Specific Educational Goals and Education

Level: PGY-4

Service: Trauma / Critical Care

Supervision: PGY-4 → Attending

All management decision will be discussed with the 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. Coordinate EMS activities for initial trauma management to include instructional programs.
  2. Manage penetrating wounds through understanding the injury potential of wounding mechanisms.
  3. Provide management for pre-existing disease states in injured patients with appropriate consultation.
  4. Perform all operative and management procedures for trauma to the chest, abdomen, extremities, and head with direct supervision.
  5. Supervise central line placement, cricothyrotomy, CT, DPL, and ultrasound by junior house staff
  6. Direct rehabilitation plans with appropriate consultation.
  7. Organize hospital resources to provide services for trauma patients and direct patient flow in the emergency department, the operating room, and the intensive care unit.
  8. Provide appropriate referrals for vocation rehabilitation, nursing home services, and physical rehabilitation.
  9. Triage multiple trauma victims.
  10. Practice the principles of damage control surgery in severely-injured patients.
  11. Direct all surgical management of patients in the ICU, including taking direct responsibility for admission and discharge
  12. Manage invasive monitoring catheters, interpret the data obtained, and manipulate the hemodynamic variables toward calculated goals.
  13. Manage the following situations:
    1. Multiple organ system failure; providing support for failing, failed, or normal organs
    2. Life threatening surgical infections (, ascending cholangitis, ascending myonecrosis or gangrene)
    3. Hypovolemic shock
    4. Renal failure
    5. Nutritional failure
    6. Liver failure
  14. Place emergency transvenous/transthoracic access for cardiac pacing.
  15. Perform emergency thoracotomy.
  16. Manage the nutritional and metabolic components of the patient's illness.
  17. Serve on code and trauma teams as a team leader.
  18. Construct a caregiver assessment to include caregiver preparedness, needs, and signs of strain. Consider caregiver emotional support and actual physical care of the patient. Consider special needs of the elderly patient.

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate an understanding of the pathophysiologic effect of blunt and penetrating trauma

Objectives: The resident will be able to:

