Specific Educational Goals and Education

Level: PGY-2

Service: Trauma / Critical Care

Supervision: PGY-2 → PGY-3 → PGY-4 → Attending

All management decisions will be discussed with the senior residents and faculty.

Duty Hours:

Hours are to be logged into GMEOne on a weekly basis and will be reviewed weekly by the Program Director for ACGME violations and reviewed weekly for delinquencies by the Program Coordinator. Over a four week period; you will not average more than 80 hours a work week, you will have one day in seven free of clinical duty, in-house call will be no more frequent than one in three nights, you should receive 10 hours free between all duty periods and after in-house call and you will not be on duty for more than 30 consecutive hours. If you are assigned more hours than mentioned heretofore or have patient care duties that are extending you beyond these limits, it is your responsibility to notify your supervising resident or faculty so arrangements can be made to relieve you.

Educational Activities:

  1. Recommended Reading
    1. Schwartz's Principles of Surgery
    2. SCORE curriculum modules
    3. ATLS Manual
  2. Conferences
    1. Wednesday Resident Educational Curriculum

Competency Based Performance Objectives:

Patient Care:

Goal: Demonstrate the ability to effectively manage the surgical care of a patient with complex multisystem injuries, demonstrate knowledge of, and the ability to, manage a variety of healthcare services for trauma patients such as pre-hospital transportation, emergency department care, in-hospital care, and rehabilitation. Demonstrate the ability to appropriately diagnose and treat patients with interrelated system disorders in the intensive care unit.

Objective: The resident will be able to:

  1. Complete an ACLS and an ATLS course
  2. Participate in trauma evaluation, resuscitation, operative management, and intensive care unit (ICU) supervision of a multiply-injured patient.
  3. Provide initial evaluation and management of the critically-ill post-operative patient.
  4. Institute the following therapeutic interventions:
    1. Manage fluid orders
    2. Determine ventilator settings
    3. Order pharmacologic support drugs
    4. Determine the need for and duration of antibiotic therapy
  5. Serve on trauma team.
  6. Manage critically ill patients in the intensive care unit:
    1. Determine need for ventilation and select situation appropriate airway and initial ventilator settings
    2. Compute initial and ongoing fluid requirements
    3. Analyze need for operative intervention
    4. Initiate rehabilitation process after stabilization of injuries, including:
      1. Attention to possible altered body habitus
      2. Requirements for special devices (physical, occupational, or speech therapy)
      3. Maintain nutritional status
      4. Provide support, interaction, and information for the family
    5. Determine need for ongoing ICU management
    6. Identify appropriate antibiotic therapy distinguishing between prophylactic, empiric, and therapeutic uses
    7. Monitor hemodynamic data
  7. Perform the following procedures:
    1. Endotracheal intubation
    2. Thoracostomy tube
    3. Central venous and pulmonary artery catheter insertion
    4. Intra-arterial catheter
  8. Apply and remove all types of dressings and splints, including the vacuum pack dressing.
  9. Make and close a variety of incisions and tie knots using sterile techniques.
  10. Direct the evaluation of an acutely-injured patient to include resuscitation and the decision for operation.
  11. Assess nutritional needs and institute necessary nutritional support.
  12. Formulate rehabilitation plans for trauma patients.
  13. Perform basic surgical procedures such as:
    1. Laparotomy
    2. Wound debridement
    3. Application of traction devices for both head and extremities
  14. Perform the following procedures:
    1. Nasotracheal intubation, nasogastric and bladder intubation
    2. Arterial catheter insertion
    3. Central venous and pulmonary artery catheter insertion
    4. Placement of tube thoracotomy
    5. Cricothyrotomy
    6. Pericardiocentesis
    7. Monitor hemodynamic data

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate an understanding of the pathophysiologic effect of blunt and penetrating trauma.  Demonstrate knowledge of the principles associated with management of critically ill patients.

