A competency based development of knowledge and skills in Medicine Consultation through clinical experience, bedside teaching, didactic conferences and readings to achieve competence, proficiency and the foundation for mastery. By a focused effort to prepare patients medically for surgery and anesthesia, residents will develop the skills to handle medical issues in the perioperative period and understand the needs of surgeons and anesthesiologists in readying patients for the operating room. Clinical Information and Didactics - Each morning at 8:45 a.m. residents will receive a 30 minute lecture on various topics related to the care of patients in the perioperative period. Residents are expected to be present even when attending to other duties for the day, with the exception of night float and resident clinics. Clinic hours are 8:30 a.m. to 5 p.m., Monday through Thursday, and 8:30 a.m. to 3:30 pm on Fridays. Residents are expected to attend their noon conferences.
- Residents will perform complete history and physicals while inputting data into the “startup” form found under orders and the appropriate “Preoperative History and Physical w/ consult” template. Residents are expected to learn and apply assessment and treatment protocols unique to this service. Presentation to the attending should be thorough with the realization that the attending will be assuming the care of these patients on the inpatient service.
- Residents are expected to hold on to the chart until the entire data set is complete before turning the chart in to the appropriate preceptor. Each of these charts will have a deadline which is the surgical date. Residents are responsible for tracking these dates and signing out the patients to the appropriate attending as they rotate off the service or cover other duties.
Online modules - Residents are expected to complete four modules from the Johns Hopkins website at http://www.jhcme.com/ by the end of the rotation and turn in a printable completion form for each module. Residents can choose amongst any of the modules available.
Contact information for the rotation : Click here Practice Based Learning and Improvement PGY2/3: Incorporate regular chart review and patient follow up to learn from your clinical care. Incorporate evidence based medicine into clinical decision making. Review the latest research pertaining to your your patients. Teach and mentor students and interns. Systems Based Practice PGY2/3: Work in a multi-disciplinary team to provide high quality coordinated care. Ensure accurate and timely documenation through the use of the electronic medical record. Use knowledge and skills in quality improvement and patient safety to deliver safe and effective care. Apply team leadership skills in appropriate settings. Practice cost effective medicine with an awareness of health care economics and patient insurance status. Interpersonal Skills and Communication PGY2/3: Use effective listening skills with patients and health care providers. Elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills. Develop interpersonal and communication skills necessary to run an effective clincal team in the ambulatory. Role model and teach effective communication techniques. Professionalism PGY2/3: Carry out your professional responsibilities in a timely manner. Adhere to the ethical principles of a patient-centered practice. Be sensitive to a diverse patient population and health care staff. Understand how biases influence clinical care, patient-physician interactions and health team interactions. Role model and provide feedback to students and interns the principles of humanism in medicine. Patient Care and Medical Knowledge A. Role of the medical consultant, approach to preoperative evaluation and testing - Appreciate concepts of effective consultations
- Recognize factors that enhance compliance with consultant recommendations
- Display professionalism in communication with patients and primary services
- Communicate effectively with primary services
- Recognize which blood and urine tests are appropriate in the preoperative assessment
- Define when a 12 lead ECG is appropriate in the preoperative assessment
- Recognize when it is appropriate to perform specialized testing
- Recognize perceived and actual pros and cons with regard to regional vs general anesthesia
- Understand medication management in the peri-operative period.
B. Preoperative cardiac risk assessment and postoperative management - Cardiac Risk Assessment
- Components of the revised cardiac risk index.
- Quantify exercise capacity and its usefulness.
- Surgical risk categorization.
- Appreciate the impact of prior revascularization.
- Appropriate use of preoperative ischemia studies
- Cardiac Risk Reduction
- Proper use of perioperative beta-blockade.
- The importance of statins.
- Proper use of preoperative revascularization.
- Proper antiplatelet management periooperatively.
- Recognition of the atypical presentations of postoperative myocardial infarctions.
