Anesthesiology Clerkship Curriculum:
To introduce clerks to clinical anesthesia covering: peri-operative assessment and optimization, monitoring techniques, management of acute medical care issues including resuscitation, acute pain, and application of basic science to clinical problems, acquisition of good basic airway skills, placement of intravenous cannula, and experience in more advanced airway management techniques. To benefit from the rotation clerks are expected to have read the “Anesthesia for medical students” textbook available on the internet, http://www.si.mahidol.ac.th/Th/department/anesthesiology/rd/sullivan.pdf is highly recommended.
Clerks should also supplement reading by QUESTIONING THE FACULTY TUTORS, observation, and clinical practice. This is one of the few times during clerkship when you are one-on-one with a member of staff all day every day; take advantage of it. Clerks are asked to ensure that their faculty tutor(s) record and deliver to them, for feedback and safekeeping, their evaluation sheet each day or evening.
Clerks will be assigned during all or part of each day to the OR, Obstetrical Unit, or acute/chronic pain services for a variety of experience. Clerk assignments within the OR is coordinated by the Anesthesia Resident Manager. We aim to avoid assigning a clerk to a room where there is also a resident. However occasionally this is unavoidable and every effort is made to try and allocate a list where the clerk can maximise their experience. Please address any concerns with list allocation to the Anesthesia Resident Manager or failing this, the anesthesia undergraduate secretary. The clerk is usually expected to complete the day in the assigned location. However, this may be altered if better learning opportunities present.
Attendance at Grand Rounds and Case Management rounds is mandatory. Attendance records will be taken** Please be punctual for rounds since it is disruptive to others and disrespectful to the person presenting. § Seminar lectures as part of the Periop lecture series Attendance will be taken. Students missing any of these sessions in their block must make arrangements to make up the session.
Clerks must evaluate their patients preoperatively, record and sign that evaluation on each patient’s anesthetic record sheet. Clerks will be evaluated on their assessment of the patients and asked to formulate an anesthetic plan. You will be assigned to your OR room the day beforehand. The OR schedule is available on the afternoon before. Please look at this to find out which list you will be doing and what type of cases are involved. As well as reviewing the patient’s record it is recommended that you read up about any underlying medical conditions and how these and the type of surgery may affect management. ‘Same Day Admission’ and ‘Outpatient’ charts are available for review in the “Same Day Area” on the afternoon prior to scheduled anesthesia.
The clerk should begin to complete the anaesthetic record found in the patients chart the evening before. Clerks are also expected to assess any ‘in-patients’. These will be identifiable as either TBA or have a designated floor beside their name on the OR list. N.B. The clerk must assess all patients before the OR list starts. It is unprofessional behaviour to arrive in the operating room with no knowledge of the patient and expect to be allowed to have active participation in their care. The staff may refuse to let you participate actively in the case if you have not assessed the patient beforehand.
Pick a patient of your choice on the list you are assigned to the evening prior. Your preceptor for that day will review this with you and may ask you some questions. OBJECTIVES 1. Preanesthetic assessment a) Perform several preanesthetic assessments including: Obtain and record pertinent history in an efficient and compassionate manner Physically assess airway, cardiovascular system, respiratory system. Review and interpret laboratory data Assign appropriate ASA classification b) Discuss how the following factors impact in the perioperative period: Age Surgery CVS: coronary insufficiency, hypertension, myocardial failure, dysrhythmias Resp: known/suspected difficult intubation, upper/lower resp. infections, asthma, COPD CNS: increased ICP GIT: factors affecting pulmonary aspiration risk Hematological: anemias, coagulopathies Personal/family history of anesthetic reactions; malignant hyperthermia, succinylcholine apnea, awareness, postoperative nausea and vomiting Lifestyle: obesity, smoking, alcohol, street drugs. c) Discuss medication history: Which drugs to discontinue and why (risk of rebound phenomena with β blockers) Chronic pain medications d) Demonstrate knowledge of objectives for premedication including: Drugs for anxiety, amnesia, analgesia, sedation, reducing gastric volume and acidity NPO guidelines e)
The clerk will be expected to devise a basic anaesthetic management plan 2. Operating Room a) Demonstrate knowledge and observe induction of anesthesia including Identify and give the advantages and disadvantages of intravenous agents, inhalation agents, neuromuscular blocking agents b) Demonstrate correct airway and ventilatory management by: Knowledge of basic upper airway anatomy Risks/benefits of mask ventilation vs endotracheal intubation vs laryngeal mask airway Identify and overcome upper airway obstruction with mask ventilation using: Various masks Jaw thrust Nasopharyngeal airway Oropharyngeal airway.