Objectives: The resident will be able to:

  1. Describe the anatomy, and physiology of all body systems affected by trauma, including the initial functional evaluation of the:
    1. Central nervous system
    2. Cardiovascular system
    3. Pulmonary system
    4. Gastrointestinal system
    5. Genitourinary system
    6. Extremity function
    7. Nutritional status
  2. Review the anatomy, physiology, and pathology applicable to the general management of trauma patients, including:
    1. Central nervous system
    2. Musculoskeletal system
    3. Hand/forearm
    4. Ear, nose, and throat
    5. Ophthalmology
  3. Outline the basic techniques of evaluation and resuscitation of trauma patients using the American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) protocol.
  4. Specify the trauma services needed for initial evaluation and resuscitation in the hospital setting.  Categorize appropriate pre-hospital or emergency medicine system levels of car
  5. Discuss wound care management in the emergency department and other settings. Outline the management of the following drains and tubes: nasogastric tube (NGT), urinary bladder catheter, chest tube (CT), central venous line (CVL), arterial line (AL).
  6. Explain the characteristics of basic surgical skill, including:
    1. Sterile technique
    2. Incisions
    3. Wound closures
    4. Knot tying
    5. Handling of tissues
    6. Selection/use of operating instruments
    7. Universal precautions
  7. Discuss the management of trauma involving the musculoskeletal system, including the need for casts, splints, and traction.
  8. Summarize basic critical care management principles.
  9. Analyze pharmacological support for trauma, resuscitation, and intensive care unit patients.
  10. Identify the management principles for a trauma patient in the intensive care unit.
  11. Outline the factors associated with rehabilitation as they apply to initial and early patient car.
  12. Discuss the indications for, and the provision of, nutritional support for elderly patients sustaining trauma.
  13. Outline the indications for such basic surgical procedures as:
    1. Laparotomy
    2. Debridement of injured tissues
    3. Ultrasound
    4. Splinting
    5. Thoracotomy/thoracostomy
    6. Hemorrhage control
  14. Discuss the primary causes/mechanisms of injury in the following list that contribute to making trauma the fifth leading cause of death in those aged 65 and older:
    1. Falls
    2. Motor vehicle crashes
    3. Pedestrian injuries
    4. Burns
    5. Domestic abuse
  15. Administration
    1. Define and describe the role of the surgeon in the critical care setting to include these aspects:
      1. Unit administration/management (surgeon as unit director)
        1. Triage of patients
        2. Economic concerns
        3. Data collection and computer usage
        4. Infection control and total quality management (TQM) issues
        5. Ethical concerns (consent, durable power of attorney, living wills)
        6. Local laws for referral to Medical Examiner
      2. Management/consultation for specific surgical conditions
      3. Coordination of multidisciplinary consultants relating and interpreting information between non-surgical consultant
    2. Identify and outline criteria for admitting patients to the intensive care unit (ICU) to include:
      1. Medical indications (related to specific diseases, e., pulmonary, cardiac, renal)
      2. Surgical indications directly related to specific surgical illness
    3. Identify and outline criteria for discharging patients from the ICU, to include:
      1. Medical indications
      2. Surgical indications
      3. Patients unacceptable for ICU (e., futile care, do not resuscitate [DNR] orders)
    4. Identify and explain the considerations surgeons must make when working with consultants in managing critical care situations.
    5. Identify potential Organ, Tissue Donor candidates, as well as the hospital specific procedure for contacting families for potential donation.
  16. General Pathophysiology--Body as a Whole
    1. Describe the normal physiologic response to a variety of insults such as sepsis, trauma, or surgery by associating the adaptation of the following systems from their pre-stress to post-stress states:
      1. Respirator
      2. Hemodynamic
      3. Renal
      4. Metabolic
      5. Endocrine
    2. Describe the concept of the Systemic Inflammatory Response Syndrome (SIRS).
    3. Describe prophylactic measures routinely used in critical care such as:
      1. Gastrointestinal (GI) bleeding prophylaxis, including neutralizing, inhibitory compounds, and surface agents
      2. Prophylactic antibiotics (demonstrate differences between true prophylaxis, empiric and therapeutic uses)
      3. Pulmonary morbidity prophylaxis (incentive spirometry)
      4. Prophylaxis against venous thromboembolic events
      5. Aseptic technique
      6. Universal precautions
      7. Skin care protocols
      8. Guidewire catheter changes for work-up of fever or change in clinical status
    4. Discuss the pharmacotherapeutics of drugs used for support and treatment of the critically ill patient with emphasis on 1) mode of action, 2) physiologic effects, 3) spectrum of effects, 4) duration of action, 5) appropriate doses, 6) means of metabolism or excretion, 7) complications, and 8) cost:
      1. Vasopressors
      2. Vasodilators
      3. Inotropic agents
      4. Bronchodilators
      5. Diuretics
      6. Antibiotics/antifungal agents
