitment to either an approved research program or an accredited Clinical
Pharmacology program, three months of ICU training may be taken under 1.2.1 of the above
requirements. The six months of research or clinical pharmacology training permitted under
sections 1.3.3, and 1.4.2 for research, and 1.3.4 and 1.4.3 for clinical pharmacology allows the
option of a full year of research or clinical pharmacology within the limitations of the training
requirements. The purpose of this period is to develop subspecialty interests, diversify the
resident’s experience, or address deficiencies in earlier training.
Those who have completed four years residency in Anesthesiology in a non RCPSC program within
a system that has been deemed acceptable to the RCPSC and within acceptable time frames and have:
Specialty Training Requirements in
Anesthesiology
© 2006 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
1. Been in a continuous practice of Anesthesiology for one or more years post certification
2. Maintained continuous enrolment with their certifying authority may fulfill the requirements for 1.3 with one of the following options:
2.1. Additional critical care training, to a maximum of 12 months
2.2. Acceptable training in Pediatrics at a senior level to a maximum of six months credit
2.3. One year of other post graduate clinical training (as outlined in the Policies and
Procedures for Certification and Fellowship under Section IV, Part 1.2.2) in Anesthesiology
2.4. An additional year of acceptable Anesthesiology specialty practice which must be
completed in an accredited, university-affiliated, academic department. The department head of that institution must be asked to complete a FITER as a reference for the candidate
REVISED - 2006
Specialty Training Requirements in
Anesthesiology
© 2006 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
2004 Reviewed 2009
Editorial Revision 2012
INTRODUCTION
A university wishing to have an accredited program in Anesthesiology must also sponsor accredited
programs in Internal Medicine, Obstetrics and Gynecology, Pediatrics and General Surgery.
The purpose of this document is to provide program directors and surveyors with an interpretation
of the general standards of accreditation as they relate to the accreditation of residency programs
in Anesthesiology. This document should be read in conjunction with the General Standards of
Accreditation, the Objectives of Training and Specialty Training Requirements in Anesthesiology.
STANDARD B1: ADMINISTRATIVE STRUCTURE
There must be an appropriate administrative structure for each residency program.
Please refer to Standard B1 in the General Standards of Accreditation for the interpretation of this
standard.
STANDARD B2: GOALS AND OBJECTIVES
There must be a clearly worded statement outlining the goals of the residency program
and the educational objectives of the residents.
The general goals and objectives for Anesthesiology are outlined in the Objectives of Training and
Specialty Training Requirements in Anesthesiology. Based upon these general objectives each
program is expected to develop rotation specific objectives suitable for that particular program, as
noted in Standard B2 of the General Standards of Accreditation.
STANDARD B3: STRUCTURE AND ORGANIZATION OF THE RESIDENCY PROGRAM
There must be an organized program of rotations and other educational experiences,
both mandatory and elective, designed to provide each resident with the opportunity to
fulfill the educational requirements and achieve competence in Anesthesiology.
Residents must be provided with increasing individual professional responsibility, under appropriate
supervision, according to their level of training, ability and experience.
The structure and organization of each accredited program in Anesthesiology must be consistent
with the specialty training requirements as outlined in the Objectives of Training and the Specialty
Training Requirements in Anesthesiology.
Specific Standards of Accreditation for
Residency Programs in Anesthesiology
© 2009 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2009 The
Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of
Education, attn: Associate Director. Written permission from the Royal College is required for all other uses. For further information regarding intellectual
property, please contact: [email protected] . For questions regarding the use of this document, please contact: [email protected] .
Page 187
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Objectives of Training in
Anesthesiology
Specific Standards of Accreditation for
Residency Programs in Anesthesiology
In addition to offering the components noted in the specialty training requirements, all accredited
programs in Anesthesiology must offer an elective community-based learning experience.
STANDARD B4: RESOURCES
There must be sufficient resources including teaching faculty, the number and variety
of patients, physical and technical resources, as well as the supporting facilities and
services necessary to provide the opportunity for all residents in the program to
achieve the educational objectives and receive full training as defined by the Royal
College specialty training requirements.
In those cases where a university has sufficient resources to provide most of the training in
Anesthesiology but lacks one or more essential elements, the program may still be accredited
provided that formal arrangements have been made to send residents to another accredited
residency program for periods of appropriate prescribed training.
Learning environments must include experiences that facilitate the acquisition of knowledge,
skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to
Anesthesiology.
1. Teaching Faculty
a. There must be a sufficient number of qualified and dedicated teaching staff to supervise
residents at all levels and in all aspects of Anesthesiology and provide teaching in the basic
and clinical sciences related to Anesthesiology.
b. There must be an adequate number of qualified teaching staff to provide for training in
regional anesthesia and analgesia, diagnostic and therapeutic nerve blocks, and the
management of pain.
c. There must be a faculty member whose responsibility it is to facilitate the involvement of
residents in research.
