Specific Educational Goals and Education HO III Rural Rotation

Specific Educational Goals and Education

Level: PGY 3

Service: Rural Rotation

Supervision: PGY -5 → Attending
All management decisions will be discussed with the faculty.

Duty Hours:

Hours are to be logged into New Innovations 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

Abdominal Surgery

Competency Based Performance Objectives:

Patient Care:

Goal: Demonstrate the ability to formulate and implement a diagnostic and treatment plan for diseases of the abdomen and pelvis that are amenable to surgical intervention.

Objectives: The resident will be able to:

  1. Perform, record, and report complete patient evaluation and assessment.
  2. Evaluate and diagnose the acute abdomen.
  3. Assist with hernia repairs in the groin or umbilicus, demonstrating a basic understanding of the anatomy and surgical repair.
  4. Interpret the following in coordination with attending radiologists and staff:
    1. Acute abdominal series (identify free air, small bowel obstruction, ileus, colonic pseudo-obstruction, volvulus; the presence of ascites, atelectasis vs. pneumonia)
    2. Upper GI series
    3. Barium enema (identify neoplasms, signs of ischemia)
    4. Abdominal ultrasound and CT scans
  5. Evaluate and institute management of abdominal wound problems, including:
    1. Infection
    2. Evisceration
    3. Fasciitis
    4. Dehiscence
  6. Coordinate pre- and post-operative care for the patient with the acute abdomen.
  7. Institute drainage for abdominal wall fistula and protection of surrounding structures, especially skin.
  8. Open and close abdominal incisions of all varieties.
  9. Treat wound complications such as infections and evisceration.
  10. Perform common Laparoscopic procedures (e.g., cholecystomy, hernia repair, colectomy, G tube placement, and appendectomy.)
  11. Perform laparotomy for acute abdomen, demonstrating a systematic approach for determination of the etiology of the process via a systematic abdominal exploration and appropriate measures for its management (e.g., acute appendicitis, small bowel obstruction, perforated peptic ulcer Perform more complex laparotomies involving diffuse peritonitis in the septic patient (e.g., a gangrenous or severely inflamed gallbladder or perforated diverticulitis requiring resection).
  12. Perform upper and lower endoscopy
  13. Perform common general surgery procedures (e.g., breast, soft tissue, hernia, and abscess)
  14. Serve as an effective surgical team leader.

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of diseases of the abdominal cavity and pelvis.

Objectives: The resident will be able to:

  1. Describe the embryological development of the peritoneal cavity and the positioning of the abdominal viscera.
  2. Diagram the anatomy of the abdomen including its viscera and anatomic spaces:
  3. Surgical outcome is dependent on coexistent disease. Describe changes in the following organ systems that result from the aging process:
    1. Heart
    2. Lung
    3. Kidney
    4. Brain
    5. Hematopoietic system
    6. Gastrointestinal tract
  4. Explain absorption and secretory functions of the peritoneal surfaces and the diaphragm.
  5. Describe the anatomy of the omentum and its role in responding to inflammatory processes.
  6. Assess the following signs associated with the acute abdomen and describe their pathophysiology:
    1. Referred pain
    2. Rebound tenderness
    3. Guarding
    4. Rigidity
  7. Specify characteristics of the history, physical examination findings, and mechanism of visceral and somatic pain for the following processes:
    1. Acute appendicitis
    2. Bowel obstruction
    3. Perforated ulcer
    4. Ureteral colic
    5. Diffuse peritonitis
    6. Biliary colic
  8. List possible distinctions in the presentation and examination of the elderly patient with the following causes of acute abdomen:
    1. Perforated viscus
    2. Cholecystitis
  9. Discuss the differences in the physiologic response to stress in the geriatric patient.
  10. Explain the mechanism of referred pain in:
    1. Ruptured spleen
    2. Biliary colic
    3. Basilar pneumonia
    4. Renal colic
    5. Pancreatitis
    6. Inquinal hernia
  11. Discuss the following causes of paralytic ileus:
    1. Post-operative electrolyte imbalance
    2. Retroperitoneal pathology
    3. Trauma
    4. Extraperitoneal disease (central nervous system, lung)
  12. Illustrate use of the following diagnostic studies in the work-up of acute surgical disease:
    1. Laboratory evaluation
    2. Urinalysis
    3. Plain x-rays
    4. Contrast gastrointestinal (GI) studies
    5. Ultrasound
    6. Computed axial tomography (CAT)
    7. Biliary studies
    8. Renal studies
  13. When considering the possibility of wound complications:
    1. What are the risk factors for abdominal wound infection?
    2. What are the contributing factors for abdominal wound dehiscence and evisceration?
    3. What are the usual clinical presentations and timing?
    4. What is the incidence of wound infection in surgeries involving the biliary tree, upper GI tract, and colon?
    5. List wound complications that are more problematic in the elderly patient.
  14. Identify the anatomic locations for the following intra-abdominal abscesses; name disease process(es) associated with each:
    1. Left subphrenic space
    2. Right subphrenic space
    3. Subhepatic space
    4. Lesser sac
    5. Interloop
    6. Pelvis
    7. Left paracolic gutter
    8. Right paracolic gutter
    9. Psoas muscle
  15. Differentiate between the conditions favoring percutaneous drainage versus operative drainage for each of the abscesses in #14. Describe the safest and most effective approach using each technique.
  16. Differentiate between the following intestinal fistulas and the organs to which they most often communicate:
    1. Esophageal
    2. Gastric
    3. Enteric (including duodenal)
    4. Colonic
  17. Explain the formation of fistulas in each of the following disease processes or factors:
    1. Operative complications (bowel injury with abscess formation)
    2. Inflammatory bowel disease
    3. Acute pancreatitis
    4. Foreign body or prosthetic material
    5. Malignancy
  18. Explain the role of a fistulogram in the diagnosis of intra-abdominal fistulas and abscesses.
  19. List the factors that prevent healing of a fistula.
  20. Summarize the conditions favoring operative versus non-operative treatment for fistulas listed in #16.
  21. Describe the anatomy, clinical presentation, and complications of non-operative management for these hernias:
    1. Direct and indirect inguinal, femoral, and obturator
    2. Sliding hiatal
    3. Paraesophageal
    4. Ventral
    5. Umbilical
    6. Spigelian
    7. Paraduodenal
    8. Richter’s
    9.  Lumbar and Petit
    10. Parastomal
    11. Diaphragmatic
      1. Posterolateral (Bochdalek)
      2. Anterior (Morgagni)
      3. Traumatic
    12. Internal
  22. Name the hernia types that are most common in elderly patients, and explain how they may become problematic.
  23. Define a Richter's hernia and describe its clinical presentation.
  24. Define a sliding hernia and describe its repair.
  25. Differentiate between incarceration and strangulation.
  26. Summarize the surgical procedures available for repair of hernias.
  27. Outline the uses of prosthetic material and management of infection for incisional or recurrent hernias involving prosthetic material.
  28. Explain the operative approaches for each of the following, including laparoscopic:
    1. Abdominal cavity: liver/biliary tract, spleen, small bowel, large bowel, and pelvis
    2. Retroperitoneal organs: kidneys, pancreas, adrenal glands, abdominal aorta
  29. Outline the techniques for wound closure (including type of suture material) for each incision