        1. Distinguish between empiric, therapeutic, and prophylactic
        2. Demonstrate knowledge of classes of anti-infectives
      7. Antidysrhythmics
      8. Antihypertensives
        1. Predict applicability of different classes in a particular situation:
        2. Use of beta blockers in hypertensive tachycardic patient
        3. Use of ace inhibitors in hypertensive patient with congestive heart failure
        4. Use of calcium channel blockers in hypertensive patient with angina
    5. Outline the indications and methods for providing nutritional support by completing the following activities:
      1. Understand the indications, selection of formulations, cost, route of administration of parenteral versus enteral forms of nutrition
      2. Explain complications of parenteral and enteral routes of feeding as well as select methods to avoid the complications
      3. Interpret findings associated with abnormalities in levels of glucose, chloride, sodium, phosphate, magnesium, trace metals/elements, and vitamins in the critically-ill patient receiving enteral or parenteral feedings; prepare recommendations for elderly patients under these same conditions
      4. Estimate protein calorie requirements for patients of varying degrees of illness, and be able to analyze adequacy of nutritional support using commonly obtainable laboratory values
    6. Outline the principles of post-operative fever with respect to causes, empiric diagnostic modalities, and specific therapy. How useful are these principles when considering the elderly patient?
    7. Describe, apply, and revise appropriate treatment interventions based upon analysis of changes in the patient's clinical and laboratory parameters:
      1. Adjustment of intravenous fluids with respect to expected stress response, including metabolic, hormonal, cardiovascular, and renal responses to replacement of fluid losses (Describe association between high levels of stress hormones and alterations of glucose metabolism remembering: do not volume resuscitate patients with excessive amounts of glucose)
      2. Efficacy of prophylactic measures for PE, stress ulceration and infection
      3. Adequacy of nutritional support in a patient with multiple sites of protein losses (e., fistulas, drain sites, or metabolic stressors [infection, acute lung injury {ALI}, hyperthermia, respiratory failure])
      4. Analysis and treatment of post-operative fever and methods of treatment
      5. Events leading to and responsible for initiation of ventilatory support
      6. Differentiate low cardiac output, hypotensive/hypertensive states in terms of preload, pump, or afterload
      7. Analysis and treatment of seizures or acute change in mental status, including the role of:
        1. ABC's (airway, breathing, circulation); draw electrolytes/blood-urea-nitrogen (BUN)/ creatinine/glucose/calcium, magnesium
        2. Glucose/thiamine intravenously
        3. Evaluate medication record for new drugs or interactions (Ativan, Versed, phenobarbital, Dilantin [not applicable in the acute event])
    8. Analysis and treatment of acute respiratory failure from changes in the airway, pump, or lung
    9. Review the management and diagram a plan for the care of the critically ill surgical patient with multiple medical problems such as:
      1. Cardiac dysrhythmias
      2. Pulmonary insufficiency from airway, bellows (pump), or parenchymal problems
      3. Acute/chronic renal failure with hemodynamic instability or need of specific fluid therapy (TPN), renal replacement therapy, high output GI fistulas
      4. Diabetes mellitus and its special problems in the realm of nutritional support
      5. Hemodynamic instability in the face of acute/chronic renal or pulmonary insufficiency
  17. Airway-Respiration
    1. Describe the commonly used indications for initiation of ventilation support, including:
      1. Indications and commonly acceptable values for initiation of mechanical ventilation
      2. Evaluation of airway
      3. Evaluation of adequacy of thoracic pump (muscle strength)
      4. Evaluation of lung parenchymal characteristics (arterial blood gases and chest x-ray)
      5. Analysis of commonly used pulmonary values (e., tidal volume [Vt], maximum ventilatory volume [MVV], compliance static and dynamic, functional residual capacity [FRC], PEEP, auto PEEP, airway pressures)
      6. Indications and commonly acceptable values for weaning from mechanical ventilation
    2. Review respiratory physiology, and describe the specific pathology involved in ventilation and perfusion deficits.
    3. Discuss the association of airway obstruction with age, giving consideration to each of the following:
      1. Repeated disruption of the balance of inflammatory mediators and humoral protection (elastase and antielastase, oxidant and antioxidant)
      2. Neutrophil recruitment
      3. Tissue repair culminating inflammatory lung destruction
      4. Accumulated environmental oxidant injuries
    4. Analyze and compare the principles of ventilator mechanics, including modes of ventilation, triggering mechanisms, and possible uses.
    5. Describe the pathophysiology of acute lung injury (ALI, with spectrum from mild to severe ALI, also known as ARDS) and the management of the long-term ventilator-dependent patient to include:
      1. Pneumonias (aspiration or nosocomial)
      2. Acute renal failure
      3. Cardiac failure
      4. Prevention of malnutrition or restitution of body stores