· Recognize the appropriate intra and postoperative management of a patient with CAD C. Thromboembolic prevention and treatment - Appreciate the magnitude of the problem
- Define which patients are at high risk for venous thromboembolism
- Recognize contraindications to anticoagulation
- Define appropriate medical prophylaxis for a variety of clinical situations and the appropriate duration of prophylaxis
- Recognize alternative strategies to thromboembolic prophylaxis
- Define appropriate diagnostic strategies in working up venous thromboembolism
D. Consultation on the patient with neurologic disease and postoperative delirium - Recognize management issues and goals with regard to hypertension in the post-CVA patient and the patient with SAH
- Recognize and be able to treat electrolyte abnormalities common to neurologic patients
- Recognize risk factors for delirium
- Define management strategies for delirium
E. Medical illness in the psychiatric patient - Appreciate communication issues that may arise in evaluating the psychiatric patient
- Recognize medical illnesses that may mimic psychiatric disorders
- Be able to perform pre-ECT risk assessment
- Recognize common side effects of psychiatric medications
F. Preoperative pulmonary risk assessment and postoperative management - Be able to assess the perioperative risk in patient with known lung disease
- Define when it is appropriate to prescribe preoperative steroids
- Be able to counsel a smoker about when/if it is appropriate to quit smoking prior to surgery
- Recognize postoperative management strategies to prevent complications in the patient with known lung disease
- Be able to evaluate the dyspneic or hypoxic patient on a non-medicine service
G. Prophylactic antibiotic use and postoperative infectious complications - Define risk factors for surgical site infections
- Recognize appropriate timing and appropriate antibiotics to prevent surgical site infections
- Recognize how to diagnose nosocomial pneumonia and recognize the appropriate treatment
- Recognize how to diagnose C. difficile associated diarrhea and the appropriate treatment
H. Hematological complications of surgery and management of anticoagulation during the perioperative period - Define when it is appropriate to prescribe red blood cell transfusion for which patients
- Recognize the appropriate evaluation for a coagulopathy
- Recognize the appropriate evaluation for a drop in hemoglobin
- Recognize which procedures are not indications for reversal of anticoagulation
- Recognize treatment strategies for patients on chronic anticoagulation that need reversal at the time of surgery
I. Common endocrine disorder in medicine consultation - Recognize appropriate management principles in the perioperative patient with diabetes
- Recognize adverse effects of medications used to treat diabetes
- Recognize when it is appropriate to administer stress dose steroids
- Recognize the appropriate evaluation and management of the hypothyroid patient
J. Medical problems during pregnancy - Appreciate the physiologic changes associated with pregnancy
- Recognize appropriate treatment of the pregnant patient with hypertension
- Recognize appropriate treatment of the pregnant patient with asthma
- Recognize risk factors associated with venous thromboembolism in the pregnant and puerperal patient
- Recognize appropriate treatment of the pregnant patient with diabetes
K. Acute renal failure and perioperative care for the patient with impaired renal function - Recognize risk factors for acute renal failure and preventative strategies
- Recognize complications of chronic renal failure that would preclude non-urgent surgery
- Define the appropriate initial evaluation of a patient with acute renal failure
- Define appropriate evaluation and management of common electrolyte disorders (hypo and hypernatremia, hypo and hyperkalemia)
L. Assessment and Management of Sleep Apnea - Screening for undiagnosed sleep apnea.
- Initiation of CPAP in the perioperative period.
- Proper monitoring of sleep apnea patients in the postoperative period.
M. Cirrhosis and Surgery - Appreciation of the risk carried by cirrhotic patients undergoing surgery.
- Management in the perioperative period.
Below are top articles selected for the case based curriculum and should be read during the month. - Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043-1049.
- Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA. 2001;285:1865-1873.
- Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med. 1999;341:1789-1794.
- Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007;116:e418-e499.
- Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349-361.
- Grines CL, Bonow RO, Casey DE, Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007;115:813-818.
- Durazzo AE, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg. 2004;39:967-975; discussion 975-966.
- McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795-2804.
- Kim A. Eagle et al. Cardiac Risk of Noncardiac Surgery : Influence of Coronary Disease and Type of Surgery in 3368 Operations. Circulation. 1997;96:1882-1887.
- Kamal A, et al. How to Interpret and Pursue an Abnormal Prothrombin Time, Activated Partial Thromboplastin Time, and Bleeding Time in Adults. Mayo Clin Proc July 2007; 82(7):864-873.
- Ramakrishna G, et al. Impact of Pulmonary Hypertension on the Outcomes of Noncardiac Surgery. J Am Coll Cardiol 2005; 45:1691-1699.
- Devereaux PJ, et al. Surveillance and Prevention of Major Perioperative Ischemic Cardiac Events in Patients Undergoing Noncardiac Surgery: a Review. CMAJ, Sept 27, 2005: 173(7)779-788.
- Landesberg G, et al. Myocardial Infarction after Vascular Surgery: The Role of Prolonged, Stress-Induced, ST-Depression-Type Ischemia. J Am Coll Cardiol, 2001: 37(7)1839-1845.
- Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery (POISE trial): a randomized-control trial. Lancet. 2008 May 31;371(9627):1839-47.
- Suman A, Carey W. Assessing the risk of surgery in patients with liver disease. Cleveland Clinic Journal of Medicine April 2006; 73(4): 398-403.
- Teh et al. Risk Factors for Mortality After Surgery in Patients With Cirrhosis. Gastroenterology 2007; 132:1261
- R M Gupta, J Parvizi, A D Hanssen, and P C Gay. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. September 2001 76(9):897-905 (abstract only)
- Glenn M. Chertow, MD, MPH et al. Preoperative Renal Risk Stratification. Circulation. 1997;95:878-884
- Lassnigg A et al. Minimal Changes of Serum Creatinine Predict Prognosis in Patients after Cardiothoracic Surgery: A Prospective Cohort Study. Am Soc Nephrol 2004; 15: 1597-1605.
- David J. Blacker. The Preoperative Cerebrovascular Consultation: Common Cerebrovascular Questions Before General or Cardiac Surgery. Mayo Clin Proc. February 2004 79(2):223-229.
- Magdy Selim. Perioperative Stroke. NEJM 2007; 356:706-713.
- Brabant S, et al. Refractory Hypotension After Induction of Anesthesia in a Patient Chronically Treated with Angiotensin Receptor Antagonists. Anesth Analg 1999; 89: 887-8.
- Cittanova M, et al. The Chronic Inhibibition of Angiotensin-Converting Enzyme Impairs Postoperative Renal Function. Anesth Analg 2001; 93: 1111-5.
- Benedetto U, et al. Postoperative Angiotensin-Converting Enzyme Inhibitors Protect Myocardium from Ischemia During Coronary Artery Bypass Graft Surgery. J Cardiovasc Med 2008; 9:1098-1103.
For an extended list of references with direct article links, sign in to the Galter Health Library website at: http://www.galter.northwestern.edu/guides/expand/resident-reading-lists |