2. Number and Variety of Patients
There must be a sufficient number and variety of patients available to the program to provide each resident
registered in the program with the opportunity to meet the following specific objectives:
a. to permit residents to be exposed to the provision of Anesthesiology services across all
age groups and over the full range of surgical, interventional, and diagnostic specialties
including Cardiac Surgery, General Surgery, major head and neck surgery, multiple
trauma, Neurosurgery, Obstetrics and Gynecology, Orthopedic Surgery, Ophthalmology,
Otolaryngology, Plastic Surgery, Thoracic Surgery, Urology, and Vascular Surgery;
b. to provide for training in regional anesthesia and analgesia, diagnostic and therapeutic
nerve blocks, and the management of pain;
© 2009 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
Specific Standards of Accreditation for
Residency Programs in Anesthesiology
c. to provide a broad experience for residents in consultations on the perioperative
management of patients of all ages and physical status, in both elective and emergency
situations, and in the fields of cardiorespiratory support and pain relief;
d. to provide experience in internal medicine and those subspecialties of particular importance
to the Anesthesiologist. These may include Cardiology, Respirology, Neurology,
Hematology, Nephrology, Endocrinology and Metabolism, Infectious Diseases, and Palliative
Care. e. to provide opportunity for residents to manage critically ill patients in a variety of critical
care settings embracing adult, pediatric and perinatal patients, including those who have
sustained multiple trauma;
f. to provide broad training in anesthesiology for emergency operations of a major nature;
g. to provide training in the anesthetic management of patients for ambulatory surgery. 3. Clinical Services Specific to Anesthesiology
a. In-patient Services
There must be:
- well equipped and adequately staffed operating and recovery rooms;
- an accredited residency program in internal medicine and a liaison which ensures that
rotations arranged for Anesthesiology residents are appropriately structured;
- an Anesthesiology consultation service which provides clinical risk assessment and
perioperative management of patient in both elective and emergency situations;
- a consultation service and facilities for the management of chronic pain;
- intensive care units organized for teaching with an appropriate level of responsibility
under expert supervision, where constant attention is paid to the particular educational
needs of the resident in Anesthesiology;
- ready access to appropriate laboratory facilities.
There should be:
- a consultation service and facilities for the management of acute pain. b. Ambulatory Services
There must be:
- facilities for ambulatory surgery;
- a consultation service or clinic for the preoperative assessment of patients for
ambulatory surgery and same-day admission.
c. Community Experiences
Each accredited program in anesthesiology must offer an elective opportunity for each
resident to have experience in Anesthesiology as practiced in a community hospital.
© 2009 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
STANDARD B5: CLINICAL, ACADEMIC AND SCHOLARLY CONTENT OF THE PROGRAM
The clinical, academic and scholarly content of the program must be appropriate for
university postgraduate education and adequately prepare residents to fulfill all of the
CanMEDS Roles of the specialist. The quality of scholarship in the program will, in part,
be demonstrated by a spirit of enquiry during clinical discussions, at the bedside, in
clinics or in the community, and in seminars, rounds, and conferences. Scholarship
implies an in-depth understanding of basic mechanisms of normal and abnormal states
and the application of current knowledge to practice. Please refer to Standard B5 in the General Standards of Accreditation, the Objectives of Training,
the Specialty Training Requirements in Anesthesiology, and the CanMEDS Framework for the
interpretation of this standard. Each program is expected to develop a curriculum for each of the
CanMEDS roles, which reflects the uniqueness of the program and its particular environment.
Specific additional requirements are listed below. 1. Medical Expert In addition to the General Standards of Accreditation, the following requirements apply: The academic program must include organized teaching in the basic and clinical sciences relevant
to anesthesiology. This program must include the following areas within the knowledge domain as
a minimum:
- basic sciences as applicable to anesthesiology including anatomy, physiology,
pharmacology, biochemistry and physics;
- internal medicine with particular reference to the cardiovascular, respiratory, renal,
hepatic, endocrine, hematologic and neurologic systems;
- physics and mechanics of anesthetic and ventilatory equipment as well as its care and
maintenance;
- preoperative evaluation of patients for anesthesia and surgery;
- local, regional and general anesthesia for all surgeries and procedures;
- postoperative management of surgical patients including the control of acute post-
operative pain;
- critical care medicine and cardiopulmonary resuscitation;
- chronic pain.
2. Communicator The General Standards of Accreditation apply to this section. 3. Collaborator The General Standards of Accreditation apply to this section. 4. Manager In addition to the General Standards of Accreditation, the following requirements apply:
Specific Standards of Accreditation for
Residency Programs in Anesthesiology
© 2009 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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Objectives of Training in
Anesthesiology
- Residents must be given opportunities to develop skills in management as applied to
Anesthesiology such as efficient practice and record management, the ethical use of
health care resources and operating room management.
5. Health Advocate
The General Standards of Accreditation apply to this section.
6. Scholar
The General Standards of Accreditation apply to this section.
7. Professional
The General Standards of Accreditation apply to this section.
STANDARD B6: EVALUATION OF RESIDENT PERFORMANCE
There must be mechanisms in place to ensure the systematic collection and
interpretation of evaluation data on each resident enrolled in the program.
Please refer to Standard B6 in the General Standards of Accreditation for the interpretation of this
standard.
Adopted by Council - April 8, 1995 Revised – March 2004 Specialty name change – March 1, 2006 Editorial Revision - June 2012
Specific Standards of Accreditation for
Residency Programs in Anesthesiology
© 2009 The Royal College of Physicians and Surgeons of Canada. All rights reserved.