      5. Systemic Inflammatory Response syndrome (SIRS, MODS - Multiple Organ Dysfunction Syndrome the most severe form known as MSOF - Multi-System Organ Failure)
      6. Sepsis
      7. vii. Skin care problems
      8. viii. Physical therapy (maintenance of muscle mass and function, prevention of contractions)
      9. ix. Psychological support for both patient and family
    6. Review management of the following complex respiratory problems:
      1. Mechanically ventilated patient with:
        1. Areas of differing compliance
        2. ARDS
        3. Borderline cardiac reserve (non-compliant left ventricle, recent myocardial infarction, valvular dysfunction)
    7. Explain why otherwise healthy elders may be more vulnerable to poor outcomes from diseases affecting diffusion (producing lower oxygen levels, e., pneumonia, COPD). Consider these factors in your explanation:
      1. Heart rate
      2. Ventilatory response to hypoxia
      3. Ventilatory response to hypercapnia
    8. Analyze the pros and cons of the use of the following drugs to improve respiratory function:
      1. Bronchodilators (aerosols vs. parenteral medications)
      2. Membrane stabilizing agents (cromolyn sodium, steroids)
      3. Diuretics Venodilators
      4. Analgesics and sedatives
      5. Mucolytics
  18. Circulation
    1. Describe and compare the following cardiac function parameters:
      1. Preload
      2. Afterload
      3. Myocardial contractility
    2. Define the information obtained from the use of the following invasive/non-invasive monitoring devices. Specify:
      1. which information is directly/indirectly measured or calculated, 2) the accuracy and 3) cost of obtaining the information, and 4) review the hemodynamic principles associated with the use of each device:
        1. Arterial catheters
        2. Central venous catheters
        3. Swan-Ganz catheters
        4. Intracranial pressure monitors
        5. End tidal carbon dioxide monitors
        6. Pulse oximetry
        7. Peripheral nerve stimulators (for testing adequacy of neuromuscular blockade)
        8. Foley catheters
        9. Intestinal pH monitors
        10. Bioelectric impedance
    3. Outline the protocols for definition of patterns and management of hemodynamically unstable patients, and analyze the selection of appropriate therapy by completing these activities:
      1. Predict improvements in hemodynamic status with manipulation of definable variables, including fluid and drug therapies.
      2. Detect and revise therapies based on the use of invasive/non-invasive monitoring devices.
    4. Review cardiac function and hemodynamic monitoring from the following standpoints. Interpret changes in accuracy of values obtained from hemodynamic monitoring devices in:
      1. Patients with severe pulmonary insufficiency who have low compliances or high PEEP
      2. Patients with severe valvular insufficiency/stenosis
      3. Various shock states (hypovolemic, septic, spinal, or cardiogenic)
      4. High dose vasopressors
    5. Summarize the effects of appropriate volume and drug therapies to manipulate the cardiovascular system in the following patients:
      1. Hypovolemic hypotensive patient
      2. Hypotensive euvolemic patient
      3. Hypotensive hypervolemic patient
      4. Hypotensive oliguric patient
      5. Hypotensive, hypervolemic oliguric patient
      6. Hypovolemic oliguric patient
      7. vii. Hypotensive, oliguric hypoxic patient
    6. Discuss the significant patient characteristics in a geriatric population associated with increased risk of thromboembolic disease, including:
      1. Underlying congestive heart failure
      2. Prolonged immobility before surgery
      3. Paralysis
      4. Previous DVT
      5. Hypercoagulable states (due to malignancy or coagulation factor deficiency)
  19. Renal
    1. Review acid-base and electrolyte abnormalities common in critically-ill patients.
    2. Identify, define, and classify the major categories of acid-base disturbance (metabolic acidosis and/or alkalosis, respiratory acidosis and/or alkalosis) in the context of the patient's altered physiology. Cite common clinical scenarios for their appearance:
      1. Metabolic acidosis (hypovolemic shock, chloride excess resuscitation, occult ischemia)
      2. Metabolic alkalosis (contraction alkalosis excessive diuretic use)
      3. Respiratory acidosis
      4. Respiratory alkalosis (early sign of sepsis vs. ventilator complication)
    3. Discuss the identification and correction of complex acid-base problems such as choice of intravenous fluids for electrolyte replacement in the:
      1. Hyperchloremic, metabolically-acidotic patient
      2. Hypochloremic, metabolically-alkalotic patient
      3. Stuporous, dehydrated, hyponatremic patient
      4. Stuporous dehydrated hypernatremic patient
      5. Patient with central diabetes insipidus
      6. Hyponatremic, volume overloaded patient with carbon dioxide retention
  20. Neurologic
    1. Describe the initial evaluation, ongoing, acute monitoring and long-term management of possible neurologic or behavioral abnormalities occurring in the ICU setting:
      1. Seizures
      2. Coma
      3. Stroke
      4. Multifactorial effects of post-operative confusion
      5. Delirium
    2. Brain death
  21. Gastrointestinal/Hepatic
    1. Discuss specific fluid compositions and the effect of the losses of such fluids as gastric, pancreatic, biliary, and succus entericus from intestinal fistulas of various levels. (Fluid should be described in terms of volume, electrolyte composition, and replacement fluid of choice).