Practice endotracheal intubation Ventilatory requirements of an adult The effects of anesthesia and surgery on oxygenation and ventilation c) Understand the principles and practice of routine intraoperative monitoring by: Explain and demonstrate lead placement and selection to detect dysrhythmias and ischemia Interpretation and potential errors in pulse oximetry Interpretation of capnography d) Prescribe and conduct appropriate intraoperative fluid and electrolyte therapy by: Identify common sites for venous access includingindications/ contraindications.
Demonstrate skill at establishing intravenous access by: Sterile technique and universal precautions Successfully insert several peripheral catheters ideally of different sizes Protect the site and immobilize the catheter Predict how preoperative conditions alter perioperative fluid requirements for: NPO Bowel prep NG suction Fever Discuss the intraoperative considerations of fluid replacement for: Blood loss Third space losses Temperature Assess volume status and interpret data via the following monitors: Examination of the patient Pulse and blood pressure measurement (NIBP/ arterial lines) Urine output CVP PCWP Discuss the indications, risks, benefits and complications of crystalloids, colloids, blood products including: Blood volume Oxygen carrying capacity Coagulation Discuss methods of recognizing and treating perioperatively: Hypoxia Hypercarbia Hypertension
Endobronchial intubation Esophageal intubation e) Identify several position related injuries that a patient may sustain whilst unconscious. f) Describe the drugs used for resuscitation, their indications, doses related to body size, and side effects. 3. Regional Anesthesia a) Demonstrate knowledge of local anesthetic pharmacology appropriate to the practice of general medicine by: Listing commonly used local anesthetics for: Topical use Local infiltration Intravenous blocks (biers blocks) Peripheral nerve blocks Spinal anesthesia Epidural analgesia/anesthesia Know the acceptable doses of at least two local anesthetic agents used for peripheral nerve blocks and epidural anesthesia
Describe and identify signs of impending local anesthetic toxicity Describe the medical management of local anesthetic toxicity including preventative measures Awareness of additives used with local anesthetic preparations, their purpose and toxicity Risks, benefits and contraindications to spinal and epidural anesthesia 4.
Ambulatory Anesthesia a) Demonstrate knowledge of the types of procedures and patients appropriate for ambulatory surgery b) Assess the ambulatory patient with respect to ASA classification NPO status Appropriate lab work Nausea and vomiting prophylaxis Pain management Discharge criteria 5.
Postoperative Pain Management a) Demonstrate knowledge of the different types of pain management including the advantages, disadvantages and monitoring required for: PCA Epidural catheters PRN medications PO medications b) Knowledge of assessment of postoperative pain via Pain scales Visual analogue scales 6.
Obstetrical Anesthesia. a) Demonstrate knowledge of: Physiological changes of pregnancy and their implications for anesthesia Regional anesthesia using local anesthetic and/or opioids for analgesia including the indications, contraindications, effects, problems, and relevant sensory pathways. The indications, contraindications, effects, and problems of general anesthesia in the obstetrical population Other methods of pain control in labour 7. Attitudes of the clerk are assessed on a daily basis and include: a) Interaction with patients (and their families) with regards to respect, compassion and empathy b) Politeness and respect for other health care professionals c) Punctuality, reliability and the ability to take initiative and responsibility where appropriate d) Ability to work effectively as part of a team e) Motivation towards patient assessment, self directed study and maximising clinical experience.
EVALUATION of CLERKS Daily evaluation by both direct observation and by oral questioning will be recorded each day. Completed daily evaluation forms are to be obtained by the clerk each day and all evaluations held by the clerk for presentation to the undergraduate secretary at the end of the rotation. You also need to complete a logbook outlining your daily experience.
Adopted from Department of Anesthesiology at Queen’s University School of Medicine in Canada