  1. Explain trauma preventive measures, both medical and legal (, the use of helmets and seat belts).
  2. Describe and explain the mechanics/ballistics associated with various wounding agents.
  3. Discuss the management of associated medical conditions seen in the trauma patient such as diabetes, chronic obstructive pulmonary disease, hypertension, coronary artery disease, and HI
  4. Identify the indications for emergency operative procedures such as burr holes, cricothyrotomy, insertion of cardiopulmonary assist devices, and resuscitative thoracotomy.
  5. Formulate a plan for rehabilitation to return the trauma patient to full functional life.
  6. Define abdominal compartment syndrome.  Describe how to measure intra-abdominal pressures and develop a treatment plan to treat abdominal compartment syndrome.
  7. Define Damage Control Surgery. Describe the sequence of damage control surgery in the treatment of the traumatized patient.
  8. Analyze the transfer of a patient to an appropriate facility utilizing air medical services.
  9. Discuss the availability and use of institutional and community support services for trauma patients such as social work, home health care, and vocation rehabilitation (physical and occupational therapy).
  10. Discuss the management of a trauma service, including the training of its members in emergency medicine services, emergency department, operating room, intensive care, and rehabilitation.
  11. Outline the economic impact of the following aspects of patient care:
    1. Vocational rehabilitation
    2. Nursing homes
    3. Insurance
    4. Diagnostic-related groups (DRG's) associated with management of trauma
    5. Billing and coding
    6. Managed care
  12. Administration
    1. Describe the criteria for predicting pre-operatively the patient's need for critical care, including:
      1. Pre-existing disease states (cardiac, pulmonary, or renal)
      2. Operation-specific requirements for post-operative intensive care management
    2. Review and interpret the relationships of physicians, nurses, and administrators in managing patients assigned to the ICU.
    3. Discuss the value of an interdisciplinary approach to health care for the critically ill, elderly surgical patient. Include consideration of these groups/disciplines, working together:
      1. Surgery Pharmacy
      2. Nursing staff Religion
      3. Family-friends as caregivers Social work
      4. Physical therapy ix. Hospital administration
      5. Medical consultants
    4. Identify new modes of intensive care therapeutics by completing the following activities:
      1. Predict and analyze the need for a new technology.
      2. Formulate a plan for the institution of new technologies or therapeutics.
      3. Critique and revise applicability of new technologies or therapeutics on a cost: benefit ratio.
    5. Summarize the following moral and ethical problems encountered in the ICU:
      1. The need for organ donation and the identification of potential donors
      2. Decisions about whom to resuscitate and to what degree
      3. Care for the mentally incapacitated or incompetent patient
      4. Dealing with a difficult family and futility of care
    6. Identifying and interacting with alternate religious/cultural beliefs
  13. General Pathophysiology--Body as a Whole
    1. Discuss the use of sepsis severity scores.
    2. Distinguish between the major characteristics of septic shock and hypovolemic shock:
      1. Summarize initial evaluation and presentation
      2. Analyze therapeutic options
      3. Revise therapeutic options based on clinical parameters obtained from monitoring devices
    3. Explain the concepts of tissue oxygen supply and demand.  Demonstrate the contributions from the following components:
      1. Calculate oxygen delivery
      2. Calculate oxygen consumption
      3. Analyze the effect of cardiac output and varying preload, pump, and afterload to oxygen delivery
      4. Analyze the contributions of hemoglobin and percent of saturation on oxygen delivery
      5. Explain the changes in tissue oxygen delivery and uptake related to pH, temperature, 2, 3-diphosphoglyceride (DPG)
    4. Discuss the evaluation and treatment of the following bleeding disorders:
      1. The role of blood vessels, platelets, fibrin cascade, and degeneration in normal hemostasis
      2. Disseminated intravascular coagulopathy (DIC), defining common causes and therapy
      3. Thrombocytopenia as a failure of production, accelerated destruction, or dilution
      4. Hemophilia A
      5. Von Willebrand's disease
      6. Idiopathic thrombocytopenia purpura (ITP) and thrombotic thrombocytopenia purpura (TTP) as causes of thrombocytopenia (compare and contrast)
      7. Heparin or Coumadin therapy misapplication
      8. Advanced liver disease
      9. The role of Protein C, S, and lupus circulating anticoagulant and their roles in bleeding disorders
    5. Outline the unique problems of the following surgical subspecialties in critical care management:
      1. Neurosurgery
      2. Urology
      3. Orthopedics
      4. Pediatric surgery
      5. Cardiac surgery
      6. Thoracic surgery
      7. Burns
      8. Trauma
    6. Discuss management of the overall hospital course of the patient with altered physiologic states:
      1. Pre-operative considerations specific to their disease
      2. Operative considerations specific to their disease
      3. Post-operative considerations specific to their disease
    7. Outline the nutritional and metabolic components for a patient with specific disease states.
  14. Renal
    1. Discuss the physiologic principles and define specific management aspects associated with the following complex acid-base problems:
      1. Renal tubular acidosis (differentiate between Type I and II)
      2. Management of high output loss states from the gastrointestinal tract in a patient with poor cardiac function
      3. Management of volume excess states associated with eunatremia or hyponatremia
  15. Gastrointestinal/Hepatic
    1. Review and summarize the management of hepatic and renal failure, including:
      1. Utility/disutility of disease-specific nutritional formulations
    2. Adjustment or elimination of toxic substances (antibiotics, contrast material, narcotics)
      1. Current means for support of renal failure, high dose diuretics, continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis (CVVHD), dialysis (peritoneal and hemodialysis)
  16. Describe and specify therapy for the following endocrine-related problems associated with critical care:
    1. Hypothyroidism/hyperthyroidism
    2. Hyperparathyroidism/hypoparathyroidism (changes in calcium and magnesium values)
    3. Adrenal cortical excess (Cushing's disease and syndrome)
    4. Adrenal cortical deficiency states (Addison's disease)

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-4 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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