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for trauma procedures

Objectives: The resident will demonstrate the ability to obtain informed consent, outlining the risks and benefits

Goal: Communicate effectively to discharge patients after surgery.

Objectives: The resident will demonstrate the ability to instruct patients regarding monitoring for trauma complications:

Goal: Communicate effectively as a member of the healthcare team.

Objectives: The resident will demonstrate the ability to communicate effectively by:

  1. Providing appropriate check out when handing patients to another team member
  2. Requesting consults from other services with appropriate information
  3. Dictating operative reports in a timely fashion

Professionalism:

Goal: Maintain patient confidentiality

Objectives: The resident will demonstrate

  1. The ability to protect health-related patient information per HIPAA compliance
  2. List and be aware of sites in the hospital and clinic where loss of privacy for the patient may occur

Goal: Maintain appropriate professional relationships

Objectives: The resident will demonstrate professional interactions with:

  1. Medical students
  2. Nursing and support staff
  3. Supervising faculty
  4. Consulting residents
  5. Physician peers
  6. Patients and their families

Practice-Based Learning and Improvement

Goal: Identify personal and practice improvement strategies

Objective: The resident will demonstrate:

  1. Receptiveness to faculty instruction and feedback
  2. Ability to use medical information with the ability to access information through traditional and online sources to support their educational experience

Goal: Use medical evidence to evaluate trauma practices

Objective: The resident will demonstrate the ability to:

  1. Discuss studies regarding trauma surgery

Systems-Based Practice

Goal: Provide safe patient care

Objective: The resident will:

  1. Attend Crew Resource Management courses as required by the hospital
  2. Follow recommended protocols in the OR for patient safety
  3. Demonstrate compliance with Medical Center policy for surgical site identification
  4. Demonstrate compliance with Medical Center policy for patient identification

Duties/Responsibilities:

  1. Serve as PGY-2 on the trauma service
  2. Appropriate, professional supervision of student teaching in light of educational goals
  3. Attend clinic as assigned
  4. Manage OR patients with supervision
  5. Assist with consultations to the trauma service as assigned by the Attending
  6. Round on post surgical service patient's as instructed.
  7. Attend educational conferences
  8. Complete surgical case logs
  9. Dictate in a timely fashion
  10. Take night call as assigned

Evaluation:

  1. Performance feedback will be given to the resident as appropriate for educational events and mid-term progress will be discussed.
  2. Global evaluation will be performed by the trauma attending physicians at the completion of each rotation. Surgical case logs will be evaluated for the appropriate number and breadth of procedures and will be present in the resident's portfolio to be reviewed at the Program Evaluation meeting held twice yearly.
  3. At the completion of this rotation, the resident is required to complete a rotation evaluation form assessing the quality of the rotation. The resident should also address the teaching undertaken by the attending physicians on the rotation at the conclusion of this rotation.

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